Approach

Although plantar fasciitis is considered a self-limiting condition, it may take up to 18 months for pain resolution, thereby presenting a challenge for clinicians. Approximately 80% of patients improve within 12 months with nonoperative therapy.[35]

The American College of Foot and Ankle Surgeons recommends categorizing patients by duration of symptoms in order to allow selection of treatments that will have the greatest effect within each stage of plantar fasciitis. They define the 3 phases of plantar fasciitis as follows:[3]

  • Acute: symptoms present for up to 6 weeks

  • Subacute: symptoms present for 6 to 12 weeks

  • Chronic: symptoms present for >3 months

A subdivision of chronic is refractory/recalcitrant. Refractory plantar fasciitis is best defined as chronic plantar fasciitis that has not improved with appropriate intervention for >6 months and is much more difficult to successfully treat.

Treatment goals

The goal of treatment is complete pain relief. This often requires many months of therapy, with reports ranging from 4 months to 18 months of conservative treatment to achieve this goal.[36] Treatment targets the anatomical, biomechanical, and environmental factors that may lead to the initiation of the cause of foot pain and disability.​[3][9]​​[37]​​​ Combination therapy is the general rule, aimed at addressing pain and inflammation, reducing tissue stress, and restoring muscle strength and flexibility.[9][38]

Controlled randomized studies typically compare combination therapies rather than relying on a single treatment to provide complete long-term resolution. Studies also vary in their means of measurement of a successful outcome, frequently relying more on patients' subjective reports than on one objective measurement tool. Nonetheless, the outcome for individuals with acute plantar fasciitis has been studied and is usually favorable.

Initial treatment

First-line therapy is nonoperative and includes various combinations of rest, weight reduction methods, foot orthotics, mechanical support, and stretching of the tendoachilles and plantar fascia. Most patients will be able to implement these strategies themselves. Corticosteroid injections or nonsteroidal anti-inflammatory drugs (NSAIDs) for short-term pain relief and cast immobilization are sometimes used. For the majority of patients, conservative therapies prove to be beneficial in relieving heel pain.

Only persistent, significantly painful heels that interfere with weight-bearing activity and that fail to respond to nonsurgical therapy after about 6 to 12 months are considered for extracorporeal shockwave therapy (ESWT) or surgical intervention.

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. One study cited rest as the therapy that worked best for 25% of patients treated for plantar fasciitis.[39]

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 nonsupportive shoes such as flip-flops and ballet slippers.[3]

Weight reduction is recommended in people with overweight or obesity. Education and counseling on exercise strategies to gain or maintain optimal lean body mass should be provided. Referral to a dietitian 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]​​

Stretching

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, aimed at the tendoachilles and the plantar fascia, is recommended 3 times daily with 10 repetitions of each stretch.[40] Patients may be referred to a physical therapist or podiatrist for help with technique, although formal physical therapy has not been shown to be more effective than home stretching exercises.[41]​ A study found nonweight-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]​ The main pain-relieving benefits of stretching appear to occur within the first 2 weeks to 4 months. Orthoses may be used to increase the benefits of stretching.[9]​​​​[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@712a6a33[Figure caption and citation for the preceding image starts]: Achilles stretchFrom the collection of Alex Koleszar, Cleveland Clinic; used with permission [Citation ends].com.bmj.content.model.Caption@1aca2e81[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@1b586a35

Low-Dye taping or strapping

Low-Dye (antipronation) taping is frequently used as a first-line short-term treatment for plantar fasciitis. It alters the mechanical function of the foot, supporting the medial longitudinal arch and decreasing stress on the plantar fascia, which leads to relief of morning pain and stiffness. The first strip of tape, used as an anchor, is applied plantarly and transversely, with no tension, just proximal to the metatarsal head. 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] It is typically applied for a period of 3 to 5 days.[46][47]​​ Low-Dye taping is effective in the short-term (up to 6 weeks) and used as a precursor to arch supports.[9]​​ 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]​​

Foot orthotics

Insoles, prefabricated 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 antipronation taping techniques.[9]​​ There is evidence that at 12 months, no significant difference exists among patient outcomes with prefabricated versus custom orthoses.[49][50]​​ Some institutions include orthotic dispensing within a physical therapy or podiatry department.​

Night splints

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 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.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Oral NSAIDs are commonly prescribed for pain and inflammation in the short term. Large randomized controlled trials are lacking. One small randomized trial found a trend toward improved pain relief and reduced disability, but no significant difference, with NSAID therapy compared with placebo and conservative treatment with night splints, visco-elastic heel cups, and stretching.[36] NSAIDs are typically used in conjunction with other therapies and are considered most effective when treating the initial stage of plantar fasciitis. 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]​​

