Plantar fasciitis/heel spurs

Anatomy & Function of the Plantar Fascia

The plantar fascia is a strong, connective tissue band on the sole of the foot. It arises from the medial (inner) part of the heel bone and fans out towards the metatarsophalangeal joints of the toes. Together with the heel fat pad, the small foot muscles and the calf-Achilles tendon complex, it stabilizes the longitudinal arch of the foot.

• Shock absorption when stepping and jumping
• Stabilization of the longitudinal arch of the foot (windlass mechanism when rolling)
• Energy recovery for efficient walking and running
• Protection of nerves and vessels on the sole of the foot

If there is overload or unfavorable tension (e.g. if the calf muscles are shortened), micro-injuries occur at the tendon base. This leads to a painful irritation – plantar fasciitis.

Typical symptoms

• Start-up pain: stabbing with the first steps in the morning or after rest
• Pressure pain on the inside of the heel (medial plantar fascia insertion)
• Improvement after a short run-in, renewed increase with longer exposure
• Discomfort when standing for long periods, on hard floors or barefoot
• Sometimes radiating along the sole of the foot
• Occasionally bilateral; Tingling or numbness suggests nerve involvement

The heel spur visible on X-rays is not a reliable indicator of pain. Many people have a spur without any symptoms. Anamnesis and examination are crucial.

Causes & risk factors

In most cases, the tissue is overloaded - due to too much, too fast or unusual stress. Systemic inflammation is less common. Plantar fasciitis is more of a degenerative irritation than a classic inflammation.

• Sudden increase in training (e.g. running volume/pace, lots of jumping)
• Hard floors, unsuitable footwear, little cushioning or stability
• Foot shape: pronounced hollow foot or arched/flat foot pattern
• Shortened calf muscles, limited ankle dorsiflexion
• Being overweight and standing for long periods of time at work
• Forefoot and leg axis deviations, leg length differences
• Previous injuries or altered gait
• Less common: underlying inflammatory rheumatic diseases

Differentiation from other causes of heel pain

Not all heel pain is plantar fasciitis. A careful differential diagnosis prevents false conclusions and leads to appropriate therapy.

• Fat pad atrophy of the heel: dull, flat pain when standing/walking, less precise
• Ledderhose's disease: nodular hardening of the plantar aponeurosis, often palpable
• Stress fracture of the calcaneus: exertional pain with clear percussion/compression pain, often after peak training
• Baxter neuropathy (inferior calcaneal nerve): burning pain, possibly tingling
• Tarsal tunnel syndrome: nocturnal paresthesia, radiating along the tibial nerve
• Achilles tendon attachment problems (Haglund, insertion tendinopathy): dorsal heel pain
• Inflammatory-rheumatic causes of bilateral morning stiffness

Our examination helps to distinguish whether the plantar fascia is primarily affected or other structures are in the foreground.

Diagnostics in our practice

We combine anamnesis, clinical examination and – if appropriate – imaging. The goal is a clear diagnosis and an individual, everyday treatment concept.

• Anamnesis: onset of pain, stress profile, footwear, occupation, training, previous illnesses
• Examination: precise pressure pain at the medial plantar fascia attachment, Windlass test (toe dorsiflexion), Silfverskiöld test (calf shortening), gait analysis
• Sonography: thickened, hypoechoic plantar fascia, possibly reactive changes; dynamic assessment
• X-ray: may show heel spurs, but is of secondary importance for the diagnosis
• MRI: only in unclear cases or suspected alternative diagnoses (e.g. stress fracture)
• Warning signs (e.g. pain at rest, redness/warmth, trauma) are specifically clarified

Conservative therapy – the basis

Most patients manage without surgery. What is crucial is a consistent but measured stretching and stress program, suitable shoes/insoles and patience. The time frame for stabilization is often several weeks to months.

