Heel Spur & Plantar Fasciitis:
Stretching Instead of Injections

1. What is plantar fasciitis?

A tough fibrous band stretches beneath the sole of your foot from the heel bone to the base of the toes: the plantar fascia. It holds the longitudinal arch together and acts like a tension spring with every step. If it is overloaded over a long period, small areas of tissue damage develop where it attaches — that is plantar fasciitis, also known as plantar heel pain.^¹

The name is easily misleading: the ending “-itis” stands for inflammation, yet according to current knowledge what predominates in the tissue is degenerative remodelling. That explains two things: why anti-inflammatory injections do not solve the problem for good, and why adjusting the load and stretching are the load-bearing pillars.^¹,²

2. The heel spur: incidental finding, not cause

When a bony spur on the heel bone shows up on an X-ray, the matter seems settled: there is a thorn digging into the sole of the foot. That image is widespread — and as a rule it is wrong.

The heel spur is a calcification in the region of the tendon attachment, in other words the result of years of pull, not a sharp foreign body. What counts is an observation that imaging keeps repeating: a great many people have a heel spur without ever having had symptoms — and conversely, many people with typical plantar heel pain have no spur at all. So the finding correlates poorly with the pain.^¹,²

In everyday speech, “heel spur” nevertheless stands for the whole picture: if your practice uses the term, plantar heel pain is almost always what is meant.

3. Symptoms: start-up pain as the key sign

One pattern of symptoms is so typical that it often carries the diagnosis on its own: start-up pain.

• The first steps in the morning — the step out of bed is the worst of the day. After a few metres the pain eases.
• After sitting for a while — the same pattern after a car journey, a morning at a desk or a trip to the cinema.
• Pinpoint tenderness — on the inner side of the sole of the heel, where the fascia attaches; usually easy to find exactly with your thumb.
• Worse with loading — after long periods of standing, long walks or time on hard ground it gets worse towards the evening.
• Pull when the toes are lifted — raising the big toe tightens the fascia and intensifies the pain.

The pain sits under the heel, not behind it at the Achilles tendon. You will find help placing the possible causes under heel pain; if further joints are involved, it is worth a look at joint pain.

4. Causes and risk factors

In most cases there is no single trigger behind it, but a combination of loading and foot mechanics. The following count as risk factors:^¹,²

• A sudden increase in loading — more kilometres, more pace, a new sport or a job that involves long periods of standing. The classic: building training back up too quickly after a break.
• Shortened calf muscles — restricted movement at the ankle increases the pull on the fascia every time you roll through a step.
• Foot posture — pronounced flat, fallen or high arches alter the pull within the longitudinal arch.
• Body weight — every kilo counts several times over with every step; obesity is regarded as the most important modifiable factor.
• Footwear and ground — new or worn-out shoes, very flat soles, long periods barefoot, tarmac and concrete floors at work.
• Age — the fascia loses elasticity over the years.

5. Diagnosis: usually without imaging

Plantar fasciitis is a clinical diagnosis. That means the conversation and the examination are usually enough; an image is mostly not needed.^³

• History: start-up pain in the morning? Since when? Any changes in training, shoes, work or weight? Which medicines are you taking?
• Tender point: a clearly localised painful spot at the inner attachment of the fascia is the most important finding.
• Stretch test: passively lifting the toes tightens the fascia and intensifies the pain.
• Checking mobility: how far can the foot be pulled up with the knee straight? A shortened calf is one thing treatment can work on.
• Imaging only where needed: ultrasound can show a thickened fascia, while X-rays serve to rule out other causes such as a stress fracture.

So a visible heel spur on an X-ray is neither proof nor a treatment target, but an incidental finding. To prepare for the conversation: Prepare for a doctor’s appointment.

6. Treatment: what helps and what does not

In hardly any everyday orthopaedic problem is the gap between what is on offer and what the evidence supports as wide as in heel pain. So here is the sober overview, ordered by the strength of the evidence. The choice is always made by your treating practice together with you.^¹,³

7. The stretches in detail

Because stretching is the measure that carries the treatment, it is worth knowing how to do it. Two exercises form the core — one for the calf, one for the fascia. Both times what matters is: a pulling sensation, not pain, and better a short session every day than a long one once a week.