Corticosteroid injections

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] [ Cochrane Clinical Answers logo ] ​​​ 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 physical therapy) 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]

Injections are administered using a plantar medial approach, typically in combination with local anesthetic 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. Ultrasound guidance has been found to be associated with superior results and a lower risk of recurrence of heel pain compared to palpation-guided injection.[3][8]​​​ Complications are uncommon, but include infection, subcutaneous fat atrophy, skin pigmentation changes, fascial rupture, peripheral nerve injury, and muscle damage.[58][59]​​ Injection therapy can be very painful and this is the most commonly reported adverse event.[60] Post-injection pain can last for several days. If the initial treatment was beneficial but symptoms return, the treatment may be repeated once with a minimum of 6 weeks between injections.​​​

Other physical therapies

  • Icing: this may be the most underreported adjunct to management. Used for 20 minutes at a time, this is a local pain reducer with virtually no adverse systemic effects.

  • Phonophoresis: a technique by which therapeutic ultrasound is used to introduce ketoprofen gel through intact skin into the subcutaneous tissues. Limited evidence suggests that it can reduce pain short-term in patients with plantar fasciitis.[9]​​

  • ​Deep tissue massage with myofascial release[3]

  • Soft tissue mobilization: mobilization of gastrocnemius and soleus myofascia, specifically targeting trigger points and areas of soft tissue restriction, may help to reduce pain and improve function.​​[3][9]​​​​[61]

  • Manual therapy: joint mobilization to improve any identified restrictions in joint mobility of the lower extremity, with an emphasis on improving talocrural dorsiflexion, may provide symptomatic relief and improve function.[9]

  • Therapeutic exercise: resistance training for the musculature of the foot and ankle. The combination of manual therapy, patient education, stretching, resistance training, and neurodynamic interventions can improve pain and function.[9]

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

  • Dry needling: use of a thin filiform needle to stimulate underlying myofascial trigger points in the gastrocnemius, soles, and plantar muscles of the foot to improve pain and function.[9] One meta-analysis found low-quality evidence that dry needling is effective for short-term pain relief.[49]​​

  • ​Iontophoresis: the application of an electrical current to promote transdermal delivery of dexamethasone 0.4% or acetic acid 5%. Due to limited evidence, iontophoresis is considered a second-line physical therapy option, with manual therapy, stretching, and foot orthoses preferred.[9]

Cast immobilization

Cast immobilization can be used to eradicate morning pain and stiffness, allow rest with weight-bearing, and provide short-term and long-term pain relief in people with extreme pain presentation or with unresponsive heel pain. The painful foot is placed in an anatomically correct position for the duration of healing. Immobilization can be difficult to tolerate, particularly for those with degenerative arthritis or obesity, and activities of daily living may be adversely affected.

Second- and third-line therapy

Only people with persistent, significant pain that interferes with weight-bearing activity and that fails to respond to nonsurgical therapy after about 6 to 12 months are considered for extracorporeal shock wave therapy (ESWT) or surgical intervention.

Extracorporeal shock wave therapy (ESWT)

The outcome for the 10% of patients who fail to respond to conservative care after 12 months is not well understood. ESWT has evolved as a noninvasive approach for recalcitrant plantar fasciitis pain and is a recommended second-line treatment.[3][65]​​​​ 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 anesthetic pre-procedure, and a series of three 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]​ No serious adverse events have been described. 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]​ A general observation across studies is that approximately 70% of patients with chronic or subacute plantar fasciitis who undergo ESWT experience meaningful improvement in their heel pain at 12 weeks.[3]

Surgery

In patients with recalcitrant pain, surgery has been shown to be generally effective and is considered as a third-line option.[1] 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). Favorable 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 two or more years post surgery. Complications include swelling, fracture, nerve damage, and arch flattening.[4][67][68]​

A frequently used surgical approach, partial plantar fascia release with nerve release, has resulted in mixed outcomes, with some reports demonstrating about a 50% success rate. The recommendation is to release <50% of the plantar fascia rather than 100% in order to prevent lateral column instability.[69] Nerve decompression may be helpful for people with neuritic pain associated with recalcitrant heel pain. An endoscopically released plantar fascia approach is another technique, with potential for quicker return to normal function. However, it is associated with specific risks, including nerve damage and insufficient or overzealous release of the plantar fascia without open visualization of the anatomy.

Weight has not been a factor in the success of surgical outcomes. Overweight individuals may experience the same success as others if surgical intervention is elected. Patients who have had symptoms for more than 2 years, who then go on to surgical intervention, have less favorable results after surgery.

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