Plantar Fasciitis

A runner sits on the exam table with his right shoe off and tells Dr. Alex Movshis the first steps out of bed feel like stepping on a tack. It started two months ago, when his long runs crossed 16 miles. His goal marathon is a few weeks away. He wants a cortisone shot, and he wants it today.

That visit is why this page is built around a decision instead of a definition. Plantar fasciitis accounts for roughly a million physician visits a year in the United States (Riddle 2004), and most of them circle the same question: should I get an injection, and if so, which one and when? The answer depends on whether the pain is really coming from the plantar fascia and on what you need your foot to do over the next few months.

First, is it the plantar fascia?

Classic plantar fasciitis hurts at the inside-bottom of the heel, at the medial calcaneal tubercle, where the fascia anchors to bone. The pain is worst on the first steps in the morning or after sitting, eases as you walk, and creeps back after a long day on your feet. One-finger pressure on that spot reproduces it. Pulling the big toe up toward the shin (the windlass test) often does too.

The name misleads. In 50 surgical specimens from chronic cases, Lemont and colleagues found myxoid degeneration and fragmented collagen rather than inflammatory cells (Lemont 2003). Established plantar fasciitis behaves like a degenerative tendinopathy. Keep that in mind for the injection decision, because cortisone is an anti-inflammatory aimed at tissue that is mostly not inflamed.

Ultrasound adds what the exam cannot. Across 23 imaging studies, people with chronic plantar heel pain had a fascia 2.16 mm thicker than controls, and a thickness above 4.0 mm was strongly associated with the diagnosis (McMillan 2009). Ultrasound also shows darker, disorganized (hypoechoic) fascia, partial tears and fluid, and it measures the heel fat pad. What thickness does not do is predict who recovers. In a Danish cohort of 174 patients followed for a mean of almost nine years after diagnosis, baseline fascia thickness and the presence of a heel spur had no effect on prognosis (Hansen 2018). He uses thickness to support the diagnosis, not to decide who needs a needle.

Heel pain that isn’t plantar fasciitis

A good share of the patients who reach Modal Pain after months of “failed plantar fasciitis treatment” never had plantar fasciitis. Plantar and medial heel pain has a short list of mimics, most of them driven by repetitive microtrauma or nerve compression, and several need a different procedure entirely (Lareau 2014).

Baxter’s neuropathy. The first branch of the lateral plantar nerve runs between the abductor hallucis and quadratus plantae muscles, just in front of where the fascia attaches. When it’s compressed, the heel burns instead of stabbing, the pain ignores the first-step pattern, and tapping over the nerve reproduces it. An ultrasound-guided diagnostic nerve block settles it: if the heel goes quiet while the anesthetic is working, the nerve is the likely source. The nerve side of this is covered on our peripheral nerve entrapment page.

Tarsal tunnel syndrome. The tibial nerve gets compressed behind the inner ankle bone. Expect burning, tingling or numbness across the sole, sometimes into the toes, worse after standing. Same diagnostic logic, same block.

Calcaneal stress fracture. This is the runner’s mimic. Pain builds through the day and through each run instead of easing, squeezing the heel from both sides hurts, and the training log usually shows a recent jump. It needs imaging, protected loading and no injection.

Heel fat pad syndrome. Pain sits in the center of the weight-bearing heel, worse barefoot on hard floors, and the pad feels thin or soft. A 2022 scoping review concluded it may be the second most common cause of plantar heel pain, while noting how small the research base is (Chang 2022). Ultrasound measures the pad. A steroid next to an already thin fat pad is the wrong move.

S1 radiculopathy. An irritated S1 nerve root can refer pain to the heel and outer foot. Back or buttock pain, calf weakness, a reduced ankle reflex and heel pain that’s worse sitting point to the spine. That’s sciatica, and it gets treated at the spine.

Insertional Achilles tendinopathy. Pain at the back of the heel, not the bottom. Different tendon, different loading program, covered under sports medicine.

If burning, numbness, back symptoms, or pain that worsens with every mile is part of your story, the plantar fascia is not the first suspect, and nobody should be injecting it yet.

The injection decision: PRP, cortisone, or neither

Here is the decision the way Dr. Movshis makes it in the room.

When the answer is neither, yet

An injection doesn’t cure plantar fasciitis. It buys a window in which rehab can work. If you haven’t put in several weeks of plantar fascia-specific stretching and progressive calf strengthening, that’s where we start, because both have randomized evidence behind them (DiGiovanni 2003, Rathleff 2015). He also holds off when the exam points to a mimic, when ultrasound shows a partial tear, or when the fat pad is already thin.

