Plantar fasciitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

all patients

1st line – rest, self-care advice, and management of precipitating factors

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1st line –

rest, self-care advice, and management of precipitating factors

Rest or modification of exercise activity (e.g., avoidance of running, dancing, jumping, prolonged standing/walking, or walking barefoot on hard, concrete floors) is typically recommended.

Patients should be advised to wear shoes with good arch support and cushioned heels (such as laced sports shoes). Patients in all stages of plantar fasciitis are advised to avoid non-supportive shoes such as flip flops and ballet slippers.[3]

Weight reduction is recommended in people with overweight or obesity. Education and counselling on exercise strategies to gain or maintain optimal lean body mass should be provided. Referral to a dietician may be considered.[9] Elevated BMI is not only a risk factor for plantar fasciitis but also a predictor of the extent of functional loss as reported by patients.[16][17] However, no studies have evaluated the effect of weight loss on occurrence of symptoms.[18]

Plus – stretching

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Plus –

stretching

Treatment recommended for ALL patients in selected patient group

Tight hamstrings and equinus are common in patients with plantar fasciitis and treatment of equinus is important for all stages of the condition.[3] Stretching is aimed at the tendoachilles and the plantar fascia. It is recommended 3 times daily with 10 repetitions of each stretch.[40] Patients may be referred to a physiotherapist or podiatrist for help with technique, although formal physiotherapy has not been shown to be more effective than home stretching exercises.[41] A study found non-weight-bearing stretching exercises, specific to the plantar fascia, to be superior to the standard weight-bearing achilles tendon-stretching exercises in patients with recalcitrant pain.[42] Recommendations for stretching are based on the hypothesis that nocturnal contracture of the gastrocnemius-soleus complex contributes to the irritation of the plantar fascia and persistence of symptoms.[43][44][Figure caption and citation for the preceding image starts]: Calf stretchFrom the collection of Alex Koleszar, Cleveland Clinic; used with permission [Citation ends]. com.bmj.content.model.Caption@1d27319a [Figure caption and citation for the preceding image starts]: Achilles stretchFrom the collection of Alex Koleszar, Cleveland Clinic; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: Plantar stretchFrom the collection of Alex Koleszar, Cleveland Clinic; used with permission [Citation ends]. com.bmj.content.model.Caption@790cd5bf

Consider – low-Dye taping or strapping

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Consider –

low-Dye taping or strapping

Additional treatment recommended for SOME patients in selected patient group

Low-Dye (anti-pronation) taping alters the mechanical function of the foot, decreasing stress on the plantar fascia, leading to relief of morning pain and stiffness in the short-term (up to 6 weeks).[9] It is typically applied for a period of 3-5 days, and subsequently the patient may move into a longer-lasting arch support.[46][47]

A strip of tape is applied plantarly and transversely, with no tension just proximal to the metatarsal head used as an anchor. A second longitudinal strip is applied around the sides of the foot just proximal to the first and fifth metatarsal heads. Then lateral to medial straps are placed plantarly on the heel and arch.[45]

One systematic review found that the addition of taping on stretching exercises has a surplus value.[48]

Strapping with elastic therapeutic tape is an alternative treatment; it is applied to the gastrocnemius and plantar fascia for short-term (1-6 weeks) pain reduction.[9]

Consider – foot orthotics

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Consider –

foot orthotics

Additional treatment recommended for SOME patients in selected patient group

Insoles, pre-fabricated devices, custom-made orthotics and heel cushions are all frequently used for treating plantar fasciitis. Meta-analyses suggest they have little to no effect as a stand-alone treatment to improve pain and function in the short-term (<3 months).[9][49] However, orthoses may be beneficial when combined with other treatments, especially in patients who respond positively to anti-pronation taping techniques.[9] There is evidence that at 12 months, no significant difference exists among patient outcomes with prefabricated versus custom orthoses.[50][70]

Some institutions include orthotic dispensing within a physiotherapy or podiatry department.

Consider – night splint

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Consider –

night splint

Additional treatment recommended for SOME patients in selected patient group

Night splints, used for a 1- to 3- month period, have been shown to be effective adjuncts to treatment for those with both acute and recalcitrant plantar fasciitis pain, particularly those who consistently have pain with the first step in the morning.[9][44][51][52]

Efficacy may be limited, however, as many patients remove them to sleep due to interference with sleep comfort.

Consider – non-steroidal anti-inflammatory drugs (NSAIDs)

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Consider –

non-steroidal anti-inflammatory drugs (NSAIDs)

Additional treatment recommended for SOME patients in selected patient group

Often used in practice, although large randomised controlled trials are lacking. One study indicated no acute benefit with NSAID therapy compared with conservative treatment with stretching, night splints, and visco-elastic heel cushions. There was a trend towards reduced pain and disability in the NSAID therapy group.[36]

NSAIDs are typically used in conjunction with other therapies and are considered most effective when treating the initial stage of plantar fasciitis.

Effective in the short term, but must be taken consistently up to a maximum of about 4 weeks to notice an improvement.

The American College of Foot and Ankle Surgeons does not recommend the routine use of NSAIDs in treating plantar fasciitis due to lack of supporting data.[3]

Primary options

naproxen: 500 mg orally twice daily when required, maximum 1250 mg/day

piroxicam: 20 mg orally once daily when required

etodolac: 200-400 mg orally (immediate-release) every 6-8 hours when required, maximum 1000 mg/day

Consider – corticosteroid injection

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Consider –

corticosteroid injection

Additional treatment recommended for SOME patients in selected patient group

Corticosteroid injections are used in the short term for acute pain management of plantar fasciitis. They are considered if conservative treatment leads to inadequate relief of pain, or if pain is especially high on initial presentation.

