Plantar fasciitisBMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e6603 (Published 10 October 2012) Cite this as: BMJ 2012;345:e6603
- John Orchard, sports physician
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 limiting1 2 with limited evidence to support any of the common treatments.3 However, the medical profession is starting to appreciate that the greatest public health challenge in Western countries is physical inactivity.4 In this context, plantar fasciitis, which inhibits physical activity due to pain, can be given its due respect.5 Many patients who develop plantar fasciitis are already overweight.6 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.
This review aims to assist the clinician in prioritising the most promising treatment options for a specific patient, rather than providing a comprehensive list of all the options with little guidance as to where to start in an individual case.
Sources and selection criteria
I conducted a PubMed search for “Plantar fasciitis”, yielding 358 references (9 March 2012). The systematic reviews retrieved from this search and other sources (including reference lists of above papers) were examined to establish the standard, commonly recommended treatments for plantar fasciitis for which moderate evidence exists. The reference list was then used to assemble supportive evidence for each of the major treatment categories.
What is plantar fasciitis?
The plantar fascia is a tight band of connective tissue that supports the arch of the foot like a windlass.7 Plantar fasciitis occurs at the proximal attachment and is an enthesopathy, the enthesis being the interface between the bony surface (periosteal) and a tendon or ligament attachment. Most tendinopathies (such as tennis elbow) are insertional and hence also enthesopathies. The plantar fascia is a ligament in anatomical terms, because it attaches bone to bone (calcaneus to metatarsal heads, crossing other joints of the foot in its path, fig 1⇓) rather than a tendon (which attaches muscle to bone). However, deep to the superficial structure of the plantar fascia is the flexor digitorum brevis muscle with a tendon enthesis attachment to the calcaneus proximally. As stress shielding (failure of a stress deprived deep surface to heal because the superficial element bears most of the load) is potentially implicated in enthesopathy,8 it is possible that proximal tendinopathy of the flexor digitorum brevis muscle is involved in the pathology of plantar fasciitis.
Plantar fasciitis is such a well established phrase that it will almost certainly remain the preferred term for the clinical syndrome of undersurface heel pain. The “itis” suffix denotes an inflammatory disorder, which is a misnomer, as the pathology is not a result of excessive inflammation. Pathological changes are degenerative in nature (although partially reversible), presumably due to repetitive microtrauma. For related tendinopathies, many experts discourage terms such as “Achilles tendinitis,” preferring, say, “Achilles tendinopathy” as a diagnosis.9 This debate over terminology has clinical relevance as cortisone injections and anti-inflammatory drugs are contraindicated in some tendionopathies10 because of the potential for long term weakening of connective tissue. This concern is of less relevance for plantar fasciitis, as cortisone injections are a treatment modality with moderate supporting evidence.3 Therefore, there is less of a need to insist on a terminology change. The fact that the plantar fascia is not a tendon means that successful treatment of the condition can be achieved by strengthening of the enthesis (as one would treat an insertional tendinopathy) or, alternatively, by stretching or even rupturing the medial aspect of the enthesis, which paradoxically can also lead to complete resolution of symptoms.11
Who gets plantar fasciitis?
Typically plantar fasciitis affects middle aged or older people, women slightly more often than men.12 Those who walk a lot, particularly at work, are more at risk,13 which is reflected in a lay term for the condition, “policeman’s heel.” Increased body weight is a well established risk factor.6 13 There is some evidence that work on hard surfaces increases the risk.14 Athletes can get plantar fasciitis, but not as often as other overuse injuries such as tendinopathies and stress fractures. Court sport athletes (who compete on hard surfaces) seem to have greater risk than footballers and others who play on softer surfaces such as grass. Reduced range of ankle dorsiflexion is associated with plantar fasciitis,6 as are calf and hamstring tightness.15
What is the differential diagnosis?
