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1 · SNAPSHOT

Plantar Fasciopathy body chart — Illustrative, not diagnostic. Canva body chart for Plantar Fasciopathy.

Who: Adults 45–64 most often, women more than men, and heavier people much more than lighter ones.
What: Pain under the heel, at the medial calcaneal tubercle, worst on the first steps of the day.
How it behaves: First-step pain in the morning and after sitting. Eases with walking, then returns with volume.

The one thing to take from this page:

It is not self-limiting. Eighty per cent of people still have it at one year, and nearly half still have it at ten.

269 people diagnosed over a decade, 174 followed a mean of 9.7 years from symptom onset [1]:

Time from symptom onset	Still symptomatic
1 year	80.5%
5 years	50.0%
10 years	45.6%
15 years	44.0%

At follow-up 54% were asymptomatic — after a mean symptom duration of 725 days, about two years. Worse prognosis for women (p < 0.01) and bilateral pain (p < 0.01). Baseline fascia thickness (p = 0.49) and heel spur (p = 0.88) predicted nothing at all.

How common: incidence 3.83 per 1,000 patient-years (95% CI 3.77–3.89) in Dutch primary care across 1.9 million patients; 0.85% (0.77–0.92) of US adults report a diagnosis with pain in the past month, rising to 1.48% in obesity against 0.29% at a BMI under 25.

⚠️ No Australian guideline exists for this presentation. Anchored to the JOSPT Heel Pain CPG, Revision 2023 [2] — a US guideline whose interpretation an international group formally challenged in JOSPT in 2025. Where this page and the guideline diverge, the primary trial is cited.

Pattern > Label. And here the label itself is contested — there is no terminology consensus between "fasciitis", "fasciopathy" and "plantar heel pain".

2 · SE — THE SUBJECTIVE PATTERN (the 70%)

Five stages, in your course's order. Insidious, so BEHAVIOUR before HISTORY.

MAIN PROBLEM

"The first few steps in the morning are agony." "It's fine once I get going, then it comes back."

BODY CHART

Under the heel, at or just distal to the medial calcaneal tubercle. They can usually point to it.
Pain travelling into the arch is common and still this pattern.
Burning, tingling, or numbness — that is a nerve question. See §3.
Posterior heel at the Achilles insertion is a different pattern.

BEHAVIOUR

Aggs: first steps in the morning, first steps after sitting, prolonged standing, walking barefoot on hard floors, a volume spike.
Eases: warming up over the first few minutes, supportive shoes, offloading.
24-hr pattern: first steps in the morning and after sitting, easing over the first few minutes of walking — the Aggs and Eases are the diurnal pattern.
Severity: VAS 0–10 at best / at worst / right now.
Irritability: resting symptoms, vigour of the provoking activity, time to settle.

First-step pain is the descriptor, and you should know its status honestly. There is no diagnostic accuracy data on it — none. It appears throughout this literature as an eligibility criterion and as an outcome, never as an index test with a reference standard.

What it is good for is measurement. Its minimal important difference is 19.2 mm on a 100 mm scale (95% CI −24.7 to −13.8), against 8.5 mm for average pain ([3], pooled n = 369, La Trobe). First-step pain moves further and needs to move further.

HISTORY

Load change — new job on their feet, a return to running, a new shoe, a weight change.
Duration, and previous episodes. Bilateral symptoms predict a worse course.
Occupation: spending most of the workday weight-bearing carries OR 3.6 (95% CI 1.3–10.1).

SPECIAL / SCREENING QUESTIONS

Inflammatory features, other joints, psoriasis, gut or eye symptoms, systemic illness, night pain, medications. See §4.

The risk factors — and which population you are reasoning from

This matters, because the two best sources disagree and both are right.

