Calf tightness maybe the cause for plantar fasciitis

That sharp, stabbing pain on the bottom of your heel when you first step out of bed in the morning. If you've experienced it, you'll know it's hard to ignore. For many people in Hamilton, it turns out to be plantar fasciitis: one of the most common causes of heel pain in adults, and one of the most frequently seen presentations at MotionPlus Osteo.

What surprises a lot of people is that the answer to their heel pain might not lie in their foot at all. It may start much higher up, in the calf.

This post explores the anatomy behind plantar fasciitis and why calf tightness, specifically the gastrocnemius muscle, is increasingly recognised as a key contributing factor. We'll cover management in a follow-up post, with a link back here when it's live.

What Is Plantar Fasciitis?

Plantar fasciitis is widely regarded as the most common cause of inferior heel pain in adults (Buchbinder, 2004), accounting for around 10% of all runner-related injuries and between 11% and 15% of all foot symptoms requiring professional care (Buchanan & Kushner, 2021). In active populations, prevalence among runners has been reported as high as 22% in some studies (Kakouris et al., 2025).

Despite its name, plantar fasciitis is now understood to be primarily a degenerative process rather than an inflammatory one. Repeated mechanical loading of the plantar fascia, the thick band of connective tissue running along the sole of your foot from your heel bone to your toes, leads to microtears, collagen disarray, and granulation tissue over time (Buchanan & Kushner, 2021; Rhim et al., 2021). The term plantar fasciopathy is increasingly preferred in clinical literature to reflect this degenerative rather than inflammatory nature.

The condition is most common in adults between 40 and 60 years of age, though it affects both recreational athletes and people whose work involves prolonged standing or walking on hard surfaces (Buchanan & Kushner, 2021). With New Zealand's active outdoor culture including running, hiking, sport, and physically demanding trades, plantar fasciitis is a familiar complaint in our Hamilton clinic.

The Anatomy: Why Your Calf Matters

To understand why the calf is so relevant, it helps to trace the anatomical chain from top to bottom.

The gastrocnemius is the large, prominent calf muscle you can feel at the back of your lower leg. It originates from two heads attached to the lower end of the femur, just above the knee, and runs down the back of the leg before converging into the Achilles tendon, which attaches to the back of the heel bone, the calcaneus.

Now here's where it gets interesting. The plantar fascia attaches to the other end of that same heel bone, on the underside. So you have the gastrocnemius pulling on the top of the calcaneus via the Achilles, and the plantar fascia attached to the bottom.

When the gastrocnemius is tight, it places increased tension through the Achilles tendon onto the calcaneus, and that tension can translate directly into increased load on the plantar fascia at its attachment point. Over time, with repeated weight-bearing and activity, this constant mechanical stress is one of the proposed contributors to the degenerative changes seen in plantar fasciitis (DiGiovanni et al., 2002; Patel & DiGiovanni, 2011).

This anatomical relationship is why calf tightness, and gastrocnemius tightness specifically, has long been associated with plantar fasciitis in the clinical literature.

What Does the Research Say?

The association between gastrocnemius tightness and plantar fasciitis has been documented across multiple studies and is now well supported in the literature.

A prospective cross-sectional cohort study by Nakale et al. (2018) examined three groups: 45 patients with plantar fasciitis, 117 patients with other foot and ankle conditions, and 61 people without foot pathology. Using the Silfverskiöld test, a clinical assessment of isolated gastrocnemius tightness, they found that 80% of plantar fasciitis patients demonstrated isolated gastrocnemius tightness, compared to 45% of those with other foot conditions and only 20% of healthy individuals. The difference between groups was statistically significant, suggesting a specific relationship between gastrocnemius tightness and plantar fasciitis rather than simply a general population finding.

A 2024 study by Tariq et al. examining 223 adults presenting with heel pain found similar results, with the Silfverskiöld test returning a positive finding for gastrocnemius tightness in 79.8% of participants, further reinforcing the clinical significance of assessing the calf in people presenting with plantar fasciitis (Tariq et al., 2024).

Pearce et al. (2021) took the research a step further by quantifying the relationship between gastrocnemius tightness and pain severity. Their study found a strong, statistically significant correlation between the degree of gastrocnemius tightness and heel pain intensity in patients with plantar fasciitis, with mean gastrocnemius tightness reducing significantly over a nine-month follow-up period alongside improvements in pain scores.