Heel pain can sometimes represent a diagnostic challenge, but most of the time the diagnosis of plantar fasciitis is straightforward, with the challenge being one of successful management. Achilles tendinopathy, the other common cause of chronic heel pain of gradual onset, is differentiated by location—on the posterosuperior aspect of the heel as opposed to the undersurface, where plantar fasciitis occurs, typically on the medial aspect of the undersurface (fig 2⇓). In general, the tenderness of heel pain localises well, which confirms the diagnosis of plantar fasciitis or Achilles tendinopathy. In cases where pain localisation is poor, a differential diagnosis needs to be considered (such as subtalar arthritis or S1 nerve root impingement16). If there is a history of trauma before the pain (such as landing on the heel from a height), other diagnoses, such as fat pad contusion or calcaneal bone bruise, need to be considered. Calcaneal stress fractures are uncommon, but they can be suspected in cases where the patient has walked for a long period carrying a heavy pack. Runners tend to get stress fractures in bones other than the calcaneus, because compared with walking, relatively less of the gait cycle is spent bearing weight through the heel. Tenderness in a case of stress fracture will be halfway between the Achilles tendon and plantar fascia attachments (seen in fig 2⇓)
What is the role of diagnostic imaging in plantar fasciitis?
Although diagnostic imaging can be used in the clinical management of plantar fasciitis, it does not commonly change management. Many authors have established that, although the diagnostic imaging features of plantar fasciitis (such as heel spur on x ray (fig 3⇓),6 thickened plantar fascia on ultrasound,17 and “hot” bone scan on calcaneus) are far more common in patients with heel pain, they can occur in asymptomatic individuals and be absent in cases of plantar fasciitis. It is recognised that the pain is not simply due to a heel spur, although the exact cause of pain in plantar fasciitis (and other enthesopathies) remains uncertain. Where the diagnosis is unclear from the standard clinical assessment, pain relief on walking after an ultrasound guided injection of local anaesthetic to the plantar fascia origin can help to confirm the diagnosis.11
Many systematic reviews of plantar fasciitis management have been performed, with a common finding that high quality evidence of efficacy for any one treatment modality is lacking.3 However, the situation in specialist clinical practice is not nearly as bleak as the systematic reviews would suggest, with multiple treatment modalities well described and many with low or moderate level evidence.18 19 All of the common treatment modalities have a place, yet all of them will be unsuccessful for some patients. The essence of good clinical practice is to provide a benefit:risk equation for the common treatments and to tailor the best treatment for a particular patient, taking into account the unique circumstances. Importantly, the condition should not be trivialised, as the holistic cost to the patient—particularly if he or she is overweight—of a prolonged period of finding everyday walking painful is high. Therefore, low or moderate cost treatments with a fair chance of success should be attempted, as the potential general health gain of return to pain-free walking is high.
What are the treatment options for plantar fasciitis?
Consistently the major categories of treatment recommended, assessed, or reviewed in studies were
1) Biomechanical treatment, including orthotics, other footwear modification, and taping
2) Stretching techniques, particularly including night splints
3) Extracorporeal shock wave therapy
4) Cortisone (or other) injections
Although other treatments are available and described, these categories cover what most expert reviews would consider to be the established treatments for plantar fasciitis. They are all consistently described as having some role in management, but no review has established that a particular treatment has the highest level of evidence (that is, consistently superior results to placebo in high quality randomised controlled trials). Treatment options should be offered to the patient in sequence, based on either (a) objective criteria that may predict who would respond best to each treatment modality (see table⇓) or (b) patient preference, as compliance with treatment is likely to be associated with success and common sense would dictate that patients are most likely to comply with their preferred treatment. In most cases it is sensible to offer isolated treatment modalities so that response can be assessed.