Population	Finding
General clinic — 50 unilateral cases, 100 matched controls [4]	Ankle dorsiflexion ≤0° vs >10°: OR 23.3 (95% CI 4.3–124.4) · BMI >30: OR 5.6 (1.9–16.6) · workday weight-bearing: OR 3.6 (1.3–10.1)
Physically active people — 16 studies [5]	Increased plantarflexion ROM MD 7.04° (5.88–8.19) · BMI MD 2.13 kg/m² (1.40–2.86) · body mass MD 4.52 kg (0.55–8.49). Reduced dorsiflexion was not among them

Look at that first interval: 4.3 to 124.4. That is where "tight calf causes plantar fasciitis" comes from. Measure it, and name which population you are reasoning from.

Ask what changed. Then ask how long it has been going on — because at a year, four in five still have it.

Assessing this region? Download the Ankle & Foot assessment template →

3 · HYPOTHESIS RANKING

Competing pattern	The one discriminating feature
Fat pad syndrome	Central, not medial. Worse barefoot on hard ground, better in cushioning. No first-step signature
Calcaneal bone stress injury	Focal bone tenderness, pain with impact and progressing through activity, a load spike behind it
Tarsal tunnel / Baxter's nerve	Burning, tingling, numbness. Symptoms that do not follow the first-step pattern
S1 radiculopathy	Symptoms above the ankle too, neural signs, and the lumbar screen changes them
Seronegative spondyloarthropathy	Other joints, psoriasis, gut or eye symptoms, inflammatory rhythm — §4
Achilles insertional tendinopathy	Posterior, at the insertion — see the Achilles page

The name is contested, and that is worth thirty seconds

There is no terminology consensus. A search for a consensus, Delphi or nomenclature statement returns nothing. The split is visible in the literature itself: the current guideline is titled "Heel Pain — Plantar Fasciitis", while the trial groups publish under "plantar fasciopathy" and the podiatry researchers under "plantar heel pain".

The histology behind "-opathy": 50 specimens from heel spur surgery showed myxoid degeneration, fascial fragmentation, bone marrow vascular ectasia — and no inflammation [6].

Carry the caveat honestly: n = 50, all chronic surgical cases — the recalcitrant tail, not your average patient. And a contemporaneous operative series reported inflammation in all cases. "Degenerative, not inflammatory" rests on one 50-case series of one end of the spectrum.

Why it matters at all: because case definitions across 214 studies vary so widely — age defined 23 different ways, symptom duration 14 — that pooling this literature is fragile by construction.

Jones' hypothesis categories that change your plan: sources of symptoms — fascia, fat pad, bone, nerve — plus pain type and prognosis, which on this pattern is the thing you are most likely to get wrong.

Say "plantar heel pain" until you have ruled the neighbours out. Then narrow.

4 · RED FLAGS — DON'T MISS THIS

This section is free, on every pattern, forever.

Signs / symptoms	Implication
Focal calcaneal bone tenderness, load spike, pain progressing through activity	Calcaneal bone stress injury
Bilateral heel pain in someone under 40, morning stiffness over 30 min, other joints, psoriasis, gut or eye symptoms, family history	Seronegative spondyloarthropathy — the one worth knowing here
Burning, tingling, numbness, night symptoms	Tarsal tunnel / Baxter's nerve entrapment
Symptoms above the ankle, neural signs	S1 radiculopathy
Fever, redness, systemic illness, a wound	Infection
Unexplained weight loss, night pain unchanged by position, malignancy history	Malignancy

The inflammatory one — and the finding that complicates it

Bilateral heel pain in a young adult with an inflammatory rhythm is a rheumatology question, not a loading question. Enthesitis at the heel is a classic spondyloarthritis feature and it is genuinely the flag to know on this pattern.

But do not assume tenderness means enthesitis. In 27 patients with known peripheral spondyloarthritis and heel tenderness [7]:


Ultrasound-confirmed inflammatory enthesitis	48%
Doppler activity	19% — all in the Achilles enthesis, none plantar
A different inflammatory pathology (tendinitis, arthritis, bursitis)	26%

So even in confirmed spondyloarthritis, a tender heel is more often not enthesitis — and plantar Doppler enthesitis was not seen at all in that cohort. Refer the systemic picture, not the tender spot.

