Plantar fasciitis

INTRODUCTION — Plantar fasciitis is one of the most common causes of foot and heel pain in adults. Plantar fasciitis is responsible for approximately one million patient visits to the doctor per year in the United States [1]. Among those with plantar foot pain, nearly two-thirds (61.5 percent) consulted a health professional in the last 12 months, most commonly a general practitioner (43.1 percent) or podiatrist (32.8 percent).

Plantar fasciitis will be discussed in this topic review. Other causes of foot and heel pain are discussed separately:

●(See "Overview of foot anatomy and biomechanics and assessment of foot pain in adults".)

●(See "Achilles tendinopathy and tendon rupture".)

●(See "Overview of lower extremity peripheral nerve syndromes".)

●(See "Evaluation of the diabetic foot".)

●(See "Running injuries of the lower extremities: Patient evaluation and common conditions".)

ANATOMY — The deep plantar fascia (ie, plantar aponeurosis) is a thick, pearly-white tissue that extends from the calcaneal tubercle to the digital flexor tendons on each proximal phalanx. The superficial plantar fascia has longitudinal fibers attached to the skin from the heel to the toes. (figure 1) The central portion is thickest and attaches to the medial process of the tuberosity of the calcaneus; distally, it divides into five slips, one for each toe.

The plantar fascia provides support to the longitudinal arch of the foot. As the toes extend while walking, the plantar fascia tightens (like a shortening rope), resulting in elevation of the longitudinal arch, inversion of the hindfoot, and external rotation of the leg [2].

Plantar fasciitis typically affects the origin of the plantar fascia at the medial tuberosity of the calcaneum.

EPIDEMIOLOGY

●Prevalence – Plantar fasciitis is one of the most common causes of foot pain in adults. Based on the general practice records of approximately 1.9 million people in the Netherlands from 2013 to 2016, the point prevalence of plantar heel pain was 0.44 percent [3]. In a large internet-panel survey of the adult United States population, the population-based prevalence of self-reported plantar fasciitis with pain in the last month was 0.85 percent [4].

The prevalence of plantar fasciitis is higher among older adults. In a community-based population sample of adults aged 50 years or older registered with four general practices in the United Kingdom, the one-month prevalence of plantar heel pain was 9.6 percent [5].

●Incidence – The peak incidence occurs between ages 40 and 60 years in the general population [4], with a younger peak in runners [6,7]. In a population-based survey conducted in the Netherlands, the overall incidence of plantar fasciitis was 3.83 cases per 1000 patient-years [3]. The peak incidence occurred in September and October each year, which might be explained by an increase in activity and change in footwear during the summer months.

ETIOLOGY AND RISK FACTORS — The etiology of plantar fasciitis is probably multifactorial. Possible risk factors for the development of plantar fasciitis include obesity, prolonged standing, jumping, flat feet, and reduced ankle dorsiflexion [7-12]. However, most studies have been cross-sectional, precluding any conclusions regarding causation [13].

●Weight – A systematic review of 51 observational studies found that the only significant clinical association with a diagnosis of plantar fasciitis was having a body mass index (BMI) over 27 (odds ratio [OR] 3.7, 95% CI 2.93-5.62) [14]. However, in the absence of prospective cohort studies in the general population, the causal role of being overweight or obese is unclear.

●Heel spurs – While heel spurs often coexist with plantar fasciitis, they may be caused by the same factors that lead to plantar fasciitis [6,9,15]. One study assessed the presence of foot pain in 137 people with heel spurs compared with age- and sex-matched people without heel spurs. This study found an association between heel spurs and increased BMI, diabetes, and lower-limb osteoarthritis [16]. People with heel spurs had a higher prevalence of foot pain, but the prevalence of plantar fasciitis was similar in both groups.

●Diabetes – Observational data suggests that the risk of plantar fasciitis may be higher among those with type 2 diabetes compared with those without diabetes [17]. However, whether diabetes is involved in the pathogenesis of plantar fasciitis is unknown.

●Microtrauma – There is a high incidence of plantar fasciitis in runners, suggesting that plantar fasciitis, at least in this population, is due to repetitive microtrauma [18]. In this group, the following have been proposed as risk factors [19-24]:

•Excessive training (particularly a sudden increase in the distance run)

•Inappropriate running shoes

•Running on hard surfaces (including some synthetic running tracks)

•Flat feet (ie, pes planus) or pronated ankles

•Limited ankle dorsiflexion (eg, due to a shortened Achilles tendon)

•Pes cavus (ie, high-arched) foot

•Prolonged walking or standing on hard surfaces

Plantar fasciitis is common among ballet dancers [25] and among those performing dance aerobic exercise. During these activities, stress applied to the Achilles tendon results in increased tension in the plantar fascia [26]. Additionally, decreased knee extension, as may occur with tight hamstring muscles, causes an increase in loading of the forefoot [27]; this could, in turn, increase the stress on the plantar fascia. However, high-quality evidence linking these factors to plantar fasciitis is limited.

●Other associations – Other associations with plantar fasciitis that have been reported include lower socioeconomic status, impaired physical and mental health, low levels of physical activity and participation, anxiety, and depression [5].

Plantar fasciitis usually occurs as an isolated problem but may be associated with systemic rheumatic diseases, particularly spondyloarthritis. Plantar fasciitis has also been reported in association with fibromyalgia [28], osteomalacia [29], and fluoride used for the treatment of osteoporosis [30].

COMMON CLINICAL FEATURES

Presenting signs and symptoms — Plantar fasciitis is characterized by pain in the plantar aspect of the heel that is worse when initiating walking. The pain typically occurs at the medial insertion of the plantar fascia into the calcaneus but can occur laterally as well.

Patients often describe the gradual onset of heel pain that is worse with their first steps in the morning or after a period of inactivity. The pain typically lessens with gradually increased activity and with rest. However, the pain worsens toward the end of the day with prolonged weightbearing. Heel pain can be worse when walking in bare feet or on hard surfaces [6,8,31].