He is also blunt about the timeline. In the Hansen cohort, the estimated chance of still having plantar fasciitis was 80.5% one year after symptoms began, and 46% of patients still had symptoms at a mean of almost ten years from onset (Hansen 2018). Those were hospital-referred patients, so they lean toward stubborn cases, but the “resolves in a few weeks” line doesn’t hold up against long-term follow-up. Plan for months, not weeks.

When cortisone is reasonable, and what it costs you

Cortisone (a corticosteroid) is the older, faster option, and its trial record is less flattering than its reputation. A meta-analysis of 47 trials found steroid beat autologous blood injection and foot orthoses for short-term pain but was not clearly better than a placebo injection, and PRP beat it in the longer term (Whittaker 2019). The Cochrane review landed in the same place: compared with placebo or no treatment, steroid may slightly reduce heel pain for up to a month, with no difference after that (David 2017).

The risk that matters is rupture. In one Atlanta series of 765 heel pain patients, 51 had a plantar fascia rupture and 44 of those followed a steroid injection. Of the 122 patients the authors injected themselves, 12 ruptured. At an average of 27 months, half of the rupture patients they re-examined had fair or poor results, with new arch strain, midfoot pain and lateral plantar nerve symptoms replacing the original heel pain (Acevedo 1998). Other series run lower. A chart review of 120 injected patients reported a 2.4% rupture rate (Kim 2010). In a Korean comparison of 35 ruptures against 251 patients without one, steroid injection was the only risk factor that stood out, with an odds ratio of 33, and 33 of the 35 ruptured fasciae had been injected (Lee 2014).

So Dr. Movshis’s criteria for cortisone are narrow. The diagnosis is confirmed on ultrasound. There’s no partial tear and the fat pad is normal. Pain is blocking the rehab, and the patient needs a few weeks of relief and understands it’s temporary. Then it’s one injection under ultrasound, not a series, done through our joint and soft tissue injection service.

Why PRP comes first for chronic heel pain

For heel pain that has lasted months despite a real rehab effort, platelet-rich plasma is the injection Dr. Movshis offers first. PRP is your own blood, spun in the office to concentrate the platelets, then injected into the thickened fascia under ultrasound. The rationale is that platelet growth factors drive a repair response in degenerated tissue. That mechanism is plausible. It has not been proven in patients.

The head-to-head trials are why he leads with it. A 2025 meta-analysis of 24 randomized trials and 1,653 patients found PRP gave better pain scores than steroid at 3 and 6 months, with no significant difference at 1 or 12 months (Zuo 2025). An earlier review of nine trials also favored PRP on pain from 1 to 12 months (Hurley 2020). The individual trials show the shape of it. In Monto’s 40-patient trial, AOFAS foot scores in the cortisone group rose from 52 to 81 at three months, then slid back to 58 at a year, while the PRP group went from 37 to 95 and was still at 92 at two years (Monto 2014). In a double-blind multicenter trial of 115 patients, steroid dropped pain fast and then plateaued, while PRP improved more slowly and finished lower at one year. At 12 months, 84.4% of PRP patients had improved by at least 25%, against 55.6% with steroid (Peerbooms 2019).

Now the part most PRP marketing leaves out. When a 2020 synthesis restricted itself to well-designed double-blind trials, the PRP advantage over steroid disappeared (Yu 2020). Placebo-controlled evidence is thin. In one double-blind trial, PRP and steroid both improved significantly at 3 weeks and 3 months, while saline did not (Mahindra 2016). PRP preparations also vary between clinics, which muddies every pooled number.

His position, stated plainly: for chronic plantar fasciitis, PRP has the better medium-term data against cortisone, and the rupture literature is a steroid literature (Lee 2014). That’s why he uses it first. It is not a guaranteed fix. Expect a sore heel for several days and no anti-inflammatory painkillers around the injection. The PRP aftercare page has the full schedule.

PRP vs cortisone at a glance

Why the needle goes in under ultrasound

The target is small, and it sits next to two things you don’t want to hit: the fat pad underneath and Baxter’s nerve in front. A palpation-guided injection aims at the tender spot and hopes. A meta-analysis of five randomized trials (149 patients) found ultrasound-guided steroid injection did better than palpation-guided injection on pain, response rate and fascia thickness afterward (Li 2014). A 2025 update was more cautious, finding better pressure-pain tolerance and more fascia thinning with ultrasound but no significant difference in pain scores (Doan 2025).

