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Heel Pain, Is It Really Plantar Fasciitis?

Heel Pain, Is It Really Plantar Fasciitis?

By Reagan Ward, PT, DPT, OCS


Plantar fasciitis is one of the most commonly diagnosed conditions in the human foot, however, new research suggests that not every case of plantar heel pain is truly plantar fasciitis. In this article we will educate on the general anatomy of the foot and ankle, the purpose of our feet and plantar fascia. The difference between true plantar fasciitis and what is now known as “Heel Pain Syndrome” is explained. Our hope is that you gain greater understanding of what is causing the heel pain and how you can be rid of it for good through a proper foot and ankle evaluation from one of our licensed and trained Doctors of Physical Therapy. 

Before understanding the function of the foot, ankle and plantar fascia, you must appreciate the general anatomy. The foot and ankle is a complex unit of engineering and mechanics. The foot contains 26 small bones that are designed for weight bearing and force distribution. The bony alignment creates three arches to provide efficient weight distribution. The three arches: medial and lateral longitudinal, as well as the transverse arch, work together to create an architectural vault.  This complicated arch system is one of the strongest load bearing structures known to mankind. The plantar fascia is a thick, web like ligament on the bottom of the foot that connects from heel to forefoot and plays a crucial role in the load bearing arch of the foot. This support system is called the “windlass” mechanism, which is a tightening of a rope or cable, particularly in sailing to haul or lift something. The plantar fascia simulates a cable attached to the heel and forefoot. During an individual’s gait, the plantar fascia will tighten, causing a chain reaction in the arches of the foot to stabilize for proper  propulsion in the push-off phase during walking or running.

The plantar surface of the foot contains four layers of muscles and tendons which all play a critical role in foot and ankle function. An important muscle in the overall performance of the foot is the flexor digitorum brevis which flexes the toes and attaches on the heel near where the plantar fascia attaches.  New research and clinical expertise has shown that pain in this region is often due to the development of a tendinopathy at the attachment site of the flexor digitorum brevis muscle on the heel. Tendinopathy is also called tendinosis, and refers to the breakdown of collagen in the tendon tissue. This is result of a failed healing response after an injury or excessive overuse of a tendon. This condition is referred to as “Heel Pain Syndrome” and because of its’ proximity to the plantar fascia it is commonly misdiagnosed as plantar fasciitis. This syndrome could be caused by a number of different factors and comorbidities that are assessed in a proper foot and ankle exam.

When you hear tendon”itis”, this suffix “itis” denotes the presence of an inflammatory response in the injured tissue, such as with plantar fasciitis. Countless evidence and research now shows that many diagnosed with plantar fasciitis actually have minimal to no inflammatory cells evident in the tissue. What experts have found is that true plantar fasciitis will first be felt in the arch of the foot and will be extremely painful intermittently. It typically strikes after long periods of being non-weight bearing such as sitting followed by weight bearing activities like walking or the first step out of bed in the morning.