Laboratory features — Laboratory testing is not helpful in the diagnosis of plantar fasciitis. Tests for inflammation (eg, erythrocyte sedimentation rate and C-reactive protein) will be normal unless there is coexistent inflammatory disease.

Imaging features — Imaging is generally not indicated for the evaluation of plantar fasciitis. The main role of imaging is to confirm the diagnosis in refractory cases and to evaluate for other potential causes of foot pain. Imaging findings associated with plantar fasciitis include:

●Radiographs – Plantar fasciitis is associated with increased plantar fascia thickness and fat pad abnormalities on plain radiographs [32]. However, the absence of these findings does not rule out plantar fasciitis.

Radiographs may be required to rule out alternative causes of pain in patients with atypical symptoms. For example, plain radiographs (including lateral and axial views) may be helpful in identifying calcaneal stress fractures.

The presence of heel spurs is of no diagnostic value in either ruling in or ruling out plantar fasciitis (image 1). (See 'Etiology and risk factors' above.)

●Magnetic resonance imaging – Features suggestive of plantar fasciitis include thickening of the plantar fascia and increased signal on delayed (T2) and short tau inversion recovery (STIR) images [33]. However, the absence of these findings does not rule out plantar fasciitis.

●Ultrasonography – Ultrasonography of the foot may detect several features indicative of plantar fasciitis, including plantar fascial thickening, hypoechogenicity at the insertion upon the calcaneus, and blurring of the boundary between fascia and surrounding tissues (image 2) [34,35]. Doppler ultrasound may provide additional information on local hyperemia, which is associated with plantar fasciitis [36].

The true sensitivity and specificity of ultrasonographic findings for a diagnosis of plantar fasciitis is not clear, mainly due to differences in study design and study population:

•One ultrasonographic study reported that plantar fascia thickening and heel spurs are present in 30 percent of people with plantar heel pain, but these changes are also commonly observed in people without heel pain (30 versus 19 percent) [37], indicating that these findings may have limited diagnostic value. This study also reported that localized heel tenderness was not associated with these ultrasonographic findings, either alone or in combination.

•In a study of 77 patients with unilateral or bilateral heel pain and a similar number of asymptomatic controls, the sensitivity and specificity of ultrasonography for the diagnosis of plantar fasciitis were 80 and 88.5 percent, respectively [38].

•Another study in 25 patients with bilateral heel pain reported lower sensitivity and specificity (66 and 75 percent, respectively), but it was unclear if the reference standard results were blinded [39].

Pathology — Specimens of plantar fascia obtained during surgery for plantar fasciitis reveal a spectrum of changes, ranging from degeneration of the fibrous tissue to fibroblastic proliferation, with or without evidence of chronic inflammation [40-42].

DIAGNOSIS — Plantar fasciitis is a clinical diagnosis based on the presence of two factors:

●A history of pain in the plantar heel that is worse when initiating walking

●Local point tenderness near the origin of the plantar fascia at the medial tuberosity of the calcaneum

Tenderness is best elicited by the examiner dorsiflexing the patient's toes with one hand in order to pull the plantar fascia taut, then palpating with the thumb or index finger of the other hand along the fascia from the heel to the forefoot (picture 1). While examining the patient, points of discrete tenderness can be found and marked for possible later injection. (See 'Glucocorticoid injections for severe pain' below.)

We do not routinely recommend additional tests. Laboratory tests, imaging, and biopsy do not add value over a clinical diagnosis alone. Magnetic resonance imaging (MRI) or ultrasound may be useful to confirm the diagnosis of plantar fasciitis in patients suspected of having an alternate diagnosis, but their limited sensitivity and specificity preclude their routine use. (See 'Differential diagnosis' below and 'Imaging features' above.)

Alternate etiologies should be considered in patients with neurologic symptoms (ie, weakness or numbness), a predisposition to infection, a history of malignancy, and/or atypical features (as discussed below). In particular, bilateral symptoms, morning back stiffness, current or previous inflammatory arthritis, and/or a history of inflammatory bowel disease or psoriasis should prompt consideration of spondyloarthritis. Calcaneal fracture should be considered if there is a history of injury or trauma.

DIFFERENTIAL DIAGNOSIS — Plantar fasciitis is the most likely cause of plantar heel pain. Other causes are rare. Moreover, persisting pain is typical for plantar fasciitis and does not necessarily suggest an alternative cause, although most patients will become asymptomatic a year after diagnosis. (See 'Prognosis' below.)

A thorough discussion of an approach to hindfoot pain other than plantar fasciitis may be found elsewhere (see "Evaluation and diagnosis of common causes of hindfoot pain in adults"). Some alternate diagnoses include the following [43-45]:

Neurologic causes

●Nerve entrapment or compression syndromes – Pain, paresthesia, and numbness on the sole of the foot can be caused by entrapment of the posterior tibial nerve as it courses beneath the medial malleolus (ie, tarsal tunnel syndrome). Pain to percussion over the posterior tibial nerve in the tarsal tunnel is suggestive of tarsal tunnel syndrome.

Compression or trauma to branches of the posterior tibial nerve, particularly the medial calcaneal branch, can lead to medial and plantar burning pain. Compression of the nerve to the abductor digiti quinti can also cause burning pain in the heel. (See "Overview of lower extremity peripheral nerve syndromes".)

●Neuropathic pain – Patients with peripheral neuropathy generally report diffuse foot pain with nocturnal symptoms. (See "Overview of lower extremity peripheral nerve syndromes", section on 'Pathogenesis'.)

●S1 radiculopathy – Patients with lumbar spine disorders may have weakness of plantar flexion and pain radiating down the posterior aspect of the leg to the heel. An absent or reduced ankle reflex is typical. (See "Acute lumbosacral radiculopathy: Etiology, clinical features, and diagnosis", section on 'S1 radiculopathy'.)