The outcome edge is modest. The precision argument is stronger: under ultrasound Dr. Movshis watches the needle tip enter the fascia and the medication spread inside it, and keeps steroid away from the fat pad and the nerve. In Hansen’s cohort, patients who’d had an ultrasound-guided steroid injection had the same fat pad thickness years later as those who hadn’t (Hansen 2018). That’s observational, but reassuring.

Heel pain in runners

Plantar fasciitis was the third most common diagnosis in a Vancouver sports medicine clinic’s analysis of 2,002 running injuries, behind patellofemoral pain and IT band syndrome (Taunton 2002). If your knee is the problem instead, start with knee pain after running or the IT band syndrome page.

Dr. Movshis’s first question for a runner is always what changed. A new marathon block, longer long runs, added hill repeats, track work, a different shoe, more hours standing at work. Something increased the load on the fascia faster than the tissue adapted.

The famous 10% rule is weaker than its fame. In 874 novice runners tracked with GPS watches, injury rates didn’t differ cleanly between those who increased weekly distance by under 10%, 10 to 30%, or more than 30%. Runners who jumped more than 30% over two weeks trended toward more distance-related injuries, a group that did not include plantar fasciitis, and even that trend fell short of statistical significance (Nielsen 2014). Treat any percentage rule as a rough guardrail. The better signal is your heel the next morning.

Calf flexibility is the modifiable risk factor with the strongest signal. In a matched case-control study, people with ankle dorsiflexion of zero degrees or less had 23 times the odds of plantar fasciitis compared with those above ten degrees. A body-mass index over 30 (odds ratio 5.6) and spending most of the workday on your feet (odds ratio 3.6) were independent risks (Riddle 2003). For runners, a stiff calf-Achilles complex is the one you can do something about this week.

On shoes and inserts, expectations should be modest. In a 135-person randomized trial, prefabricated and custom orthoses produced similar small short-term gains in function, and neither beat a sham insert at 12 months (Landorf 2006). We don’t send runners for custom orthotics as a first step. Low-Dye taping is more useful during a race build than people assume. A 2026 meta-analysis of 11 trials found it reduced pain compared with control but did not beat other active treatments, so it works best as an add-on (Zhang 2026).

Should you get a cortisone shot before a marathon?

This question comes up in the weeks before almost every goal race. Here is Dr. Movshis’s rule.

If you can finish your long run and your heel is no worse the next morning than it was the morning before, you don’t need a shot. Taper, tape, keep up the heel raises and the morning stretch, and race.

If the only way you reach the start line is with a cortisone shot, he won’t give one in the run-up to a marathon. The benefit over placebo is small and lasts about a month at best (David 2017, Whittaker 2019). Steroid is the dominant risk factor for rupture (Lee 2014), and in the Atlanta series most ruptures announced themselves as a sudden tearing at the heel (Acevedo 1998). A marathon is hours of repetitive impact on fascia that was just injected. Nobody has run a trial of pre-race injection timing, so this is clinical judgment, and he would rather you defer a race than tear a fascia.

PRP won’t rescue race day either. Its advantage shows up at 3 to 6 months (Zuo 2025), and the heel is sore for several days afterward. For a chronic heel, the right time for PRP is after the race, when you can take the reduced-mileage weeks the rehab needs.

One more rule. If the pain builds during runs instead of easing, or squeezing your heel hurts, stop and get imaged before race day. That pattern is a stress fracture until proven otherwise, and racing on one turns a short layoff into a long one.

Return-to-run criteria

No trial has validated a return-to-run test for plantar fasciitis. These are the criteria Dr. Movshis uses, built on the next-morning response:

• You walk a full day without limping, and first-step pain is clearly better than it was.
• Single-leg heel raises with a rolled towel under the toes, done slowly, cause no heel pain during the set or the next morning.
• You can hop on the affected foot without pain.
• The first runs are easy run-walk intervals on flat ground, and you only add time when the next morning is no worse than baseline.
• Hills and speed work come back last, one at a time.

The rehab that does the real work

Two exercises carry most of the evidence. DiGiovanni’s trial randomized 101 patients with heel pain of at least ten months to plantar fascia-specific stretching or standard Achilles stretching. At eight weeks, the fascia-specific group did better on worst pain and on first-step pain (DiGiovanni 2003). Sit, cross the painful foot over the other knee, pull the toes back toward the shin until the arch goes taut, and hold. Do a set before your feet touch the floor in the morning and a few more through the day.

