Plantar fasciitis is a common cause of pain under the inner heel. Pain with the first steps after rest is typical, but it is not unique to plantar fasciitis, and several other conditions can feel similar. In long-standing cases the term plantar fasciopathy is often used, because the tissue changes are not simply acute inflammation. At Novo Soft Tissue in the Denver Tech Center, care starts with an exam to determine what is causing the heel pain. When the presentation and your treatment history support it, focused or radial shockwave (ESWT) may be an option. Not every painful heel needs shockwave, and some need a different evaluation first.
Background
Plantar Fasciitis or Plantar Fasciopathy?
Plantar fasciitis is still the familiar name. In persistent cases, clinicians and researchers often say plantar fasciopathy, because long-standing pain can involve structural changes within the fascia, including thickening and altered collagen organization, rather than ongoing inflammation alone.
During the exam, we also assess tenderness, load tolerance, and surrounding soft-tissue restriction. Those findings help guide care, but they do not by themselves prove microscopic fibrosis, and fascia thickness alone does not show where the pain is coming from.
Does a Heel Spur Cause Plantar Fasciitis?
Heel (calcaneal) spurs are common on X-ray and can coexist with plantar heel pain, but a spur does not automatically identify the source of the pain. Spur size alone should not decide treatment. The goal of care is less pain and better function, not making a spur disappear on an X-ray.
Examination
What We Examine in Persistent Heel Pain
- Exact pain location, how long it has been present, and the first-step pattern
- How pain changes with activity, standing, and load
- Plantar fascia tenderness and load tolerance
- Ankle dorsiflexion, calf flexibility, and calf strength
- Foot and ankle function, and surrounding soft-tissue mobility
- Nerve symptoms such as burning, numbness, or tingling
- Footwear and training load, prior treatment, and how you responded to it
Differential diagnosis
Not All Heel Pain Is Plantar Fasciitis
Heel pain is a symptom, not a diagnosis. Conditions that can resemble plantar fasciitis include:
- Heel fat-pad irritation, often felt in the center of the heel
- Irritation or entrapment of a small nerve near the inner heel (Baxter's nerve), or tarsal tunnel symptoms
- A calcaneal stress injury
- Insertional Achilles tendon pain at the back of the heel
- Pain behind the inside ankle bone or along the arch toward the midfoot, which may point to posterior tibial tendinopathy
- Pain referred from the back or nerves and, when the history suggests it, inflammatory or systemic conditions
Burning, numbness or tingling, significant night pain, a recent injury, marked swelling, or pain in an unusual location change the evaluation and may call for imaging or referral.
Treatment selection
Why Diagnosis Comes Before Shockwave
Many people improve with load modification, calf and plantar fascia stretching, progressive exercise, taping, footwear changes, orthoses, or other conservative care. When heel pain persists despite an appropriate trial of care, the next step is to confirm the diagnosis and decide whether another intervention, such as ESWT, fits.
The research supports shockwave for selected cases of persistent plantar fasciopathy, and the positive trials enrolled patients who met defined diagnostic criteria. Shockwave is not a diagnosis. The first step is determining whether the presentation actually fits plantar fasciopathy. Only then does it make sense to decide between focused ESWT, radial ESWT, another treatment, or further evaluation.
How Treatment Is Selected
Focused shockwave (ESWT) concentrates energy at a selected target and depth. It has strong placebo-controlled evidence in chronic plantar fasciitis and may be chosen when a localized area near the fascia's heel attachment is the target.
Radial shockwave spreads pressure waves across a broader, more superficial area. The plantar fascia is accessible to radial treatment, and radial ESWT also has strong placebo-controlled evidence.
Research has not established either one as the better choice for plantar fasciitis. How the two differ in general is covered in radial vs. focused shockwave.
Manual treatment may be used for restricted calf or foot soft tissue identified on exam. It is not a way to break down the plantar fascia itself.
All four of our tools are compared on the services page. You do not need to choose focused or radial shockwave before your visit. The exam determines whether ESWT fits and which approach makes sense.
Imaging & referral
When Heel Pain Needs Imaging or Referral
Plantar heel pain is usually diagnosed from the history and examination. Imaging or referral may come first when:
- heel pain follows a fall or jump, or the heel bone itself is tender when squeezed, which raises the question of a stress fracture
- burning, numbness or tingling suggests nerve involvement rather than the plantar fascia
- the heel is markedly swollen, warm or red, or several joints or tendons are painful at once
- pain is significant at night or at rest, or comes with fever or unexplained weight loss
- symptoms are not improving with appropriate care and the diagnosis remains unclear
We review any imaging you already have at the exam.
Evidence
Does Shockwave Help Plantar Fasciitis?
Shockwave has a substantial evidence base in chronic plantar fasciitis. Two large multicenter placebo-controlled trials reported clinically meaningful benefit, one with focused ESWT and one with radial ESWT. Recent meta-analyses also support improvements in pain and function, including better pain and function than corticosteroid injection at three to six months. Both focused and radial shockwave have shown benefit, and research has not established one as clearly better.
Not every study is positive. In a 200-patient 2024 trial in which everyone received advice and custom foot orthoses, adding radial ESWT gave no additional heel-pain benefit at six months. Treatment protocols also vary widely, and no single protocol has been shown to be best. That variation is one reason we start with the diagnosis rather than the device.
Read the full shockwave evidence review →
Sources: Gollwitzer et al., J Bone Joint Surg Am 2015 · Gerdesmeyer et al., Am J Sports Med 2008 · Cortés-Pérez et al., Clin Rehabil 2024 · Heide et al., Br J Sports Med 2024 · Koc et al., J Orthop Sports Phys Ther 2023