Skeletal causes

●Calcaneal stress fracture – Calcaneal stress fracture is associated with calcaneal pain, exacerbated by weightbearing. Stress fractures should be considered if the pain is sudden in onset or associated with trauma. Axial loading of the foot following a fall from a height is the most common cause of severe calcaneal fractures. While plain radiographs may be diagnostic, early changes are better differentiated by MRI. (See "Overview of cancer pain syndromes" and "Nonvertebral osteomyelitis in adults: Clinical manifestations and diagnosis", section on 'Diagnosis' and "Overview of stress fractures" and "Calcaneus fractures".)

●Bone contusion – Direct trauma or excessive weightbearing exercise can lead to a contusion, which is characterized by generalized pain over the inferior heel.

●Osteomyelitis – Infection of the calcaneus may be accompanied by more constant pain and systemic signs such as fever. (See "Nonvertebral osteomyelitis in adults: Clinical manifestations and diagnosis", section on 'Clinical manifestations'.)

●Neoplasm – Tumors in the calcaneal bone are rare and are characterized by deep bone pain, which is often worse at night. (See "Bone tumors: Diagnosis and biopsy techniques", section on 'Clinical presentation'.)

●Paget disease – This may be another source of calcaneal bone pain and is generally apparent on plain radiographs, which will demonstrate coarsened trabecular bone. An elevated serum alkaline phosphatase may also be present. (See "Clinical manifestations and diagnosis of Paget disease of bone".)

●Haglund deformity – Haglund deformity describes a prominent, enlarged, bony, posterior-superior calcaneal tubercle. Posterior calcaneal tubercule impingement syndrome describes a Haglund deformity associated with posterior heel pain above the site of attachment of the Achilles tendon [46]. The foot pain may be caused, in part, by a retrocalcaneal bursitis.

Patients with this syndrome may report discomfort when wearing shoes. On examination, patients may have a palpable 2 to 3 mm bony extrusion at the calcaneus with an area of erythema and swelling of the overlying skin. (See "Evaluation and diagnosis of common causes of hindfoot pain in adults", section on 'Achilles tendon insertion and Haglund deformity'.)

Soft tissue causes

●Achilles tendinopathy – Disorders of the Achilles tendon typically produce posterior heel pain. Achilles tendinopathy and its management are reviewed in detail separately. (See "Achilles tendinopathy and tendon rupture".)

●Tendinitis of the posterior tibialis or flexor digitorum longus tendons – These typically have an insidious onset with pain and tenderness along the course of the tendons and tendon sheaths. Subtle changes in the position of bones of the midfoot may be indicative of tendon rupture. (See "Non-Achilles ankle tendinopathy".)

●Fat-pad atrophy – Atrophy of the heel pad occurs in older adults. Palpation reveals bony prominence without the padding usually afforded by subcutaneous fat. Unlike pain due to plantar fasciitis, pain due to atrophy of the heel pad is absent in the morning, and it develops and worsens during weightbearing throughout the day.

●Bursitis – Retrocalcaneal bursitis may cause localized swelling and erythema of the posterior heel.

●Painful heel pad syndrome – The painful heel pad syndrome occurs most often in marathon runners. It is thought to result from disruption of the fibrous septae that compartmentalize the fat in the heel pad. With this syndrome, pain is localized to the heel pad. The plantar fascia is not tender, and pain is not accentuated as the examiner dorsiflexes the toes. Insertion of heel cups [47] and "Plastazote" that is individually molded to the patient's heel may be useful [48]. (See "Evaluation and diagnosis of common causes of hindfoot pain in adults", section on 'Heel contusion'.)

●Plantar fascia rupture – Rupture of the plantar fascia generally follows physical activity and has a sudden onset, unlike the more gradual appearance of the pain of plantar fasciitis. Examination of the affected foot may reveal a loss of height of the arch. There may be visible swelling, or ecchymosis may be present. Ultrasound or MRI can be used to confirm plantar fascia rupture.

●Piezogenic papules – Piezogenic papules are herniations of fat that occur as painful papules at the medial inferior border of the heel (picture 2). They may be noted only upon weightbearing and are an uncommon cause of painful heels. Weight reduction, use of felt padding, and cushion- or crepe-soled shoes may provide relief [49]. (See "Evaluation and diagnosis of common causes of hindfoot pain in adults", section on 'Piezogenic papules'.)

Inflammatory disorders

●Reactive arthritis and other forms of spondyloarthritis – Spondyloarthritis frequently affects the joints and entheses of the lower extremities. Back pain with inflammatory features (eg, night pain, prolonged morning stiffness) is frequently present in patients with ankylosing spondylitis, while a prior history of enterocolitis or of genitourinary infection is suggestive of reactive arthritis. There are no findings on physical examination that can distinguish between plantar fasciitis and these inflammatory conditions unless other entheses or joints are affected. (See "Reactive arthritis" and "Clinical manifestations and diagnosis of peripheral spondyloarthritis in adults", section on 'Musculoskeletal features'.)

●Sarcoidosis – Heel pain has been reported to occur in sarcoidosis [50]. Patients with acute sarcoidosis may present with Löfgren syndrome, which comprises erythema nodosum, hilar adenopathy, migratory polyarthralgia, and fever. (See "Clinical manifestations and diagnosis of sarcoidosis", section on 'Typical presentations'.)

TREATMENT

Patient counseling — Patients may have unrealistic expectations that medical care can eliminate their symptoms [51]. We suggest providing all patients with a description of the likely course of the condition, as well as the fact that treatment is largely symptomatic, and explaining that it is not clear whether interventions significantly shorten the duration of the problem.

The vast majority of patients with plantar fasciitis will recover fully with time. It is likely that, similar to lateral epicondylitis (ie, tennis elbow), this occurs at random, with approximately 50 percent of people improving every three months irrespective of treatment [52]. Therefore, patient management focuses on providing temporary relief rather than long-term interventions.