Strength adds speed. Rathleff’s group randomized 48 patients with ultrasound-confirmed plantar fasciitis to daily stretching or high-load single-leg heel raises with a towel under the toes every other day, both with shoe inserts. The strength group’s Foot Function Index was 29 points better at three months, though the groups were similar at 1, 6 and 12 months (Rathleff 2015). Heavy heel raises get you there faster, not further.

Our in-house physical therapy builds both into one progression with calf mobility, footwear review and a running plan, which is what turns an injection’s window into a lasting result.

Shockwave and surgery: where we refer

Extracorporeal shockwave therapy (ESWT) is not something Modal Pain offers. We refer for it, and it’s a reasonable alternative for patients who would rather not have a needle. In a 250-patient placebo-controlled trial, three weekly sessions of focused shockwave reduced a composite heel pain score by 69.2%, against 34.5% with placebo, with overall success rates between 50% and 65% (Gollwitzer 2015). Temporary pain and swelling were the only device-related side effects.

Surgical release of the plantar fascia is the last step, for disabling pain after a long, honest non-operative course. A release deliberately does what a rupture does by accident, cutting the fascia’s tension on the arch, which is a big reason it sits at the end of the line. When it’s the right answer, we refer to a foot-and-ankle surgeon.

What a heel pain visit at Modal Pain looks like

The first visit covers the history and a foot and back exam. Ultrasound of the heel is added when the diagnosis or an injection decision depends on it, and a guided injection is scheduled when it is the right call. If a nerve looks like the source, the next step is a diagnostic block.

Dr. Alex Movshis is dual board-certified in Anesthesiology and Pain Medicine and completed an ACGME-accredited interventional pain medicine fellowship at the Icahn School of Medicine at Mount Sinai (NPI 1942741160). The office is at 369 Lexington Avenue, Floor 25, New York, NY 10017, with same-week appointments.

A sudden pop under the heel followed by bruising and a flattened-feeling arch needs to be seen promptly, not in a few weeks. Fever with a red, hot, swollen foot is not plantar fasciitis. Call 911 or go to the nearest emergency room.

If your heel has been hurting for more than a few weeks, or you have a race on the calendar and an injection decision to make, book a visit and bring the shoes you run in.