Calf stretch against the wall

1. Stand with both hands against a wall, the affected leg stretched out behind you, the other bent in front.
2. The rear heel stays on the floor and the toes point straight ahead.
3. Push your pelvis forwards until you feel a clear pull in the calf; hold for about 30 seconds.
4. Repeat with the rear knee slightly bent — that reaches the deeper calf muscle. Three rounds per side, two to three times a day.

Plantar fascia stretch while sitting

1. Sitting down, rest the affected foot across your other knee.
2. Slowly pull the toes towards your shin with your hand until you can feel the fascia beneath the sole as a taut band.
3. Hold for 30 seconds, breathing calmly. Three rounds are enough.
4. Particularly effective before the first steps in the morning — still on the edge of the bed, before you stand up. Also worth doing before getting up after sitting for a long time.

Add-ons that have proved their worth

• A massage roller under the sole — roll slowly from the ball of the foot to the heel for one to two minutes; it does not replace the stretching.
• Slow calf raises on a step — let the heel hang and lower it pointedly slowly; usually after the acute phase.
• Cooling after loading — 10 to 15 minutes, never directly on the skin. Eases things in the short term.

8. Insoles, shockwave therapy and injections

Insoles and night splints

Insoles take load off the tendon attachment and can make everyday life more bearable; in studies, off-the-shelf ones often do about as well as custom-made, so try a simple version first. Night splints hold the foot in a slight stretch and work above all against the start-up pain in the morning.^¹

Shockwave therapy

Extracorporeal shockwave therapy is offered frequently. The data are limited and inconsistent: some of those affected report improvement, but a reliable advantage over the basic treatment cannot be derived from that. Within the German statutory health insurance system it is as a rule not covered in outpatient care.^⁴

Cortisone injections: powerful short term, tricky long term

An injection of a glucocorticoid — from the same group as prednisolone, for instance — can damp the pain down markedly within a few days. The effect usually lasts only a few weeks, though, and a long-term advantage over the basic treatment has not been shown.^¹,³

Other injection procedures are offered as well; the evidence is limited and you usually pay for them yourself. Surgery only comes into question after many months of consistent conservative treatment.

9. Painkillers: only as a bridge

In heel pain, painkillers treat the symptom, not the cause. They make sense for bridging a painful phase or for getting the stretching programme started — not for carrying on as before while taking them.

One thing matters in sport: taking painkillers before training in order to “push through” is a bad idea here — the pain is the only reliable feedback you have about the limit of what the tissue can take (Medications and exercise).

10. Ruling things out: when it is not the fascia

Not every heel pain comes from the plantar fascia. These causes should be kept in mind, above all when the picture does not fit the typical start-up pain:^³

• Nerve-related causes: burning, tingling or numbness point to nerve irritation. In polyneuropathy the symptoms are usually on both sides, in a stocking distribution and worse at night.
• Pain referred from the back: sciatic pain runs from the buttock down the back of the leg into the foot and changes with the position of the trunk.
• Achilles tendon problems: the pain sits behind, at the tendon, not under the sole; the calf can be involved too, see calf pain.
• Stress fracture of the heel bone: after a sharp increase in loading, with pain at rest and tenderness from the sides — imaging makes sense here.
• Inflammatory rheumatic causes: a look at rheumatic disease is worthwhile if further joints, nail changes or back pain come into the picture.
• Heel fat pad syndrome: a thinned fat pad tends to cause more diffuse tenderness centrally under the heel.

Complaints at other tendon attachments — tennis elbow or calcific tendinitis of the shoulder, for example — follow a similar principle: managing the load and exercise therapy up front, injections as the exception.

11. Everyday life and prevention

• Not barefoot on hard floors — at home in the morning a cushioned slipper beats bare tiles.
• Shoes with a slight heel drop — a moderate rise at the heel takes load off the fascia; very flat or worn-out shoes are unhelpful.
• Increase loading in small steps — volume first, pace later, and only ever change one variable at a time. Switching to cycling and swimming keeps your fitness up.
• Weight as a lever — even a moderate reduction lowers the load with every step and has a favourable effect on the course.
• Write the course down — rate the pain of that first step once a week on a scale from 0 to 10. That number shows progress more reliably than gut feeling.

Stretch, record, stick with it — with brite

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