The first-step pain is the diagnosis. Sharp pain under the inner heel with the first few steps out of bed, easing after a few minutes’ walking, returning after sitting, and returning at the end of a long day is the classic pattern.

It is not really an “-itis”. Despite the name, the problem is wear and tiny tears where the band of tissue attaches to your heel bone, rather than true inflammation. That is why resting alone rarely fixes it, and why gently using and strengthening the foot matters.

It is common — around 1 in 10 adults at some point, most often between 40 and 60, and one of the leading causes of training-limiting heel pain in runners.

More than 90% of people settle without surgery, usually within 6 to 12 months of structured treatment. It can take time, but lots of things can help speed this up.

Treatment works in phases, not all at once. The things you do yourself come first, then physiotherapy and shockwave treatment, then an injection if you need one — and each stage needs a fair trial of at least 6 to 12 weeks before moving on. Doing everything at once can aggravate it.

The heel spur is not the problem. Spurs are common incidental findings and are not the cause of pain in the vast majority of patients.

Tight calves are the most consistent risk factor — and in stubborn cases, the reason nothing else is working.

Plantar fasciitis is the most frequent cause of heel pain in adults. It affects roughly 1 in 10 adults at some point in life and accounts for around a million GP and specialist consultations in the UK each year.

It is most common between the ages of 40 and 60, but is also seen frequently in younger people who run, dance or play high-impact sport, as an overuse injury. It is common too in people who spend long hours on their feet — healthcare workers, teachers, retail and hospitality staff — and in anyone who has recently increased their walking after starting a new fitness routine.

Typical of plantar fasciitis:

• Sharp pain under the heel, usually on the inner side, where the band attaches
• First-step pain in the morning or after sitting
• Pain that eases with walking, then returns later in the day
• Pain after running or long walks
• Tenderness when you press on the inner part of your heel
• A persistent feeling of tightness in the calf and arch

Red flags — not typical, and worth a specialist assessment:

• Numbness, pins and needles or burning spreading into the foot — this can mean a nerve is being squeezed, such as Baxter’s nerve or tarsal tunnel syndrome
• Night pain, or constant and worsening pain at rest — a small stress fracture in the heel bone needs to be ruled out, particularly in runners
• A sudden pop with immediate severe pain, swelling or bruising — may indicate a plantar fascia tear
• Pain at the back of the heel rather than underneath — this is Achilles-related, not plantar fascia
• Pain in both heels in a younger person, along with morning stiffness in other joints — occasionally the first sign of an inflammatory type of arthritis
• Fever, or pain failing to improve with appropriate treatment — rarely, infection or tumour

These matter because standard plantar fasciitis advice will not help them, and months can be lost applying it to the wrong diagnosis.

In most cases, no. The diagnosis is made from your symptoms and an examination. Scans are kept for cases where the pattern is unusual, where symptoms carry on despite the right treatment, or where something else may be causing the pain.

Ultrasound is the first-line test. It is quick, radiation-free and shows the fascia directly — if the band is thicker than about 4 mm, that supports the diagnosis. It also helps guide injections and shows whether the band is partly or fully torn.

MRI is reserved for persistent symptoms or diagnostic uncertainty. It shows the fascia, surrounding soft tissue and the heel bone in detail, and it picks up stress fractures, swelling inside the bone and squeezed nerves.

A standing X-ray is not needed to make the diagnosis, but it can rule out other bone problems that cause heel pain.

Blood tests may be requested where the pattern is atypical, affects both heels, or comes with other joint symptoms, to look for types of arthritis that cause inflammation where tissue attaches to bone.

It is worth knowing how strong the evidence is behind each rung of that ladder, because heel pain is a large commercial market and the claims made for some treatments outrun the data.

The basics do more work than people expect. In a Norwegian study, 200 patients all received advice plus made-to-measure insoles. They were then split at random into four groups: one added shockwave treatment, one a dummy version of shockwave, one a supervised twelve-week exercise programme, and one nothing further. At six months there was no meaningful difference between any of the groups.

The interpretation is not that shockwave and exercise are useless — it is that the basic package of advice plus insoles was doing most of the work. Which is precisely why Phase 1 deserves a proper six weeks rather than a fortnight.

Strengthening may be quicker than stretching alone. One study compared stretching the arch with a strengthening exercise — heel raises with a towel rolled under the toes, done every other day. The strengthening group were noticeably more able to get on with things at three months; by six and twelve months the two groups were the same. So progressive strengthening may get you comfortable sooner, but both routes arrive at a similar place within a year.

Shockwave: supported, but not a shortcut. NICE supports ESWT in chronic plantar fasciitis, and several reviews pooling the results of many studies report a real benefit — one rated the evidence for a large improvement in pain and function as high quality, and another found a big reduction in pain compared with dummy treatment or standard care. Set against that, the four-arm trial above found no benefit over advice and insoles alone. The reasonable reading is that shockwave has a genuine role in stubborn cases that have not responded to several months of basic measures — which is exactly where the algorithm puts it — but it is not a substitute for the groundwork, and it should not be sold as a first step.

Steroid injection: useful, but not a cure. A review pooling 47 studies and 2,989 patients found steroid injection worked better in the short term than some other treatments, including injections of the patient’s own blood, insoles and physiotherapy. But compared with a dummy injection, it was no better for pain in the short or medium term, and when the least reliable studies were left out, no clear advantage remained. In the longer term it did worse than dry needling, and worse than platelet-rich plasma (PRP) injections. This does not make injection pointless. It makes it what the algorithm already calls it: a selective Phase 3 tool for breaking a severe pain cycle so that rehabilitation can proceed — not a treatment that fixes the underlying problem, and not something to repeat freely.

Platelet-rich plasma. A review of ten studies with 543 patients found PRP gave better pain scores than a steroid injection at three and six months. The studies vary in quality and prepare PRP in different ways, so this is promising rather than proven. It is not a first-line treatment, and availability and cost vary.

Surgery for plantar fasciitis is uncommon and should be. It is considered only after a comprehensive trial of non-surgical care — typically at least 6 to 12 months through Phases 1 to 3 — and only for persistent, disabling pain with a secure diagnosis.

Which of these is right for you depends on your examination, your scans, and a full discussion of the risks, the benefits and the recovery involved. One point worth holding onto: “failed treatment” and “failed diagnosis” look identical from the outside. Before an operation, it is worth confirming that what is being treated is actually plantar fasciitis.