Treatment options for plantar fasciitis cover

Treatment Options for Plantar Fasciitis


Plantar fasciitis, or more appropriately called fasciopathy in its more common chronic state, is the most common cause of heel pain in adults. It occurs due to repetitive microtrauma of the plantar fascia as it inserts into the calcaneus. Symptoms are famously worse in the morning when first getting out of bed and tend to improve with activity. Diagnosis is primarily clinical and the vast majority of patients will have improvement or resolution of symptoms by 12 months with conservative management only.[1]Davies MS, Weiss GA, Saxby TS. Plantar fasciitis: how successful is surgical intervention? Foot Ankle Int 1999;20:803–807 Here we review some of the treatment options and the evidence behind them.
Illustration of Plantar Fasciitis
Illustration of Plantar Fasciitis

First Line Therapy

Initially, all cases of plantar fasciitis can be treated similarly. Most patients will start with discontinuing any provocative activities such as running or sports, using NSAIDS and acetaminophen to treat pain, initiating a home stretching plan and using ice. Commonly, a frozen water bottle is used to roll along the arch of the foot.

Physical Therapy

Physical therapy is a first line treatment modality and the primary treatment for plantar fasciitis. Emphasis should be on stretching the plantar fascia, the Achilles tendon, calf and posterior chain. One study found that calf stretching with eccentric loading may be the most important exercise.[2]DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain: a prospective, randomized study. J Bone Joint … Continue reading All patients will benefit from trengthening extrinsic and intrinsic foot muscles, strengthening abductor and lateral rotator hip muscles, and stretching.[3]Cheung RT, Sze LK, Mok MW, Ng GY. Intrinsic foot muscle volume in experienced runners with and without chronic plantar fasciitis. J Sci Med Sport 2016;19:713–715.

Foot Orthotic

Foot orthotics are commonly used as part of a broader treatment plan and the goals are to decrease foot pronation and off-load the proximal insertion of the plantar fascia. Although helpful, its not clear whether custom orthotics are needed. One randomized controlled trial compared over the counter inserts to custom orthotics and found benefit from both, but no difference in relief at 12 months.[4]Landorf KB, Keenan AM, Herbert RD. Effectiveness of foot orthoses to treat plantar fasciitis: a randomized trial. Arch Intern Med 2006;166:1305–1310. Heel cups are another type of orthotic you can place in shoe to offload the plantar fascia. Orthotics are more effective when they are combined with night splints.[5]Lee WC, Wong WY, Kung E, Leung AK. Effectiveness of adjustable dorsiflexion night splint in combination with accommodative foot orthosis on plantar fasciitis. J Rehabil Res Dev. … Continue reading

Example Shoe Insert

Exmple Heel Cup

Example Night Splint

Night Splints

Night splints, sometimes called nocturnal splints, aim to stretch the plantar fascia while sleeping to prevent morning pain and stiffness.[6]Roos E, Engstrom M, Soderberg B. Foot orthoses for the treatment of plantar fasciitis. Foot Ankle Int 2006;27:606–611.. They are known to be beneficial, especially when used as part of a broader treatment program.[7]Batt ME, Tanji SL, Skattum N. Plantar fasciitis: a prospective randomized clinical trial of the tension night splint. Clin J Sport Med 1996;6:158–162.. However, the biggest problem is that patients don’t tolerate wearing them very well and compliance can be challenging.
Ultrasound Guided Corticosteroid Injection for Plantar Fasciitis
A) Increased thickness of plantar fascia in ultrasound examination of a patient with plantar fasciitis. (B) Ultrasound guided plantar fascia injection in transverse (short axis) view. White arrows indicate the needle. B: calcaneus bones; F: fat pad; M: flexor digitorum brevis muscle; P: plantar fascia.[8]Babaei-Ghazani, Arash, et al. “Comparison of ultrasound-guided local ozone (O2-O3) injection vs corticosteroid injection in the treatment of chronic plantar fasciitis: a randomized clinical … Continue reading

Corticosteroid Injection

Although commonly used, corticosteroid injections (CSI) are of questionable utility in the treatment of plantar fasciitis. This is likely due to the majority of cases being chronic in nature and the anti-inflammatory effects of corticosteroids are limited. A Cochrane review showed low quality evidence of benefit at 1 month, but none after.[9]David JA, Sankarapandian V, Christopher PR, Chatterjee A, Macaden AS. Injected corticosteroids for treating plantar heel pain in adults. Cochrane Database Syst Rev 2017;11:CD009348. There are risks associated with CSI, namely heel pad atrophy and rupture of the plantar fascia, both of which have significant morbidity. For this reason, there is a growing belief that other modalities should be tried prior to injecting corticosteroids. When possible, ultrasound should be used to increase precision and decrease risk of adverse events.

Other Treatments

Autologous Blood Injection. This procedure involves taking a small amount of the patients blood, making no modifications or manipulations to the specimen, and then injecting it back into the plantar fascia. Although not commonly used, one small study showed some benefit.[10]Wheeler, Patrick. “Autologous blood injections for chronic plantar fasciitis–a pilot case-series study shows promising results.” International Musculoskeletal Medicine 35.1 (2013): 3-7.

Botulinum Toxin A Injection. Botulinum toxin, commonly called botox, has been used to treat a lot of similar conditions throughout the body. For plantar fasciitis, one small randomized controlled trial showed statistically significant changes in the treatment group.[11]Babcock MS, Foster L, Pasquina P, Jabbari B. Treatment of pain attributed to plantar fasciitis with botulinum toxin A: a short-term, randomized, placebo-controlled, double-blind study. Am J Phys Med … Continue reading

Platelet Rich Plasma (PRP). PRP is also a blood based therapy, but after the aspiration of about 50 cc of blood, it is placed in a centrifuge and the platelets are concentrated for injection. This treatment is used for a wide variety of musculoskeletal conditions. In plantar fasciitis, a recent systematic review and meta-analysis showed benefit at 3 months making it more appealing than corticosteroids.[12]Singh, Prashant, et al. “A systematic review and meta-analysis of platelet-rich plasma versus corticosteroid injections for plantar fasciopathy.” International orthopaedics 41.6 (2017): … Continue reading

Extracorporeal Shock Wave Therapy (ECSWT). ECSWT involves using shock waves to the injured tissue to break up scar tissue and promote healing. A meta-analysis for plantar fasciitis found that it can improve pain but could draw no firm conclusions about its role in the treatment of plantar fasciitis.[13]Sun, Jiale, et al. “Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: A meta-analysis of RCTs.” Medicine 96.15 (2017).

Radiation Therapy. Targeted radiation therapy has been used on many soft tissues for a wide variety of diseases. It is thought to have an anti-inflammatory effects that reduce inflammatory mediators and pain. In a study comparing radiation therapy to corticosteroid injection, it was superior for pain relief at 3 and 6 months.[14]Canyilmaz E, Canyilmaz F, Aynaci O, et al. Prospective randomized comparison of the effectiveness of radiation therapy and local steroid injection for the treatment of plantar fasciitis. Int J Radiat … Continue reading


There are many treatment options for plantar fasciitis and its more chronic present, plantar fasciopathy. The vast majority of cases will get better in a year with appropriate treatment. First line therapy includes activity modification, NSAIDS, shoe inserts, ice and and physical therapy. If that is insufficient, there are a wide variety of additional treatment options that can be deployed.
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