Persistent symptoms are not unusual and do not imply that the plantar fasciitis will evolve into a chronic condition. For many patients, counseling and reassurance is more effective than many of the interventions routinely suggested for plantar fasciitis. (See 'Limited role for other interventions' below and 'Prognosis' below.)

Initial management for all patients — We suggest treatment with rest, avoidance of aggravating factors, and reducing pressure on the heel with a prefabricated silicone insert. We also suggest addressing underlying conditions that may have led to plantar fasciitis. However, the efficacy of these interventions for accelerating the resolution of plantar fasciitis is unclear [43,53].

For patients with severe pain, we suggest glucocorticoid injections. These may be more effective for patients with morning pain and stiffness or pain after periods of inactivity.

Rest and avoidance of exacerbating factors — Many patients with plantar fasciitis will have adequate symptomatic relief with rest and avoiding or modifying activities associated with heel impact, such as running, dancing, and jumping. Decreasing the frequency or duration of these activities may help prevent plantar fasciitis.

In a meta-analysis of 8806 runners, reduction in training load (eg, duration, frequency, distance) was associated with a reduction in lower limb soft tissue running injuries, including plantar fasciitis [54]. For example, people who train one to three days weekly are less likely to be injured than people who train five days weekly (relative risk [RR] 0.19). (See 'Etiology and risk factors' above.)

Cushioned footwear — Footwear should provide sufficient cushioning to reduce pressure on the heel. We suggest modifying the patient’s current footwear with a prefabricated silicone heel insert [55-57]. Patients who work or reside in buildings with concrete floors should use cushion- or crepe-soled shoes with or without silicone heel inserts depending on what is most comfortable for the patient. Other types of inserts (including custom orthotics) have not been proven to be more effective than inexpensive silicone heel inserts and do not merit the additional cost, unless the patient has an underlying condition that requires the use of an orthotic (eg, pes planus). (See 'Ineffective and experimental treatments' below.)

In a study of 236 patients with plantar fasciitis, patients were randomized to stretching exercises alone or stretching exercises in combination with one of four different shoe inserts (ie, silicone heel pad, felt pad, rubber heel cup, or custom-made polypropylene orthotic devices, which are hard inserts that partially cover the sole of the shoe).

After eight weeks, patients who were randomized to use a silicone heel insert with stretching exercises were more likely to report symptomatic improvement than patients randomized to stretching exercises alone (95 versus 72 percent) [55]. Felt inserts and custom orthoses resulted in improvement in 81 and 68 percent of patients, respectively.

Address underlying conditions — We suggest treatment of obesity, symptomatic flat feet, and other underlying conditions that may contribute to plantar fasciitis. However, whether addressing underlying conditions helps prevent future episodes of plantar fasciitis is not clear. (See "Obesity in adults: Overview of management", section on 'Approach to therapy'.)

Glucocorticoid injections for severe pain — For patients who have more acute and severe pain, we suggest a glucocorticoid injection into the plantar fascia. Glucocorticoid injections appear to be most effective for patients with morning pain and stiffness and/or pain after inactivity. Glucocorticoid injections are also a reasonable option for patients with mechanical symptoms (eg, pain mainly associated with specific activities); however, we first discuss with the patient that mechanical symptoms are less likely to benefit from glucocorticoid injections.

For patients who experience a recurrence in pain following glucocorticoid injection, a second glucocorticoid injection may be administered. There are no studies demonstrating a minimum amount of time that must elapse between injections, or a maximum number of injections that may be safely administered during a given time period. However, most patients will only require one or two injections before their symptoms begin to resolve.

●Technique for glucocorticoid injection – The points of tenderness along the plantar fascia may be injected with a glucocorticoid and local anesthetic mixture (eg triamcinolone 10 mg or betamethasone 6 mg mixed 1:1 with 1 or 2% lidocaine) (picture 3). A medial approach may be less painful than a lateral approach [58]. While the author uses a single injection directed to the site of maximal tenderness, other approaches include injections into more than one tender location along the fascia. The patient should be informed that the injection may provide only short-term pain relief but, if effective, can be repeated as needed. There is low- to moderate-quality evidence that use of ultrasound to guide placement of the injection does not improve pain more than palpation-guided injections [59,60].

●Rationale for glucocorticoid injection – Numerous randomized trials and systematic reviews have indicated that glucocorticoid injections provide modest short-term pain relief [60-65]. These trials, in general, do not demonstrate sustained benefits to glucocorticoid injections.

•A 2017 Cochrane review that pooled data from eight trials that compared glucocorticoid injection with either placebo injection (five trials) or no treatment (three trials) confirmed a modest short-term (<1 month) benefit of glucocorticoid injection (ie, mean difference in 100 point visual analog scale for heel pain: -6.4) [60]. However, it may have underestimated the size of the benefit by defining "short-term" as less than four weeks, thereby excluding trials that measured the outcome at six weeks.

•A 2019 study of 90 patients with plantar fasciitis compared glucocorticoid injections with strength training and stretching or with a combination of both [66]. At three months, both groups that received glucocorticoid injections had greater improvement in pain than the group that received exercises alone (ie, a 20 point mean difference on a 100 point visual analog scale for pain during function). At six months, the group that received both glucocorticoid injections and exercise fared better than patients who received either intervention alone.

●Risk of plantar rupture – In theory, repeat injections may cause heel pad atrophy or plantar fascia rupture [67-69]. However, evidence linking repeat injections to plantar fascia rupture is limited and inconclusive. Furthermore, no serious adverse events have been reported in randomized trials that have evaluated one or more glucocorticoid injections.

Studies indicate an increased prevalence of plantar fascia rupture among patients who have received glucocorticoid injections, but this association may not be causal. For example, one study reported a series of 37 patients with a presumptive diagnosis of plantar fascia rupture, all of whom had had a prior episode of plantar fasciitis treated with glucocorticoid injection into the calcaneal origin of the fascia [68]. In another study of 765 patients with plantar fasciitis, 43 of 51 patients with plantar fascia rupture had received one or more glucocorticoid injections, although the number of patients without plantar fascial rupture who received one or more glucocorticoid injections was not reported [69].

