The Evidence
The most common treatments include stretching of the gastroc/soleus/plantar fascia, shockwave, orthotics, ultrasound, iontophoresis, night splints and joint mobilization/manipulation.
There is Level 1a evidence for:
- Night Splints (poor patient compliance as they are hard to sleep with. Most won’t wear them)
There is Level 1b evidence for:
- Strength Training (we do)
- Stretching (we do)
- Iontophoresis (we don’t use)
There is Level 2b evidence for:
- Orthotics (we don't use routinely unless Strength Training, Stretching and Shockwave hasn't provided complete symptom resolution)
There is Level 4 evidence for:
- Manual Therapy (we don't use - we teach patients how to self-treat)
Shockwave
A network meta-analysis (NMA) was to assess the pain relief performance of eight different plantar fasciitis therapies, including nonsteroidal anti-inflammatory medications, corticosteroid injections (CSs), autologous whole blood, platelet-rich plasma (PRP), extracorporeal shockwave therapy (ESWT), ultrasound therapy (US), botulinum toxin A (BTX-A), and dry needling (DN). According to the SUCRA, Shockwave ranked first for all measures of outcomes. (We use Shockwave between 3 and 12 months and it’s a very effective pain-reliever and stimulus for tissue healing. The pain-relief aspect then allows people to do the strength and stretching work to fix the problem.)
Clinical Review
Plantar fasciitis
BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e6603 (Published 10 October 2012)Cite this as: BMJ 2012;345:e6603
Summary points
- Plantar fasciitis is a condition which generally resolves over time with minimally-invasive management
- There is no one treatment with the highest level of evidence, but several with moderate levels of evidence, including stretching, orthotics, shock wave therapy, and injections
- The secondary cost of prolonged immobility can be severe (and can also worsen plantar fasciitis), so it is worth treating plantar fasciitis actively rather than with neglect
- Choice of treatments should be tailored to the individual patient’s circumstances and likelihood of response
Plantar fasciitis unfortunately has the reputation of being a trivial condition clinically, in that it is described as benign and self limiting. However, the medical profession is starting to appreciate that the greatest public health challenge in Western countries is physical inactivity. In this context, plantar fasciitis, which inhibits physical activity due to pain, can be given its due respect. Many patients who develop plantar fasciitis are already overweight. Once everyday walking becomes painful, the difficulty in losing weight is extreme and the risk of gaining further weight increases, contributing to a worsening of the condition. Since being inactive and overweight are major risk factors for many diseases, an efficient treatment paradigm for plantar fasciitis—as opposed to a “wait and see” approach—becomes essential.