• Load adjustment: reduction of pain-provoking activities, maintenance of basic fitness through alternatives (cycling, swimming)
• Targeted stretching of the plantar fascia and calf muscles (gastrocnemius/soleus) several times a day
• Cool the painful area for 10-15 minutes, especially after exertion
• Short-term use of anti-inflammatory painkillers, if tolerated and discussed by a doctor
• Insoles/heel cups to relieve pressure on the medial heel base; If necessary, temporarily softer cushioning
• Taping (low-dye) to support the longitudinal arch
• Night splints are an option for severe morning pain
• Physiotherapy: manual therapy, mobilization of ankle dorsiflexion, gait/running style advice
• Weight management and everyday modifications (e.g. soft mats at work, more frequent position changes)
• Shoe advice: enough space, stability, moderate drop, good cushioning

Therapy success varies from person to person; there can be no guarantee. We accompany you closely and adapt the measures to your progress.

Regenerative and minimally invasive options

If there is no sufficient improvement after consistent basic therapy over 6-12 weeks, additional procedures can be considered. The selection is made based on indication, benefit-risk assessment and your goals.

• Extracorporeal shock wave therapy (ESWT): can stimulate tissue healing; Evidence level is moderate, often in series of 3–5 sessions
• PRP (autologous platelet-rich plasma): the body's own growth factors; Studies mixed, option for stubborn cases
• Cortisone injection: can reduce pain in the short term; Risk of fascia or fat pad damage, therefore cautious and targeted
• Ultrasound-assisted microfasciotomy/tenotomy: selective scar removal in therapy-resistant cases, decision made on a case-by-case basis
• Surgery (partial plantar fasciotomy): only rarely necessary, after long conservative therapy and careful information; Possible risks include lowering of the arch, nerve irritation and prolonged rehabilitation

We provide transparent information about expected effects, side effects and alternatives. Regenerative procedures do not replace active therapy, they can complement it.

Exercises & self-help – this is how you use your program

Regular, measured exercise is key. Increase slowly, stay below a well-tolerated pain threshold and carry out the exercises consistently.

• Seated plantar fascia stretch: foot over knee, pull toes with hand toward shin side, hold for 30-45 seconds, 3-5 repetitions per side, 2-3 times daily
• Calf stretch (gastrocnemius): while standing, hands on the wall, pain-side leg behind, heel on the floor, knee extended, hold for 30 seconds, 3-5 repetitions
• Calf stretch (soleus): same position, bend back knee slightly, hold for 30 seconds, 3-5 reps
• Fascia massage with ball/roller: Tennis or hedgehog ball under the sole of the foot, slowly roll it back and forth for 1-2 minutes, without causing sharp pain
• Towel Gripping/Toe Strength: Gather towel with toes, 2-3 sets of 10-15 reps, 3-4 times per week

Course, prognosis and relapse prevention

The process is individual. Many patients report noticeable relief within a few weeks if stretching, stress management and shoe/insole adjustment are consistently implemented. Complete stabilization may take months.

• Consistency beats intensity: it's better to use it moderately on a regular basis than rarely and too much
• Early return to high stress increases the risk of relapse
• Maintenance program (short daily stretches, appropriate shoes) prevents relapses
• When working under strain: soft surfaces, breaks, alternation of standing/sitting

Prevention: This keeps your heels resilient

• Increase training slowly and planned (10% rule)
• Regular stretching of the calves and plantar fascia
• change shoes on time; sufficient cushioning and stability
• Consider insoles/heel cups if you have known foot axis problems
• Weight management and varied exercise
• Warm up before, mobilization and gentle stretching after exercise

When should you seek medical advice?

• Severe pain that does not subside despite relief
• Pain at night at rest, fever, redness/overheating
• Acute trauma with significant swelling or sudden "snapping" in the sole of the foot
• Tingling/numbness or radiation – suspected nerve involvement
• Bilateral morning stiffness or other signs of inflammatory rheumatic disease
• Complaints for several weeks without improvement despite self-medication

Your orthopedics in Hamburg-Winterhude

We take the time for diagnostics, information and an easy-to-implement therapy plan. Our practice is centrally located at Dorotheenstraße 48, 22301 Hamburg. You can easily get appointments online via Doctolib or by email. If you wish, we can coordinate your exercise program with your physiotherapy.