Optional interventions — For patients who have persistent symptoms, we again reassure the patient that plantar fasciitis almost always resolves spontaneously, albeit at an unpredictable rate. (See 'Patient counseling' above.)

For patients who wish to explore other options, we use low-cost interventions that are unlikely to harm the patient, such as the interventions listed below.

Stretching exercises — For patients who are interested, stretching exercises are a reasonable option. Some patients report benefit and stretching is unlikely to cause harm. However, the efficacy of stretching exercises as a treatment for plantar fasciitis is uncertain.

Stretching exercises that can be tried include plantar and calf-plantar fascia stretches (figure 2 and picture 4), foot-ankle circles (picture 5), toe curls (picture 6), toe towel curls (picture 7), and unilateral heel raises with toe dorsiflexion (picture 8) [70]. The optimal approach to using stretching exercises is not known. However, one suggestion is to select one of these exercises and perform 10 repetitions three times daily.

Stretching exercises may provide short-term benefit, although the evidence is conflicting [71-73].

●In a study of 82 patients with plantar fasciitis, patients who stretched the plantar fascia for eight weeks reported greater improvements in pain than patients who engaged in less specific stretching exercises (ie, Achilles tendon stretches) [71]. However, there was no difference between these two groups after two years of follow-up, since most patients in both groups had symptom resolution [72].

●In a second study, 92 patients with plantar fasciitis were randomized to calf muscle stretches and sham ultrasound versus sham ultrasound alone [73]. After two weeks, there was no statistically significant difference in improvement in foot pain, foot function, or general foot health.

Formal physical therapy is not more efficacious than home stretching exercises [74]. It is unclear if ice massage and deep friction massage improves the efficacy of stretching exercises.

Nonsteroidal antiinflammatory agents — In our experience, nonsteroidal antiinflammatory agents are unlikely to improve the symptoms of plantar fasciitis. However, for patients who do not achieve adequate pain relief with rest, avoidance of aggravating factors, and cushioned footwear, it is reasonable to use a two- to three-week course of NSAIDs in those without contraindications (table 1).

A well-designed but small trial that randomly assigned 29 patients to NSAID or to placebo reported a nonsignificant trend toward improved pain and disability in the NSAID group [75].

Use of NSAIDs for longer than two or three weeks should be reserved for patients with systemic inflammation. Topical NSAIDs (eg, diclofenac 1% up to four times daily) are also an option, although there are no data about their effects specifically for plantar fasciitis.

Limited role for other interventions — We do not routinely use the interventions listed below. However, limited data support these approaches, which may provide temporary relief as the patient waits for the condition to resolve spontaneously.

When patients are offered these interventions, they should be provided with information about the available evidence to help them make evidence-based decisions about their care. They should also be reminded that plantar fasciitis is self-limited and will eventually resolve without any additional interventions. (See 'Prognosis' below.)

Noninvasive strategies — We do not routinely use any of these interventions, although limited data support their use.

●Low-Dye taping – Low-Dye taping is predominantly used for patients with a recent diagnosis of plantar fasciitis with severe pain or pain immediately upon standing. It is unlikely to benefit patients with chronic symptoms, and even in the acute setting the benefits may be limited [76-78].

With low-Dye taping, four strips of tape are applied to the plantar surface of the affected foot to provide such support (picture 9). The tape should not be applied too tightly, and use of hypoallergenic tape is recommended to avoid allergic reactions [77].

In a study of 105 patients with plantar fasciitis, low-Dye taping for three to five days was associated with a mean 20 mm improvement in a 100 mm visual analog pain scale compared with control patients, whose pain worsened by a mean of 6 mm [76]. In a second study of 92 patients with plantar fasciitis, both low-Dye taping with sham ultrasound for one week and sham ultrasound alone were associated with improvement in "first step" pain (ie, pain associated with weightbearing after prolonged non-weightbearing) [77]. However, the magnitude of improvement was greater among patients who received low-Dye taping (analysis of covariance [ANCOVA] adjusted mean difference -12.3 mm).

●Night splints – Multiple studies have failed to demonstrate a significant benefit associated with the use of resting padded foot splints [79-82]. These splints can usually be purchased in pharmacies that feature orthopedic supplies (picture 10). The splints are worn at night to keep the ankle in the neutral position with or without dorsiflexion of the metatarsophalangeal joints during sleep.

A clinical trial reported night splints were as effective as custom-fitted orthotics [83]. However, custom-fitted orthotics may not be effective for the treatment of plantar fasciitis; therefore, this study may demonstrate that both interventions are equally ineffective. In another randomized trial with 40 unblinded participants, the addition of a night splint to a home exercise program provided no additional clinically important benefit [84].

●Casting – A short walking cast is used by some orthopedists, though there are no published trials of this treatment approach.

●Topical corticosteroids – Topical corticosteroids may provide short-term benefits for plantar fasciitis.

In a participant-blinded randomized trial of 80 participants, patients received either topical clobetasol ointment or petroleum jelly in an occlusive dressing 30 minutes before four weekly sessions of low-energy extracorporeal shock wave therapy (ESWT) [85]. The combination of topical corticosteroids and ESWT yielded greater improvement in morning pain and function at one but not three months compared with the control group. Given that ESWT is ineffective for the treatment of plantar fasciitis, the benefit was likely derived from the topical corticosteroids alone. (See 'Ineffective and experimental treatments' below.)

●Laser therapy – Laser therapy involves the application of lasers to the plantar aspect of the foot to stimulate wound healing. Limited data from small trials indicate that both low- and high-level laser therapy may be effective for the treatment of plantar fasciitis.

