GPAtlas🧭 When to suspect
Plantar fasciitis (increasingly termed plantar fasciopathy) is the commonest cause of plantar heel pain in adults, peaking between 40 and 60 years. Despite the “-itis”, it is now understood as a degenerative process of the plantar fascia – microtears and disordered healing rather than active inflammation – which is why loading-based treatment, not anti-inflammatories, changes the natural history.
Suspect it in an adult with medial heel pain that is classically sharp or stabbing and shows the hallmark of “start-up” pain: worst with the first few steps in the morning or after rest, easing as the foot “warms up”, then returning after prolonged standing or walking. Key risk factors are raised BMI, prolonged weight-bearing occupations, a sudden increase in running or walking load, reduced ankle dorsiflexion / a tight calf, and pes planus or pes cavus.
An important caveat: plantar heel pain is not reliably self-limiting. Left untreated it can persist for many months and significantly impair work, activity and mood – so structured, stepped management started early matters.
Before settling on the diagnosis, place the pain pattern against the common mimics:
| Pain pattern / clue | Consider |
|---|---|
| Medial heel, maximal on first steps, eases with activity | Plantar fasciitis (fasciopathy) |
| Central/diffuse heel pain, worse later in the day and on hard surfaces, older patient | Heel fat-pad atrophy |
| Pain at the posterior heel / Achilles insertion, worse on push-off | Insertional Achilles tendinopathy or retrocalcaneal bursitis |
| Burning, tingling or numbness in the sole; positive Tinel's behind the medial malleolus | Tarsal tunnel syndrome (tibial nerve) |
| Diffuse heel pain after a load spike or trauma; positive calcaneal squeeze | Calcaneal stress fracture |
| Bilateral heel pain, often under 40, with inflammatory features | Enthesitis of seronegative spondyloarthropathy |
Source: Royal College of Podiatry · British Journal of Sports Medicine
|
🧠 Clinical pearl Bilateral heel pain – especially in someone under 40, or with inflammatory back pain, psoriasis, inflammatory bowel disease or recurrent uveitis – is enthesitis until proven otherwise. Screen for seronegative spondyloarthropathy and consider rheumatology rather than reflexively labelling it plantar fasciitis. |
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