Orthotics, taping, and footwear modifications
Perhaps the most common group of treatments for plantar fasciitis is footwear modifications, including orthotic devices (prefabricated or custom made, fig 4⇓). Although there is no strong evidence that orthotics are effective for all cases of plantar fasciitis,20 analysis of pooled papers suggest moderate improvements.21 Cost effectiveness of custom made orthotics is not well established, as they are moderately expensive and have not been shown in trials to be superior to cheaper prefabricated orthotics.20 However, custom made orthotics are more durable and are likely to be better tolerated because of their specific fitting.
Orthotic devices theoretically reduce pronation and thereby unload the plantar fascia. This is also the suggested mechanism of action for low-dye taping (fig 5⇓), which also has limited evidence.22 Because of the moderate expense of custom made orthotics and their variable efficacy, it is suggested that they are not prescribed routinely but are used in cases where patients report improvement with prefabricated orthotics or low-dye taping. Kinesiotaping, involving both calf and foot, may work in a similar fashion.23
Biomechanical teaching would also suggest that orthotics are more likely to be successful in patients with flat feet (who over-pronate). Practical considerations mean that orthotics will be less helpful and less likely to be tolerated by patients who prefer to wear open or tight fitting shoes. Paradoxically, women often report less pain from plantar fasciitis when wearing high heeled shoes, yet regular wearing of high heels is blamed for the development of a shortened plantar fascia, making the condition more likely.
Another footwear modification that has the potential to help some patients is the rocker-sole shoe (fig 6⇓).24 Patients should be warned that these shoes lead to poorer balance and can potentially aggravate knee, hip, and low back problems. However, as the weight bearing is more through the midfoot and less through the heel and toe, they can be valuable, for example, for patients who walk regularly at work.
Stretching and night splints
Stretching has been shown to provide some help in plantar fasciitis,25 although it is arduous treatment with limited success. Stretching can be performed against a solid object or by using a hard object such as ball or bottle. A night splint (whether rigid (fig 7⇓) or a “sock”) can in theory provide a stretch lasting for many hours, with the potential for greater effect.26 Compliance is the major argument against a trial of night splints.27 Poor sleepers would probably be wasting their time if they tried to use one of these devices, as they certainly do not promote a good night’s rest. However, for those who tolerate them, they are a good, low risk, non-invasive option. They seem to be particularly good for those patients with severe pain on getting up in the morning. Stretches themselves are of use and should be encouraged for most patients.
Extracorporeal shock wave therapy
Extracorporeal shock wave therapy is a well established treatment for kidney stones and was initially trialled in the management of plantar fasciitis because the x ray appearance of a calcaneal spur was similar to that of a renal calculus. There have been many randomised controlled trials of shock wave therapy for treating plantar fasciitis, making it the most researched modality, but the results have been somewhat inconclusive.28 A 2007 review analysed 17 controlled trials as having mixed but generally positive results28 with further encouraging subsequent publications29 30 and support from recent meta-analysis.31 Most, but not all, patients will tolerate the therapy (fig 8⇓) without anaesthetic because of the attenuation of shock from the fat pad. It has still not been determined whether the shock is best aimed at the calcaneal spur, if present, or at the area of maximum tenderness. Although no comparison has been made of results in patients with and without calcaneal spur, since shock wave therapy tends to work only for tendinopathies with calcific change, it would be more advised in patients with an obvious spur on x ray.
Cortisone (including iontophoresis) and other injections
Cortisone injections are the most common “medical” treatment used for plantar fasciitis. They have evidence of efficacy in the short term, with some trials showing greater response than other treatments.32 However, because cortisone has greater side effects than modalities such as extracorporeal shock wave therapy, it can equally be argued that the cheaper (cortisone injection) or less invasive treatment (shock wave) should be used initially.33 One comparison study suggested that if ultrasonography revealed perifascial oedema then cortisone injections gave superior results, but if not then shock wave therapy gave superior results.34 Cortisone iontophoresis has also been used, for those who wish to avoid the pain of an injection.35 Injections are notoriously painful, particularly when ultrasound guided (as the procedure takes longer), although it is argued that ultrasound guided injections are more accurate.36 37 Non-guided injections can be performed more rapidly, but there is risk of depositing the cortisone into the fat pad, with fat pad wasting a potential complication of these injections. Another approach is to try to reduce the pain of injection with a median calcaneal nerve block.