At a tissue level, Zhou et al. (2020) used shear wave elastography, an ultrasound technique that measures the stiffness of soft tissue, to compare the elastic properties of the gastrocnemius in people with and without plantar fasciitis. They found that the medial head of the gastrocnemius was significantly stiffer in people with plantar fasciitis, and that this stiffness correlated with pain intensity. Interestingly, the lateral head showed no significant difference, suggesting the relationship is not uniform across the entire muscle, which has practical implications for how and where the calf is assessed clinically.

It's Not Just the Calf

While the gastrocnemius connection is well supported, plantar fasciitis is a multifactorial condition, meaning the calf is rarely the only factor in play.

Other contributors that have been identified in the literature include limited ankle dorsiflexion range, increased body mass index in non-athletic populations, prolonged occupational standing on hard surfaces, and biomechanical factors including foot alignment and loading patterns (Hamstra-Wright et al., 2021; Rhim et al., 2021).

There is also an emerging association between the hamstring muscle group and plantar fasciitis, through the posterior chain fascial connections running from the base of the skull all the way to the plantar fascia, though the extent of this influence is still being explored in the literature (Labovitz & Kim, 2011). We'll dedicate a separate post to this connection.

The clinical picture matters. Two people can present with identical heel pain and have quite different contributing factors, which is why a thorough assessment of the whole lower limb is more informative than focusing on the foot alone.

What This Means Clinically

The consistent finding across multiple studies is that gastrocnemius tightness should be actively assessed in anyone presenting with plantar fasciitis. It is not a peripheral consideration but a central part of the clinical picture (Nakale et al., 2018; Pearce et al., 2021; Tariq et al., 2024).

The 2023 revised Clinical Practice Guideline for plantar heel pain, published in the Journal of Orthopaedic & Sports Physical Therapy, recommends gastrocnemius and soleus stretching as a core component of management, reinforcing the posterior chain as a priority in both assessment and care (Martin et al., 2023).

In our next post, we'll look at what management of plantar fasciitis actually involves, including how we approach the gastrocnemius as part of a broader osteopathic assessment at our Hamilton clinic.

This post is intended for general educational purposes only and does not constitute medical advice. If you are experiencing heel pain, please seek an individual assessment from a registered healthcare professional. Craig O'Connor is a registered osteopath with the Osteopathic Council of New Zealand (OCNZ).

References

Buchanan, B. K., & Kushner, D. (2021). Plantar fasciitis. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK431073/

Buchbinder, R. (2004). Clinical practice: Plantar fasciitis. New England Journal of Medicine, 350(21), 2159–2166. https://doi.org/10.1056/NEJMcp032745

DiGiovanni, C. W., Kuo, R., Tejwani, N., Price, R., Hansen, S. T., Cziernecki, J., & Sangeorzan, B. J. (2002). Isolated gastrocnemius tightness. Journal of Bone and Joint Surgery, 84(6), 962–970. https://doi.org/10.2106/00004623-200206000-00005

Hamstra-Wright, K. L., Huxel Bliven, K. C., Bay, R. C., & Aydemir, B. (2021). Risk factors for plantar fasciitis in physically active individuals: A systematic review and meta-analysis. Sports Health, 13(3), 296–303. https://doi.org/10.1177/1941738120970976

Hyland, M. R., Webber-Gaffney, A., Cohen, L., & Lichtman, P. W. (2006). Randomized controlled trial of calcaneal taping, sham taping, and plantar fascia stretching for the short-term management of plantar heel pain. Journal of Orthopaedic & Sports Physical Therapy, 36(6), 364–371. https://doi.org/10.2519/jospt.2006.2078

Kakouris, N., Yener, N., & Fong, D. T. P. (2025). Running distance and biomechanical risk factors for plantar fasciitis: A 1-yr prospective 4HAIE cohort study. Medicine & Science in Sports & Exercise, 57(3), 512–521. https://doi.org/10.1249/MSS.0000000000003609

Labovitz, J. M., & Kim, J. (2011). Hammertoe deformity and plantar fasciitis: A potential relationship. Journal of the American Podiatric Medical Association, 101(5), 403–408. https://doi.org/10.7547/1010403

Lopes, A. D., Hespanhol, L. C., Yeung, S. S., & Costa, L. O. P. (2012). What are the main running-related musculoskeletal injuries? Sports Medicine, 42(10), 891–905. https://doi.org/10.1007/BF03262301

Martin, R. L., Davenport, T. E., Reischl, S. F., McPoil, T. G., Matheson, J. W., Wukich, D. K., & McDonough, C. M. (2023). Heel pain — plantar fasciitis: Revision 2023. Clinical practice guidelines linked to the ICF from the Academy of Orthopaedic Physical Therapy and American Academy of Sports Physical Therapy of the APTA. Journal of Orthopaedic & Sports Physical Therapy, 53(12), CPG1–CPG39. https://doi.org/10.2519/jospt.2023.0303