Bone stress

Anchored to the 2025 international Delphi consensus on bone stress injuries in athletes ([8]; 41 panellists across six continents, consensus on 41 of 58 statements). Focal bone pain that worsens through a session, in someone whose load changed, is a bone question until imaging says otherwise.

(No verified accuracy data exists in our library for the calcaneal squeeze or hop test.)

Bilateral heel pain in a young adult with other joints involved is a rheumatology referral, not a loading programme.
Burning and numbness is a nerve, not a fascia.
Focal bone tenderness plus a load spike is bone until proven otherwise.

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Guideline anchor

No Australian guideline for this presentation.

Anchored to Heel Pain — Plantar Fasciitis: Revision 2023 — JOSPT clinical practice guideline (Koc et al.)

PubMed

No Australian clinical practice guideline or clinical care standard exists for plantar heel pain. ACSQHC has no standard; RACGP has no equivalent. The strongest Australian contribution is the primary evidence itself — La Trobe (Landorf, Menz, Whittaker, Cotchett), UQ (Vicenzino) and UniSA (Bishop).

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The evidence summary is for members

Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.

Sources · 28

Show

Every source on this page resolves and title-verifies against PubMed. Newest first.

2018Hansen et al. (2018). Long-Term Prognosis of Plantar Fasciitis: A 5- to 15-Year Follow-up Study of 174 Patients With Ultrasound Examination. Orthopaedic journal of sports medicine, 6(3), 2325967118757983. https://doi.org/10.1177/2325967118757983
2023Koc TA et al. (2023). Heel Pain - Plantar Fasciitis: Revision 2023. The Journal of orthopaedic and sports physical therapy, 53(12), CPG1-CPG39. https://doi.org/10.2519/jospt.2023.0303
2024Landorf et al. (2024). Revised minimal important difference values for the visual analogue scale and Foot Health Status Questionnaire when used for plantar heel pain. Journal of foot and ankle research, 17(4), e70021. https://doi.org/10.1002/jfa2.70021
2003Riddle et al. (2003). Risk factors for Plantar fasciitis: a matched case-control study. The Journal of bone and joint surgery. American volume, 85(5), 872-7. https://doi.org/10.2106/00004623-200305000-00015
2021Hamstra-Wright et al. (2021). Risk Factors for Plantar Fasciitis in Physically Active Individuals: A Systematic Review and Meta-analysis. Sports health, 13(3), 296-303. https://doi.org/10.1177/1941738120970976
2003Lemont et al. (2003). Plantar fasciitis: a degenerative process (fasciosis) without inflammation. Journal of the American Podiatric Medical Association, 93(3), 234-7. https://doi.org/10.7547/87507315-93-3-234
2022Felbo et al. (2022). Ultrasound of the Heel Improves Diagnosis-Tender Entheses in the Heel Region Rarely Corresponds to Inflammatory Enthesitis in Patients with Peripheral Spondyloarthritis. Journal of clinical medicine, 11(9). https://doi.org/10.3390/jcm11092325
2025Hoenig et al. (2025). International Delphi consensus on bone stress injuries in athletes. British journal of sports medicine, 59(2), 78-90. https://doi.org/10.1136/bjsports-2024-108616
2003De Garceau et al. (2003). The association between diagnosis of plantar fasciitis and Windlass test results. Foot & ankle international, 24(3), 251-5. https://doi.org/10.1177/107110070302400309
2007Alshami et al. (2007). Biomechanical evaluation of two clinical tests for plantar heel pain: the dorsiflexion-eversion test for tarsal tunnel syndrome and the windlass test for plantar fasciitis. Foot & ankle international, 28(4), 499-505. https://doi.org/10.3113/FAI.2007.0499
2019Osborne et al. (2019). Muscle Function and Muscle Size Differences in People With and Without Plantar Heel Pain: A Systematic Review. The Journal of orthopaedic and sports physical therapy, 49(12), 925-933. https://doi.org/10.2519/jospt.2019.8588
2008Menz et al. (2008). Plantar calcaneal spurs in older people: longitudinal traction or vertical compression?. Journal of foot and ankle research, 1(1), 7. https://doi.org/10.1186/1757-1146-1-7