Three systematic reviews concluded that low-level laser therapy significantly improves short-term pain associated with plantar fasciitis [86-88]. However, one of these reviews indicated that low-level laser therapy was no more efficacious than ESWT. Given that ESWT is ineffective for the treatment of plantar fasciitis, this study implies that laser therapy is no more effective than placebo [87]. (See 'Ineffective and experimental treatments' below.)

Clinical trials have not consistently demonstrated that high-level laser therapy is more effective than low-level laser therapy for plantar fasciitis [89-91]

Procedure-based strategies — We do not routinely use any of these interventions, although limited data support their use.

●Electric dry needling – Electric dry needling uses an electric current, transmitted through the plantar fascia, to increase blood flow and reduce pain. There are limited data supporting its use as a potential therapy for plantar fasciitis.

A randomized trial investigated the value of up to eight sessions of electric dry needling (one to two times a week for four weeks, needles inserted into eight points for 20 minutes each session) as an adjunct to exercise, manual therapy, and ultrasound in 111 patients with plantar fasciitis [92]. Patients in the dry-needling group were found to have a clinically relevant benefit in pain and disability at one and four weeks and at three months, although 67 percent experienced post-needling muscle soreness and 26 percent experienced mild bruising that resolved within two to four days.

A second trial in 73 patients with heel pain found that electrolysis administered by a single needle once a week for five weeks resulted in improvements in pain and function at one week; this benefit was maintained for six months [93].

A systematic review that included six trials found low certainty evidence of short- and long-term benefits in pain and disability with (nonelectric) dry needling [94], but the trials were at high risk of bias and there was significant heterogeneity across trials, indicating that these results should be interpreted with caution.

●Botulinum toxin injection – Low-certainty evidence indicates that injection of the plantar fascia with botulinum toxin may be an effective treatment for plantar fasciitis.

Systematic reviews of varying quality that have included between 6 to 10 randomized trials have observed a benefit in both pain and function when compared with control patients [95-97]. However, all trials have been small, subject to bias, and had highly heterogenous results, indicating these data are of low certainty.

Surgery — We generally discourage surgical intervention. The efficacy of surgery remains unproven. Some clinicians offer surgery for patients who continue to have symptoms beyond 6 to 12 months. However, most of these patients will eventually improve spontaneously. While numerous surgical procedures have been described, almost none have been assessed in randomized trials.

●Surgical options – The optimal surgical approach to fasciotomy for plantar fasciitis is not clear. Some relevant considerations include the following:

•Open versus closed release – In comparison with open-release procedures, closed-release procedures may allow more rapid recovery and resumption of usual activities [98,99]. In an uncontrolled series of 16 runners and 10 walkers with refractory plantar fasciitis, closed (uniportal) plantar fasciotomy gave good or excellent results, provided that the patient’s body mass index (BMI) was less than 27 [100]. Runners in this series required a mean of 2.6 months before returning to jogging.

•Deep versus superficial fasciotomy – A small trial reported better early postoperative function scores and fewer adverse events in patients undergoing superficial (rather than deep) fasciotomy; however, the functional scores at one year were similar [101]. Combining release of the plantar fascia and the first branch of the lateral plantar nerve may enhance results. In one series of 28 patients (33 feet), over 90 percent of patients had a good outcome and would recommend the procedure to others [102].

•Adding microtenotomy – Radiofrequency microtenotomy uses low-dose radio waves to promote healing by stimulating angiogenic growth factors in the tendon. However, it may not improve outcomes among patients undergoing surgery for plantar fasciitis.

The use of radiofrequency microtenotomy, which can be performed via open or percutaneous surgery, has been described as a treatment for plantar fasciitis either alone or in conjunction with plantar fasciotomy. A retrospective review including 91 patients treated at one center reported similar outcomes from radiofrequency microtenotomy compared with plantar fasciotomy and no added benefit from having both procedures [103]. Patients undergoing both procedures tended to have more complications compared with either procedure alone.

●Surgical outcomes – It is estimated that 2 to 5 percent of patients with plantar fasciitis undergo surgical procedures [6,18,31,104], although the true rate may be much lower. For example, a report of the surgical experience at the Mayo Clinic found that only 16 operations had been performed during a 12-year study period [105].

Favorable outcomes are reported in more than 75 percent of published case series, although recovery time may be prolonged and persistent pain is not uncommon. Without a control group, it is impossible to know whether surgery accelerated symptom improvement.

A single small open randomized trial compared endoscopic fasciotomy (and removal of bone spur if present) with glucocorticoid injection in 30 participants recruited from sports magazines, all of whom wished to return to their sports [106]. Both groups also received instruction in strength training. There was no clinically important difference between groups in the Foot Function Index at six months. However, at 12 months, the results appeared to favor the surgical group. We have low confidence in these results due to lack of blinding and baseline differences between groups (eg, age, walking/standing hours per day, symptom duration, morning pain, pain during function).

Potential complications of surgery include transient heel pad swelling, calcaneal fracture, injury to the posterior tibial nerve or its branches, and flattening of the longitudinal arch with resultant midtarsal pain. These potential harms should be balanced against the high probability that plantar fasciitis will eventually resolve spontaneously and the lack of high-certainty evidence that surgery is beneficial. (See 'Prognosis' below.)

Ineffective and experimental treatments — Patients have access to multiple approaches to plantar fasciitis that are not supported by high-certainty evidence or are experimental. We discourage patients from using any of the following treatment strategies.

●Noninvasive strategies

•Extracorporeal shock wave therapy – There is high-certainty evidence from randomized trials that ESWT of the plantar fascia is ineffective for treating plantar fasciitis.

A systematic review published in 2005 included 11 trials and performed a pooled analysis of data from six trials involving 897 participants [107]. There was no clinically important benefit of ESWT, despite a small statistically significant benefit in morning pain of less than 0.5 cm on a 10 cm visual analog scale. Furthermore, no statistically significant benefit was observed in a sensitivity analysis that only included studies at low risk of bias. Flaws in study identification, data extraction, and analysis have led subsequent systematic reviews to overestimate the benefits of ESWT [108,109].