Nakale, N. T., Strydom, A., Saragas, N. P., & Ferrao, P. N. F. (2018). Association between plantar fasciitis and isolated gastrocnemius tightness. Foot & Ankle International, 39(3), 271–277. https://doi.org/10.1177/1071100717744175

Patel, A., & DiGiovanni, B. (2011). Association between plantar fasciitis and isolated contracture of the gastrocnemius. Foot & Ankle International, 32(1), 5–8. https://doi.org/10.3113/FAI.2011.0005

Pearce, C. J., Seow, D., & Lau, B. P. (2021). Correlation between gastrocnemius tightness and heel pain severity in plantar fasciitis. Foot & Ankle International, 42(3), 323–328. https://doi.org/10.1177/1071100720955144

Rhim, H. C., Kwon, J., Park, J., Borg-Stein, J., & Tenforde, A. S. (2021). A systematic review of systematic reviews on the epidemiology, evaluation, and treatment of plantar fasciitis. Life, 11(12), 1287. https://doi.org/10.3390/life11121287

Tariq, Z., Zahoor, H., Ayub, R., Abbas, A., Afzal, R., & Kamran, W. I. (2024). Association of isolated gastrocnemius tightness in patients with heel pain. Journal of Health and Rehabilitation Research, 4(1), 484. https://doi.org/10.61919/jhrr.v4i1.484

Thomas, J. L., Christensen, J. C., Kravitz, S. R., Mendicino, R. W., Schuberth, J. M., Vanore, J. V., Weil, L. S., Zlotoff, H. J., Bouche, R., & Baker, J. (2010). The diagnosis and treatment of heel pain: A clinical practice guideline-revision 2010. Journal of Foot and Ankle Surgery, 49(3), S1–S19. https://doi.org/10.1053/j.jfas.2010.01.001

Zhou, J., Lu, N., Wang, H., Li, J., & Zhang, P. (2020). Modulation in the elastic properties of gastrocnemius muscle heads in individuals with plantar fasciitis and its relationship with pain. Scientific Reports, 10(1), 2770. https://doi.org/10.1038/s41598-020-59715-8

Reference

Buchanan BK, Kushner D. Plantar Fasciitis. [Updated 2022 May 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431073/

Buchbinder R. (2004). Clinical practice. Plantar fasciitis. The New England journal of medicine, 350(21), 2159–2166. https://doi.org/10.1056/NEJMcp032745

DiGiovanni, C. W., Kuo, R., Tejwani, N., Price, R., Hansen, S. T., Jr, Cziernecki, J., & Sangeorzan, B. J. (2002). Isolated gastrocnemius tightness. The Journal of bone and joint surgery. American volume, 84(6), 962–970. https://doi.org/10.2106/00004623-200206000-00010

Hyland, M. R., Webber-Gaffney, A., Cohen, L., & Lichtman, P. T. (2006). Randomized controlled trial of calcaneal taping, sham taping, and plantar fascia stretching for the short-term management of plantar heel pain. The Journal of orthopaedic and sports physical therapy, 36(6), 364–371. https://doi.org/10.2519/jospt.2006.2078

Labovitz, J. M., Yu, J., & Kim, C. (2011). The role of hamstring tightness in plantar fasciitis. Foot & ankle specialist, 4(3), 141–144. https://doi.org/10.1177/1938640010397341

Lopes, A. D., Hespanhol Júnior, L. C., Yeung, S. S., & Costa, L. O. (2012). What are the main running-related musculoskeletal injuries? A Systematic Review. Sports medicine (Auckland, N.Z.), 42(10), 891–905. https://doi.org/10.1007/BF03262301

Patel, A., & DiGiovanni, B. (2011). Association between plantar fasciitis and isolated contracture of the gastrocnemius. Foot & ankle international, 32(1), 5–8. https://doi.org/10.3113/FAI.2011.0005

Pearce, C. J., Seow, D., & Lau, B. P. (2021). Correlation Between Gastrocnemius Tightness and Heel Pain Severity in Plantar Fasciitis. Foot & ankle international, 42(1), 76–82. https://doi.org/10.1177/1071100720955144

Thomas, J. L., Christensen, J. C., Kravitz, S. R., Mendicino, R. W., Schuberth, J. M., Vanore, J. V., Weil, L. S., Sr, Zlotoff, H. J., Bouché, R., Baker, J., & American College of Foot and Ankle Surgeons heel pain committee (2010). The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons, 49(3 Suppl), S1–S19. https://doi.org/10.1053/j.jfas.2010.01.001