2022Drake et al. (2022). Medical imaging for plantar heel pain: a systematic review and meta-analysis. Journal of foot and ankle research, 15(1), 4. https://doi.org/10.1186/s13047-021-00507-2
2003DiGiovanni et al. (2003). Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. The Journal of bone and joint surgery. American volume, 85(7), 1270-7. https://doi.org/10.2106/00004623-200307000-00013
2006Digiovanni et al. (2006). Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. The Journal of bone and joint surgery. American volume, 88(8), 1775-81. https://doi.org/10.2106/JBJS.E.01281
2021Morrissey et al. (2021). Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values. British journal of sports medicine, 55(19), 1106-1118. https://doi.org/10.1136/bjsports-2019-101970
2023Lourenço et al. (2023). Efficacy of pharmacological and non-pharmacological therapies on pain intensity and disability for plantar fasciitis: a systematic review and meta-analysis. British journal of sports medicine, 57(23), 1516-1521. https://doi.org/10.1136/bjsports-2022-106403
2023Riel et al. (2023). Does a corticosteroid injection plus exercise or exercise alone add to the effect of patient advice and a heel cup for patients with plantar fasciopathy? A randomised clinical trial. British journal of sports medicine, 57(18), 1180-1186. https://doi.org/10.1136/bjsports-2023-106948
2024Heide et al. (2024). Is radial extracorporeal shock wave therapy (rESWT), sham-rESWT or a standardised exercise programme in combination with advice plus customised foot orthoses more effective than advice plus customised foot orthoses alone in the treatment of plantar fasciopathy? A double-blind, randomised, sham-controlled trial. British journal of sports medicine, 58(16), 910-918. https://doi.org/10.1136/bjsports-2024-108139
2021Rasenberg et al. (2021). Custom insoles versus sham and GP-led usual care in patients with plantar heel pain: results of the STAP-study - a randomised controlled trial. British journal of sports medicine, 55(5), 272-278. https://doi.org/10.1136/bjsports-2019-101409
2015Rathleff et al. (2015). High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scandinavian journal of medicine & science in sports, 25(3), e292-300. https://doi.org/10.1111/sms.12313
2019Whittaker et al. (2019). Corticosteroid injection for plantar heel pain: a systematic review and meta-analysis. BMC musculoskeletal disorders, 20(1), 378. https://doi.org/10.1186/s12891-019-2749-z
2019Rasenberg et al. (2019). Incidence, prevalence, and management of plantar heel pain: a retrospective cohort study in Dutch primary care. The British journal of general practice : the journal of the Royal College of General Practitioners, 69(688), e801-e808. https://doi.org/10.3399/bjgp19X706061
2018Nahin (2018). Prevalence and Pharmaceutical Treatment of Plantar Fasciitis in United States Adults. The journal of pain, 19(8), 885-896. https://doi.org/10.1016/j.jpain.2018.03.003
2023Gulle et al. (2023). Predicting the outcome of plantar heel pain in adults: a systematic review of prognostic factors. Journal of foot and ankle research, 16(1), 28. https://doi.org/10.1186/s13047-023-00626-y
2018Whittaker et al. (2018). Foot orthoses for plantar heel pain: a systematic review and meta-analysis. British journal of sports medicine, 52(5), 322-328. https://doi.org/10.1136/bjsports-2016-097355
2018Bishop et al. (2018). Custom foot orthoses improve first-step pain in individuals with unilateral plantar fasciopathy: a pragmatic randomised controlled trial. BMC musculoskeletal disorders, 19(1), 222. https://doi.org/10.1186/s12891-018-2131-6
2023Guimarães et al. (2023). Effects of therapeutic interventions on pain due to plantar fasciitis: A systematic review and meta-analysis. Clinical rehabilitation, 37(6), 727-746. https://doi.org/10.1177/02692155221143865

Mapped to this pattern

Generic measures that also apply

Related: achilles tendinopathy

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