References

• Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int. 2004;25(5):303–10. doi:10.1177/107110070402500505 · PubMed
• Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003;93(3):234–7. doi:10.7547/87507315-93-3-234 · PubMed
• McMillan AM, Landorf KB, Barrett JT, Menz HB, Bird AR. Diagnostic imaging for chronic plantar heel pain: a systematic review and meta-analysis. J Foot Ankle Res. 2009;2:32. doi:10.1186/1757-1146-2-32 · PubMed
• Hansen L, Krogh TP, Ellingsen T, Bolvig L, Fredberg U. Long-Term Prognosis of Plantar Fasciitis: A 5- to 15-Year Follow-up Study of 174 Patients With Ultrasound Examination. Orthop J Sports Med. 2018;6(3):2325967118757983. doi:10.1177/2325967118757983 · PubMed
• Lareau CR, Sawyer GA, Wang JH, DiGiovanni CW. Plantar and medial heel pain: diagnosis and management. J Am Acad Orthop Surg. 2014;22(6):372–80. doi:10.5435/JAAOS-22-06-372 · PubMed
• Chang AH, Rasmussen SZ, Jensen AE, Sørensen T, Rathleff MS. What do we actually know about a common cause of plantar heel pain? A scoping review of heel fat pad syndrome. J Foot Ankle Res. 2022;15(1):60. doi:10.1186/s13047-022-00568-x · PubMed
• DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am. 2003;85(7):1270–7. doi:10.2106/00004623-200307000-00013 · PubMed
• Rathleff MS, Mølgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scand J Med Sci Sports. 2015;25(3):e292–300. doi:10.1111/sms.12313 · PubMed
• Whittaker GA, Munteanu SE, Menz HB, Bonanno DR, Gerrard JM, Landorf KB. Corticosteroid injection for plantar heel pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2019;20(1):378. doi:10.1186/s12891-019-2749-z · PubMed
• David JA, Sankarapandian V, Christopher PR, Chatterjee A, Macaden AS. Injected corticosteroids for treating plantar heel pain in adults. Cochrane Database Syst Rev. 2017;6(6):CD009348. doi:10.1002/14651858.CD009348.pub2 · PubMed
• Acevedo JI, Beskin JL. Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int. 1998;19(2):91–7. doi:10.1177/107110079801900207 · PubMed
• Kim C, Cashdollar MR, Mendicino RW, Catanzariti AR, Fuge L. Incidence of plantar fascia ruptures following corticosteroid injection. Foot Ankle Spec. 2010;3(6):335–7. doi:10.1177/1938640010378530 · PubMed
• Lee HS, Choi YR, Kim SW, Lee JY, Seo JH, Jeong JJ. Risk factors affecting chronic rupture of the plantar fascia. Foot Ankle Int. 2014;35(3):258–63. doi:10.1177/1071100713514564 · PubMed
• Zuo A, Gao C, Jia Q, et al. Platelet-Rich Plasma Versus Corticosteroids in the Treatment of Plantar Fasciitis: A Systematic Review and Meta-analysis. Am J Phys Med Rehabil. 2025;104(7):613–621. doi:10.1097/PHM.0000000000002677 · PubMed
• Hurley ET, Shimozono Y, Hannon CP, Smyth NA, Murawski CD, Kennedy JG. Platelet-Rich Plasma Versus Corticosteroids for Plantar Fasciitis: A Systematic Review of Randomized Controlled Trials. Orthop J Sports Med. 2020;8(4):2325967120915704. doi:10.1177/2325967120915704 · PubMed
• Monto RR. Platelet-rich plasma efficacy versus corticosteroid injection treatment for chronic severe plantar fasciitis. Foot Ankle Int. 2014;35(4):313–8. doi:10.1177/1071100713519778 · PubMed
• Peerbooms JC, Lodder P, den Oudsten BL, Doorgeest K, Schuller HM, Gosens T. Positive Effect of Platelet-Rich Plasma on Pain in Plantar Fasciitis: A Double-Blind Multicenter Randomized Controlled Trial. Am J Sports Med. 2019;47(13):3238–3246. doi:10.1177/0363546519877181 · PubMed
• Yu T, Xia J, Li B, Zhou H, Yang Y, Yu G. Outcomes of platelet-rich plasma for plantar fasciopathy: a best-evidence synthesis. J Orthop Surg Res. 2020;15(1):432. doi:10.1186/s13018-020-01783-7 · PubMed
• Mahindra P, Yamin M, Selhi HS, Singla S, Soni A. Chronic Plantar Fasciitis: Effect of Platelet-Rich Plasma, Corticosteroid, and Placebo. Orthopedics. 2016;39(2):e285–9. doi:10.3928/01477447-20160222-01 · PubMed
• Li Z, Xia C, Yu A, Qi B. Ultrasound- versus palpation-guided injection of corticosteroid for plantar fasciitis: a meta-analysis. PLoS One. 2014;9(3):e92671. doi:10.1371/journal.pone.0092671 · PubMed
• Doan HN, Choo YJ, Chang MC. Comparison of Effectiveness Between Ultrasound-Guided and Blind Corticosteroid Injections in Plantar Fasciitis: A Systematic Review and Meta-Analysis. Life (Basel). 2025;15(7):1107. doi:10.3390/life15071107 · PubMed
• Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002;36(2):95–101. doi:10.1136/bjsm.36.2.95 · PubMed
• Nielsen RØ, Parner ET, Nohr EA, Sørensen H, Lind M, Rasmussen S. Excessive progression in weekly running distance and risk of running-related injuries: an association which varies according to type of injury. J Orthop Sports Phys Ther. 2014;44(10):739–47. doi:10.2519/jospt.2014.5164 · PubMed
• Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for Plantar fasciitis: a matched case-control study. J Bone Joint Surg Am. 2003;85(5):872–7. doi:10.2106/00004623-200305000-00015 · PubMed
• Landorf KB, Keenan AM, Herbert RD. Effectiveness of foot orthoses to treat plantar fasciitis: a randomized trial. Arch Intern Med. 2006;166(12):1305–10. doi:10.1001/archinte.166.12.1305 · PubMed
• Zhang L, Chen L, Zhang X, Chen J, Luo Y. Effectiveness of low-dye taping in the treatment of patients with plantar fasciitis: A systematic review and meta-analysis. Medicine (Baltimore). 2026;105(8):e46770. doi:10.1097/MD.0000000000046770 · PubMed
• Gollwitzer H, Saxena A, DiDomenico LA, et al. Clinically relevant effectiveness of focused extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: a randomized, controlled multicenter study. J Bone Joint Surg Am. 2015;97(9):701–8. doi:10.2106/JBJS.M.01331 · PubMed