Plantar fasciitis — Rapid | Doctor’s Passport

Synopsis

Recognise the characteristic first-step medial heel pain of plantar fasciopathy, exclude stress fracture, nerve, inflammatory and malignant causes, and deliver progressive load, flexibility and footwear care without overusing imaging or injections.

The classic symptom is medial plantar heel pain on the first steps after waking or sitting, easing with initial movement and returning after prolonged standing, walking or running.
High-yield examination findings are tenderness at the medial calcaneal tubercle and reproduction with passive great-toe dorsiflexion or the windlass manoeuvre.
First-line investigation is clinical assessment; routine radiographs, ultrasound and MRI are unnecessary in a typical presentation without red flags.
Use radiographs or MRI for a suspected fracture, inflammatory disease, mass or atypical persistent pain; a calcaneal spur is common and does not prove the pain source.
First-line management combines plantar-fascia-specific and calf stretching, progressive calf and intrinsic-foot loading, temporary load adjustment and supportive footwear over several months.
A heel cup, taping, prefabricated insole or night splint can be trialled as an adjunct when it improves function, but no device replaces exercise and load progression.
Consider shockwave treatment for persistent well-localised symptoms after a credible rehabilitation programme; corticosteroid injection offers limited short-term benefit with rupture and fat-pad risks.
Refer when red flags, neurological findings, diagnostic uncertainty or major disability persists despite six to twelve months of well-supported non-operative care.

Key red flags

A fall, sudden training increase or osteoporosis risk with diffuse calcaneal squeeze pain and inability to bear weight suggests stress or acute fracture.

Fever, puncture wound, ulcer, spreading warmth or immune compromise requires urgent soft-tissue and calcaneal infection assessment.

Unremitting night pain, weight loss, palpable mass or previous cancer requires imaging for tumour rather than a plantar-fasciitis label.

Burning, paraesthesia, intrinsic weakness or a positive tarsal-tunnel nerve provocation suggests neurological heel pain.

Bilateral heel pain with prolonged morning stiffness, psoriasis, uveitis or inflammatory bowel disease suggests enthesitis within spondyloarthritis.

Investigation priorities

First-line clinical heel localisationFirst stepFirst line

Confirm characteristic timing and medial fascial-origin tenderness and screen fracture, nerve, inflammatory and systemic alternatives.

Management branches

First-lineMake a clinical diagnosis

First-step medial heel pain and focal fascial-origin tenderness occur without red flags.

Map pain precisely and reproduce it at the medial calcaneal origin with palpation and gentle windlass loading.
Check calcaneal squeeze, fat pad, Achilles, tarsal tunnel, ankle dorsiflexion, skin, sensation and pulses.
Explain the slow favourable course and avoid routine imaging or assigning causation to an incidental heel spur.
Agree walking, work or running outcomes and begin footwear, stretching and progressive loading care.

Key medicines

Topical diclofenac gelUse 2–4 g of diclofenac 1.16% gel over intact medial-heel skin at each application, up to three or four applications daily for a brief trial within the licensed maximum.Avoid broken or neuropathic uninspected skin and NSAID hypersensitivity, account for other NSAIDs and pregnancy, and stop if local dermatitis develops.

Short-course oral naproxen with protection when suitableIf symptoms prevent rehabilitation and risks are acceptable, use naproxen 250–500 mg orally twice daily with food briefly and add omeprazole 20 mg once daily during treatment when gastroprotection is indicated.Check gastrointestinal, renal, hepatic, blood-pressure and cardiovascular hazards, frailty and antithrombotic treatment; never combine NSAIDs, and apply the restrictions on use from 20 weeks of pregnancy.

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