•Custom orthotics – Mounting evidence casts doubt on the effectiveness of all forms of foot orthoses for plantar heel pain except for silicone heel inserts [110,111].

Custom-fabricated inserts, usually provided by podiatrists, include inserted orthoses with foam-rubber raised arches and rubber or tub heels, as well as molded ankle-foot orthoses. Customized orthotics cost approximately two- to sixfold more than prefabricated ones [112].

A Cochrane systematic review of 691 participants that assessed the use of custom-made foot orthoses for plantar fasciitis was inconclusive [113]. Comparators varied across trials and included sham orthoses, no treatment, non-custom foot orthoses, night splints, and a combination of manipulation, mobilization, and stretching; all trials were judged to be at high risk of bias. Four trials reported comparable outcomes between treatment groups, while a fifth found better functional outcomes but comparable pain relief with the use of custom-made foot orthoses compared with sham orthoses at 3 and 12 months [112].

Two subsequent systematic reviews also found that foot orthoses of various types were not superior to sham orthoses or other nonsurgical interventions (eg, antiinflammatory agents, exercise) for improving pain and function [110,111].

•Radiation therapy – Radiation of the plantar fascia is sometimes used in Europe to treat chronic plantar fasciitis that is unresponsive to more conservative approaches [114]. Because of concern about the possibility of late-onset hematopoietic malignancy, radiation therapy is seldom used to treat plantar fasciitis in other parts of the world.

Its effectiveness has not been assessed in randomized placebo-controlled trials. In one unblinded and unregistered trial comparing low-dose radiation with platelet-rich plasma injection in 40 sportspeople, similar improvements in pain and function at six months were reported [115].

•Other therapies – Topical application of wheatgrass cream twice daily to the plantar aspect of the foot for six weeks was ineffective when compared with placebo in a randomized trial involving 80 participants [116].

Multiple studies have demonstrated that ultrasound applied to the plantar surface of the foot is ineffective for the treatment of plantar fasciitis [117-119].

●Procedure-based strategies

•Micronized dehydrated human amnion/chorion membrane injection – A single study indicates that dehydrated human amnion/chorion membrane (dHACM) injection into the plantar fascia may be an effective treatment for plantar fasciitis.

A randomized trial involving 145 participants with plantar fasciitis found that a single 1 mL dHACM injection into the plantar fascia resulted in clinically relevant benefits in pain and foot function at three months compared with placebo [120]. However, collected outcomes at 6 and 12 months were not reported. There were three adverse events following dHACM injection (two patients with post-injection pain and one with itching). The cost of the injection was not specified and the trial was industry-sponsored. Further trials are needed to confirm these results.

•Dextrose prolotherapy – Dextrose prolotherapy is purported to induce a regenerative process. Limited data indicate that dextrose prolotherapy may be effective for alleviating pain associated with plantar fasciitis. However, high-quality, placebo-controlled trials are needed to determine the true value of this intervention.

A systematic review of eight randomized trials comparing dextrose prolotherapy with placebo (ie, saline and lidocaine) or other interventions concluded that almost all of these studies had a high risk of bias [121].

A second systematic review of six randomized trials found that dextrose prolotherapy was inferior to glucocorticoid injection for improving short-term function (ie, one to two months following the intervention). This review also concluded that dextrose prolotherapy is inferior to ESWT and equivalent to platelet-rich plasma for improving short-term function [122]. However, both ESWT and platelet-rich plasma are probably ineffective for plantar fasciitis; therefore, these results imply that dextrose prolotherapy may be no more effective than placebo.

•Other injection therapies – Other injection therapies that have been tested in small trials include polydeoxyribonucleotide injection [123] and local ozone (O2-O3) injection [124]. There are limited data supporting the use of these interventions for the treatment of plantar fasciitis.

Polydeoxyribonucleotide is derived from salmon sperm and is also purported to stimulate regeneration [123]. One trial including 44 participants compared this therapy with glucocorticoid injection and found superior pain relief with glucocorticoid injection at two and six weeks and superior effects on function at six weeks, while outcomes were similar at six months [123]. The lack of any between-group differences at six months suggests this treatment is ineffective, and improvements in both groups at six months may reflect the natural history of the condition.

Ozone injection is purported to reduce local inflammation [124]. In the single trial of this therapy, 30 participants were randomized to receive either ozone or glucocorticoid injection [124]. Glucocorticoid injection provided superior pain relief at two weeks, while the visual data presented in the paper suggested no important between-group differences at 12 weeks. Similar to the aforementioned study, these results confirm the short-term benefits of glucocorticoid injection but do not support effectiveness of the new therapy.

•Autologous whole blood injections – Injection of autologous whole blood has been proposed as a treatment for plantar fasciitis because it contains various growth factors that may stimulate angiogenesis and healing [125]. However, autologous whole blood injections have not been demonstrated to be effective for the treatment of plantar fasciitis.

While no trials have assessed the efficacy of autologous blood injection compared with placebo for plantar fasciitis, several trials have compared this treatment with glucocorticoid injection. A systematic review that included five trials found that glucocorticoid injection was more effective than autologous whole blood injection in alleviating pain in the short term (up to six weeks), and this finding was consistent across all the trials [126].

•Autologous platelet-rich plasma injections – Autologous platelet-rich plasma injections are an adaptation of autologous whole blood injections, in which whole blood is centrifuged to a concentrated state and is injected into the plantar fascia. However, the quality of data supporting the use of these injections is poor.

One three-arm randomized trial involving 75 participants reported that autologous platelet-rich plasma injection was significantly more effective than placebo in relieving pain and improving the American Orthopaedic Foot and Ankle Society Score and was of similar efficacy to glucocorticoid injection [127]. However, mean between-group differences were not reported and the placebo group failed to improve over time, which does not reflect the natural history of the condition.

