Plantar fasciitis or fasciopathy: what the evidence says

By Dr. Lizeth Ortiz Barboza · Published October 13, 2026

Fasciitis or fasciopathy?

The plantar fascia is a thick band of tissue that runs from the heel to the base of the toes and supports the arch of the foot. “Fasciitis” means inflammation of the fascia. But when tissue from people with months of pain is studied, something else shows up: disorganized collagen fibers, a thicker fascia, changes in the surrounding tissue and blood vessels, and few inflammatory cells.

That is why it is called fasciopathy: tissue that became disorganized because the load it receives exceeds what it can tolerate. The name matters because it changes the plan. If it were all inflammation, reducing it would be enough. In a chronic case, the tissue also needs to regain its capacity to bear load.

How it is diagnosed

The diagnosis is mainly clinical. The typical picture is:

• Pain on the inner side of the sole of the heel.
• Pain that is worse with the first steps after getting up or after sitting.
• Pain when pressing where the fascia attaches to the heel bone.

The exam checks how far the ankle bends upward, whether the calf is tight or shortened, the strength of the foot and ankle muscles, and how the foot lands. It also looks for what increases the load: more activity or sport, long hours standing, unsuitable footwear or weight gain.

Not every heel pain is the fascia. Other causes that are ruled out are a stress fracture of the calcaneus, heel fat pad syndrome, nerve entrapment, a plantar fibroma or other bone lesions.

What ultrasound can show

Ultrasound is not only for guiding the needle. In the plantar fascia it helps to see:

• Thickness. Near the heel, a fascia thicker than 4 mm is considered thickened; in people with chronic pain it is usually about 2 mm thicker than in people without pain.
• Darker areas (hypoechoic) and loss of the orderly fiber pattern.
• Changes where the fascia attaches to the bone (the enthesis) and, sometimes, more blood vessels on Doppler.

That information complements the exam, helps rule out other causes and, if an injection is done, lets the needle be seen at all times.

First, the foundation

An injection is not the first step. The most recent clinical practice guideline for heel pain recommends starting with load, tissue capacity and biomechanics:

• Education and adjusting everyday loads.
• Specific stretching of the plantar fascia and the calf.
• Progressive exercise and strengthening of the foot and ankle.
• Manual therapy or taping when indicated.
• Insoles or orthoses, and a night splint, in some patients.

The goal is not only less pain, but changing the mechanical environment that keeps the injury going. Many people improve with these measures alone.

When it does not improve: what the options are

Before considering an injection, it helps to answer:

• Is the diagnosis correct?
• Which mechanical factors are still loading the fascia?
• What changes are there in the tissue?
• Which treatments have already been tried, and how?
• Which intervention makes sense for this particular case?

The most studied options:

None is for everyone. The choice depends on how long the pain has lasted, the load on the foot, what the exam and ultrasound show, and what each patient wants. In every case, the injection goes along with exercise and load adjustment; it does not replace them.

In summary

Two slides by Dr. Lizeth Ortiz on this topic. The images in the second one are illustrations, not ultrasound scans of patients.

Slide 1 of 2Slide 2 of 2

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If your heel hurts

Heel pain explains how we assess it and which treatments we offer. More about each procedure: prolotherapy, platelet-rich plasma and ultrasound-guided injections.

Educational. It does not replace an individual medical evaluation. Results vary.

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