When Is (and Isn’t) Your Heel Pain Plantar Fasciitis?

An Article By Cecilia Brennan, Podiatrist – New Step Podiatry.

When Is (and Isn’t) Your Heel Pain Plantar Fasciitis?

Heel pain is one of the most common things we see in clinic, and quite often people come in already assuming it’s plantar fasciitis.

Sometimes that’s exactly what it is. But just as often, it’s not quite that simple.

The term “plantar fasciitis” tends to get used as a blanket label for pain under the heel. The issue is that it implies a very specific process, namely inflammation of the plantar fascia, and that’s not always what’s going on.

So rather than focusing purely on the label, we tend to step back and look at how the tissue is actually being loaded.

In simple terms, we’re usually thinking about heel pain in terms of how load is being applied to the tissue, most commonly as traction (tensile load) or compression. Often both are present, but one tends to be the main driver.

The Problem with Calling All Heel Pain Plantar Fasciitis

“Fasciitis” suggests inflammation. But in many cases of heel pain, especially when it’s been there for a while, there isn’t a strong inflammatory component.

What we often see instead is a tissue that’s been overloaded over time.

That’s why terms like plantar fasciopathy are sometimes more accurate. But even then, the label doesn’t tell us how the tissue is being stressed.

And that’s the part that really guides treatment.

But my Ultrasound Says Plantar Fasciitis?

Some of the confusion here also comes from how the term “plantar fasciitis” is used in imaging. On ultrasound, increased thickness of the plantar fascia is often reported as plantar fasciitis. In that context, the term is being used to describe a structural finding.

Clinically, we tend to use the term a bit differently. We’re not just describing what the tissue looks like, we’re trying to understand what’s driving the pain and how the tissue is being loaded. So while an ultrasound report might say “plantar fasciitis,” that doesn’t necessarily tell us whether the issue is inflammatory, traction-related, compression-related, or a combination of these. It’s not that one is right and the other is wrong, it’s simply that the same term is being used in different ways, and that can lead to some confusion when it comes to treatment.

Traction-Dominant Heel Pain

This is what most people picture when they think of plantar fasciitis.

The plantar fascia is being repeatedly pulled, particularly where it attaches into the heel. Over time, that tensile load becomes more than the tissue can comfortably handle.

You’ll usually see a familiar pattern:

• sharp pain with the first few steps in the morning
• pain after rest that eases as you get moving
• tenderness right under the heel

Tight calves, changes in activity levels, and reduced foot strength or control are common contributors here.

At its core, this is a pulling (traction) problem; the fascia is under too much tensile load.

Compression-Dominant Heel Pain (Often Overlooked)

Not all heel pain behaves like that.

Some people notice their pain builds the longer they’re on their feet. It doesn’t really “warm up,” and can feel more like a deep ache or bruised sensation under the heel.

In these cases, we’re often dealing with a compressive load.

Instead of the fascia being predominantly pulled, the tissue is being pressed against the heel bone. The plantar fascia, fat pad and surrounding structures are all taking repeated pressure, especially on harder surfaces.

This can be influenced by:

• long periods of standing
• reduced cushioning under the heel
• footwear choices
• certain foot postures

This is a pressure (compressive) problem, even though it’s often labelled as plantar fasciitis.

Why the Difference Matters

Even though the pain is in the same area, the dominant load is different, and that changes how we approach it.

For example:

• Stretching and load management can be very helpful in traction-dominant pain
• But in compression-dominant presentations, overstretching can increase load at the insertion and may aggravate symptoms if not appropriately managed.
• Cushioning, footwear changes, and reducing time on hard surfaces can help with compression
• But won’t fully address a traction overload on their own

So if we treat every case of heel pain the same way, we can miss the mark.

It’s Not Always About Pathology

We don’t always look at heel pain as a strict “pathology” first.

Instead, we ask:

• what type of load is driving this?
• is it more traction or compression dominant?
• how is that load showing up in day-to-day activity?

Because quite often, heel pain is less about something being structurally “wrong” and more about how the tissue is being used and overloaded.

So is it Plantar Fasciitis?

Sometimes, yes.

But in many cases:

• there isn’t a strong inflammatory component
• the issue is more mechanical than pathological
• and the label “plantar fasciitis” doesn’t fully explain what’s happening

Understanding whether your heel pain is more traction- or compression-dominant gives us a much clearer direction for treatment.