They have been shown to be efficacious in relieving pain; however, most studies report only short-term (up to 6 weeks), and not sustained, benefits.[53][54][55] [ ] One study, however, found that the significant reduction in thickness of plantar fascia seen at 1 month following corticosteroid injection persisted on re-scanning at 6 months.[56] A Cochrane review pooled data from 8 trials and found only a modest short-term (<1 month) benefit of glucocorticoid injections compared with placebo.[55] Another systematic review found that corticosteroid injection was more effective than some comparators (autologous blood injection, foot orthoses, and physiotherapy) for the reduction of pain and the improvement of function in people with plantar heel pain in the short term. However, it was no more effective than placebo injection for reducing pain in the short and medium term.[57]

Administered using a plantar medial approach, typically in combination with local anaesthetic to work as an immediate analgesic and anti-inflammatory agent. Lidocaine and bupivacaine are used in combination to achieve a faster onset and longer relief.

Complications are uncommon, but include infection, subcutaneous fat atrophy, skin pigmentation changes, fascial rupture, peripheral nerve injury, and muscle damage.[58][59]

Corticosteroid injections have shown decreased thickness of plantar fascia on sonography.

Injection therapy can be painful.[60] Post-injection pain can last for several days.

Long-lasting effects have been reported with 6-month post-procedure ultrasonography follow-up.[56] If the initial treatment was beneficial but symptoms return, the treatment may be repeated once with a minimum of 6 weeks between injections.

Primary options

bupivacaine: (0.5%) 1 mL intrafascially

and

lidocaine: (1%) 1 mL intrafascially

-- AND --

dexamethasone sodium phosphate: 4 mg intrafascially as a single dose

triamcinolone acetonide: 10 mg intrafascially as a single dose

Consider – other physical therapies

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Consider –

other physical therapies

Additional treatment recommended for SOME patients in selected patient group

Phonophoresis, iontophoresis, deep tissue massage with myofascial release, manual therapy, soft tissue mobilisation, therapeutic exercise, and dry needling can be done with the help of a physiotherapist.[3][9][61][71]

Multiple systematic reviews suggest that low-level laser therapy can be used to reduce pain and activity limitations short-term.[62][63][64]

Due to limited evidence, iontophoresis is considered a second-line option for physiotherapy, with manual therapy, stretching, and foot orthoses preferred.[9]

Icing is simple and effective and most ideal when applied for 20 minutes/hour.

Consider – cast immobilisation

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Consider –

cast immobilisation

Additional treatment recommended for SOME patients in selected patient group

This is an effective tool with extreme pain presentation or with unresponsive heel pain. It can be used to eradicate morning pain and stiffness, allow rest from weight-bearing, and provide short-term and long-term pain relief.

The painful foot is placed in an anatomically correct position for the duration of healing.

Immobilisation can be difficult to tolerate, particularly for those with degenerative arthritis or obesity, and activities of daily living may be adversely affected.

2nd line – extracorporeal shockwave therapy (ESWT)

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2nd line –

extracorporeal shockwave therapy (ESWT)

Considered as a therapeutic option in people with persistent and severe symptoms despite 6 to 12 months of conservative care. It is non-invasive and involves a short recovery time, claiming a success rate comparable to surgery.[3][65][67][72]

It is proposed that ESWT creates local tissue injury that causes selective dysfunction of unmyelinated sensory nerves, neovascularisation, and increased amounts of tissue growth factors within the locally injured structures.[65]

Two techniques have been described: a high-energy single-treatment approach with local anaesthetic pre-procedure, and a series of 3 low-energy treatments. A therapeutic response in the plantar fascia is expected by 12 weeks. One study found that low-intensity treatment was more effective for pain relief and improved function versus high-intensity treatment.[66]

Multiple systematic reviews have examined the benefit of ESWT and overall, it appears to provide better longer-term outcomes over corticosteroid injections and most other interventions studied.[8] Approximately 70% of patients with chronic or subacute plantar fasciitis who undergo ESWT experience meaningful improvement in their heel pain at 12 weeks.[3]

3rd line – surgery

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3rd line –

surgery

Considered for patients who have persistent and severe symptoms despite 6 to 12 months of conservative care.

Various surgical techniques exist (e.g., partial or complete plantar fascia release with or without calcaneal spur resection, excision of abnormal tissue, and nerve decompression). Favourable outcomes have been reported in more than 75% of patients, but recovery time is often slow. Persistent pain may occur in up to one quarter of patients up to 2 or more years post surgery. Complications include swelling, fracture, nerve damage, and arch flattening.[4][67][68]

Closed or endoscopically approached plantar fasciotomy may allow a quicker recovery with earlier return to activity, but good-quality evidence is required to confirm this. Complications associated with this approach include nerve damage and insufficient or overzealous release of the plantar fascia without open visualisation of the anatomy.

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Plantar fasciitis

Treatment algorithm

all patients

rest, self-care advice, and management of precipitating factors

stretching

low-Dye taping or strapping

foot orthotics

night splint

non-steroidal anti-inflammatory drugs (NSAIDs)

Primary options

corticosteroid injection

Primary options

other physical therapies

cast immobilisation

extracorporeal shockwave therapy (ESWT)

surgery