There have been numerous trials of varying quality that have compared this treatment with glucocorticoid injections [128-131]. Most have not blinded participants, and the results have been conflicting. Systematic reviews have graded the evidence as very low certainty based upon very serious limitations of the included trials and serious inconsistency and imprecision [60,126]. Additionally, high-quality trials evaluating this treatment for other soft tissue conditions including tennis elbow [132] and Achilles tendinopathy [133], as well as knee and ankle osteoarthritis [134,135], have found no benefit over placebo.

•Cryosurgery – Cryotherapy involves the use of a cryoprobe to ablate the nerves associated with plantar fascitis symptoms. There are limited data supporting its use as a potential treatment for plantar fasciitis.

A single-arm study that used percutaneous cryosurgery, a minimally invasive technique for freezing tissue, to treat plantar fasciitis in 59 patients reported a benefit at one year but did not report earlier outcomes [136]. The effectiveness of this technique needs to be assessed in controlled trials.

PROGNOSIS — The outcome for patients with plantar fasciitis is generally favorable; approximately 80 percent of patients have complete resolution of pain within one year [31,104,137,138]. The favorable natural history of this benign condition should be borne in mind when weighing the potential benefits and risks of unproven and sometimes costly treatments.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Plantar fasciitis".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Heel pain caused by plantar fasciitis (The Basics)")

●Beyond the Basics topics (see "Patient education: Heel and foot pain (caused by plantar fasciitis) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Epidemiology – Plantar fasciitis, characterized by pain in the plantar region of the foot that is worse when initiating walking, is one of the most common causes of foot and heel pain in adults. The peak incidence occurs between ages 40 and 60 years in the general population, with a younger peak in runners. It may be bilateral in up to one-third of cases. (See 'Epidemiology' above.)

●Etiology – The etiology is poorly understood and is probably multifactorial. Possible risk factors include obesity, prolonged standing or jumping, flat feet, and reduced ankle dorsiflexion. Plantar fasciitis usually occurs as an isolated problem but may be associated with systemic rheumatic diseases, particularly reactive arthritis and the spondyloarthritides. (See 'Etiology and risk factors' above.)

●Clinical features and diagnosis – The diagnosis of plantar fasciitis is based upon a history of the gradual onset of pain in the inferior heel that is worse when initiating walking, plus the finding of local point tenderness (see 'Common clinical features' above and 'Diagnosis' above):

•Patients often describe heel pain that is worse with their first steps in the morning or after a period of inactivity. The pain typically lessens with gradually increased activity but worsens toward the end of the day with prolonged weightbearing.

•Tenderness is best elicited by the examiner dorsiflexing the patient's toes with one hand in order to pull the plantar fascia taut, then palpating with the thumb or index finger of the other hand along the fascia from the heel to the forefoot (picture 1).

The diagnosis of plantar fasciitis is made clinically; we do not generally obtain laboratory studies, imaging, or biopsy to confirm the diagnosis.

●Patient counseling on expected outcomes – We counsel all patients that plantar fasciitis resolves with time. Approximately 50 percent of patients experience improvement in three months, and over 80 percent have complete resolution within one year. No intervention clearly alters the natural history. Thus, we focus on symptomatic management with behavioral modifications and low-cost, conservative interventions. (See 'Patient counseling' above.)

●Initial management for all patients

•Rest and activity modification – We advise all patients to rest when possible and minimize activities that repetitively place pressure on the plantar fascia. Patients should avoid aggravating factors such as running, dancing, jumping, and walking barefoot as much as possible. Many patients have adequate symptom relief with rest and activity modification.

•Supportive footwear – Footwear should provide sufficient cushioning to reduce pressure on the heel. We suggest a prefabricated silicone heel insert rather than other shoe inserts (Grade 2C). These can improve pain, and data do not clearly demonstrate that other, more expensive inserts, such as custom orthotics, offer more substantial benefit.

•Address underlying conditions – We also address other conditions (eg, obesity, symptomatic flat feet) that may predispose patients to developing plantar fasciitis. (See 'Initial management for all patients' above.)

●Glucocorticoid injection for severe pain – For patients with plantar fasciitis who have severe pain, we suggest a glucocorticoid injection (Grade 2C). We typically use triamcinolone 10 mg mixed 1:1 with 1 or 2% lidocaine. If effective, the injection can be repeated as needed (picture 3).

Glucocorticoid injections are most likely to be effective for patients with morning pain and stiffness and/or pain after periods of inactivity. However, glucocorticoid injections may also help patients with other presentations. (See 'Glucocorticoid injections for severe pain' above.)

●Stretching and NSAIDs as optional interventions – For patients who do not achieve adequate pain relief with the interventions listed above, we reassure the patient that plantar fasciitis almost always resolves with time, albeit at an unpredictable rate.

For patients who wish to try other interventions, we focus on inexpensive therapies associated with low risk to the patient. This includes stretching exercises and nonsteroidal antiinflammatory drugs (NSAIDs) in patients.

Stretching exercises that can be tried include plantar and calf-plantar fascia stretches (figure 2 and picture 4), foot-ankle circles (picture 5), toe curls (picture 6), toe towel curls (picture 7), and unilateral heel raises with toe dorsiflexion (picture 8) [70]. The patient may select one of these exercises and perform 10 repetitions three times daily. (See 'Optional interventions' above.)

●Limited role for other interventions – We do not routinely use other interventions (eg, low-Dye taping, night braces, casting, surgery) for plantar fasciitis because of insufficient high-quality evidence to support their use over conservative measures and/or concern for unnecessary cost or potential harm.

Although other clinicians may offer surgery for patients who continue to have symptoms beyond 6 to 12 months, most of these patients eventually improve spontaneously. It is unknown whether it accelerates symptom improvement. (See 'Limited role for other interventions' above and 'Ineffective and experimental treatments' above.)