It is quite plausible (because plantar fasciitis is considered an enthesopathy but not a tendinopathy) that cortisone injections are more successful in plantar fasciitis than tendinopathies. It is also possible that studies of cortisone injections in plantar fasciitis have not generally reported long enough follow-up to reveal a reversal of initially good results.10 In other enthesopathies (such as tennis elbow) there has been a shift towards the use of newer injection options such as platelet rich plasma.10 38 The only comparative study to date showed no difference in effectiveness between platelet rich plasma and cortisone for plantar fasciitis,39 although a larger trial is under way.40
At least three trials have shown a potential role for botulinum toxin injections in plantar fasciitis.41 42 43 If further high quality study confirms a benefit, it will suggest that flexor digitorum brevis tendinopathy is part of the plantar fasciitis pathology, as a muscle toxin can theoretically have an effect only on a tendon (by relieving muscular pulling) rather than the ligament component of the plantar insertion.
Surgery remains an option for longstanding cases of plantar fasciitis, with case series evidence of success.44 45 46 47 As with many other musculoskeletal conditions, there is no evidence from randomised control trials to support surgery. Given that the prognosis for most cases is benign, it is hard to justify surgery in a case of only a few months’ duration given the likely success with less invasive methods. The fact that rupture of the plantar fascia has been reported to sometimes cure the condition11 suggests that surgical division of the origin (performed with open or arthroscopic technique) might give success in resistant cases. Although hamstring and calf tightness are associated with plantar fasciitis,15 cause and effect has not been proved, and it may be that these phenomena are all caused by subtle L5 and S1 nerve impingement in older people.48 Good results obtained from gastrocnemius release in plantar fasciitis47 49 either supports a role for aetiology or suggests that much of the success of surgery may be due to a prolonged period of unloading and reloading.
Weight loss in plantar fasciitis
Weight loss can be particularly problematic in plantar fasciitis, as one of the primary components of a sensible weight loss programme (less sitting, more standing and walking) can be compromised by the pain of plantar fasciitis. Cross training (such as swimming and cycling) can be particularly valuable until the pain starts to resolve. Although it is not covered in the literature as a plantar fasciitis treatment, tracking daily step counts with pedometers can be useful in the management of plantar fasciitis—initially to unload, and then to manage return to higher loads. Pedometers are currently the most common method for managing step counts (and hence loads), but they are likely to be superseded soon by global positioning system (GPS) and accelerometer technology in mobile phones which could equally record steps per day.
What is the prognosis?
There are no treatments for plantar fasciitis with the highest level of evidence of efficacy (that is, a meta-analysis of multiple, well conducted, randomised controlled trials). However, there are many treatments of low to moderate cost with a lesser degree of supportive evidence. Clinical experience can impart a sense of which treatments are most likely to be useful in which subgroup of patients (table⇑). In the absence of high quality evidence, it is still possible (and indeed likely) to achieve a high success rate with a combination of the treatments for plantar fasciitis. Allowing a moderately rapid return to ambulation can help address the spiral of immobility causing further weight gain, which contributes to a worsening of the condition, presenting a major challenge in treating many plantar fascia patients. For this reason, immobilisation (which decreases energy expenditure) is generally a poor choice of treatment for overweight patients with plantar fasciitis.
The prognosis for most patients with plantar fasciitis is generally good, particularly if a wide variety of treatment modalities is attempted. For this reason, the condition should be considered a curable one and every effort made to achieve this, with a high potential secondary gain (in terms of future ability to exercise) if a cure is achieved.
Cite this as: BMJ 2012;345:e6603
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Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; externally peer reviewed.