Plantar fasciitis (heel pain): why does it happen, how does it resolve?

Short answer

Plantar fasciitis is the most common cause of heel pain in adults. The typical finding: a sharp pain in the inner-lower part of the heel on the first steps in the morning or after prolonged sitting. The good news is this: most cases resolve without surgery, with conservative treatment. The core treatment is stretching (plantar fascia + calf), load management, appropriate footwear/insoles, and progressively high-load strengthening.

Two important points: (1) The "heel spur" often seen on X-ray is usually not the cause of the pain — it is also found in people without pain. (2) Recovery requires patience; plantar fasciitis resolves in most people within 6–18 months, but adherence to regular exercise and load management during this process is decisive.

Why does it happen?

The plantar fascia is a strong connective-tissue band that extends from the heel to the toes and supports the sole of the foot. With excessive and sudden loading (running, occupations requiring prolonged standing), weight gain, tightness of the calf muscles, and reduced ankle movement, a load-related strain develops in this tissue. The classic "first-step pain in the morning" is the typical sign of this picture.

Treatment: gradual and conservative

First step (sufficient in most patients):

Stretching: Plantar-fascia-specific stretching and calf (gastrocnemius/soleus) stretching; it particularly reduces morning pain.
Load management: Activity that triggers the pain (long runs, hard surfaces barefoot) is temporarily modified.
Footwear and insoles: Supportive shoes and insoles, together with other treatments, reduce pain. Prefabricated (off-the-shelf) insoles work as well as expensive custom-made ones in most patients.

High-load strengthening: Slow-paced single-leg heel raises done with a towel placed under the toes (every other day) can accelerate recovery — in studies it produced faster improvement than stretching at 3 months (with similar long-term outcomes).

Refractory cases

In cases that do not improve despite an adequate duration (generally ≥6 months) of conservative treatment:

ESWT (shock wave therapy): In chronic/refractory plantar fasciitis (generally cases lasting ≥6 months and unresponsive to first-line treatment), it is the interventional option with the best evidence. Analyses pooling randomized placebo-controlled trials show that ESWT significantly improves success rate and pain in this group; the benefit is particularly evident in the short-to-medium term (e.g., ~3 months). Even so, the effect size is modest, long-term data are more limited, and the energy level/protocol affects the outcome. Being needle-free and non-surgical makes it a reasonable option that can be tried before surgery.
Corticosteroid injection: Provides only short-term (up to a few weeks) relief; it has risks — plantar fascia rupture and heel fat-pad atrophy (permanent, deep pain on the ground). For this reason it should be used in a limited and selective manner; it is not first-line.

Heel spur and imaging

The heel spur (calcaneal spur) often seen on X-ray is usually not the cause of the pain; it is also found in people without pain. Therefore the "let's remove the spur" approach is generally unnecessary. Routine imaging is also not needed — the diagnosis is largely clinical. Imaging is considered only in an atypical course, diagnostic uncertainty, or treatment resistance (for differential diagnoses such as stress fracture or nerve entrapment).

For clinicians

In terms of terminology, plantar fasciopathy/plantar heel pain is more accurate. First step: stretching + load management + footwear/insoles ± high-load strengthening (Rathleff 2015, early-phase advantage; similar to stretching at 12 months). In refractory cases, ESWT and selective corticosteroid. Differential diagnosis: calcaneal stress fracture, Baxter's nerve entrapment, seronegative enthesopathy. Telling the patient upfront that the recovery period is long (6–18 months) but the prognosis is good reduces the pursuit of unnecessary injection/surgery.

Frequently asked questions

My heel hurts a lot on the first step in the morning, then it eases — what is this?

This is the most typical finding of plantar fasciitis. A sharp heel pain on the first steps after long rest, which eases after a few steps. The diagnosis is usually made from this history and the examination; most people improve with stretching and load management.

Is heel-spur surgery necessary?

Usually no. The heel spur on X-ray is usually not the cause of the pain and is also seen in people without pain. Treatment focuses not on removing the spur, but on stretching, load management, and strengthening.

How long does it take to resolve?

It requires patience: plantar fasciitis resolves in most people within 6–18 months. The good news is that the prognosis is generally good. Adherence to regular stretching/strengthening and load management accelerates recovery.

Should I get a cortisone shot?

It is not the first option. It provides short-term relief but has risks such as plantar fascia rupture and heel fat-pad atrophy. It is considered only in a limited number of selected cases refractory to conservative treatment.

Which footwear/insoles help?

Supportive shoes that cradle the heel, and insoles, help reduce pain. Off-the-shelf (prefabricated) insoles work as well as expensive custom-made ones in most patients. Insoles provide benefit not on their own, but when used together with stretching and load management.

Can I keep running?

It is often possible to continue the activity by adjusting volume and surface so as not to trigger the pain. Load management and strengthening are preferred over complete rest; the plan is tailored to the individual.

Does shock wave therapy (ESWT) work?

In chronic and refractory plantar fasciitis (generally cases lasting more than 6 months and unresponsive to first-line treatment), the evidence for ESWT is relatively good: randomized trials show it significantly improves the success rate and pain, particularly in the short-to-medium term. It is needle-free and non-surgical; it is a reasonable option before surgery. However, it is not first-line — stretching, load management, and strengthening should be established first.

Scientific references

Rathleff MS et al. High-load strength training improves outcome in patients with plantar fasciitis: randomized controlled trial. Scand J Med Sci Sports 2015;25(3):e292-300.
Koc TA Jr, Bise CG, Neville C, Carreira D, Martin RL. Heel Pain–Plantar Fasciitis: Clinical Practice Guidelines (2023 revision). J Orthop Sports Phys Ther 2023;53(12):CPG1-39.
Morrissey D et al. Management of plantar heel pain: best practice guide. Br J Sports Med 2021.
Lou J et al. Is extracorporeal shock wave therapy clinically efficacious for chronic, recalcitrant plantar fasciitis? A systematic review and meta-analysis of randomized controlled trials. 2014 (7 studies, 550 patients; significant benefit in success and pain).
Sun J et al. Efficacy of different energy levels of focused and radial ESWT in plantar fasciitis: meta-analysis of randomized placebo-controlled trials. 2019 (high-energy ESWT superior at ~3 months).
Own opinion: press statements by Assoc. Prof. Dr. Oğuz Yüksel on plantar fasciitis.

This information is for general guidance only; it does not replace an examination, a diagnosis, or your physician's individual advice. Please consult a physician for your symptoms. About the author: Doç. Dr. Oğuz Yüksel — Academic Profile.