Plantar heel pain and plantar fasciitis
Introduction
Plantar heel pain, also known as plantar fasciitis, causes soreness or tenderness of the sole of the foot under the heel, which sometimes extends into the medial arch. Pain associated with the condition may cause substantial disability and poor health-related quality of life. The prevalence and prognosis are unclear, but the symptoms seem to resolve over time in most people.
Methods and outcomes
We conducted a systematic overview, aiming to answer the following clinical questions: What are the effects of conservative treatments for plantar heel pain? What are the effects of non-conservative treatments for plantar heel pain? We searched: Medline, Embase, The Cochrane Library and other important databases up to November 2013 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review).
Results
At this update, searching of electronic databases retrieved 162 studies. After deduplication and removal of conference abstracts, 84 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 39 studies and the further review of 45 full articles. Of the 45 full articles evaluated, five systematic reviews and nine RCTs were included at this update. We performed a GRADE evaluation for 30 PICO combinations.
Conclusions
In this systematic overview, we categorised the efficacy for 12 interventions based on information relating to the effectiveness and safety of corticosteroid injection alone (both short-term and longer-term effects), corticosteroid injections plus local anaesthetic injection (both short-term and longer-term effects), customised foot orthoses, extracorporeal shock wave therapy, heel pads and cups, local anaesthetic injection alone, night splints, stretching exercises, surgery, and taping.
Clinical context
General background
Plantar heel pain, also known as plantar fasciitis, causes soreness or tenderness of the sole of the foot under the heel, which sometimes extends into the medial arch. Pain associated with the condition may cause substantial disability and poor health-related quality of life. Those affected can also have significant limitations in activities of daily living, ability to exercise, and work-related activities. The prevalence and prognosis are unclear, but the symptoms seem to resolve over time in most people.
Focus of the review
In this overview, we look at commonly used conservative and non-conservative interventions that patients may receive.
Comments on evidence
This overview contributes to the evidence base for treating plantar heel pain by providing a summary of evidence that is of high quality. Importantly, many weak studies have been filtered out by our inclusion criteria, ensuring that estimates of treatment effectiveness and adverse effects are as accurate as possible.
Search and appraisal summary
The update literature search for this overview was carried out from the date of the last search, January 2007, to November 2013. For more information on the electronic databases searched and criteria applied during assessment of studies for potential relevance to the overview, please see the Methods section. Searching of electronic databases retrieved 162 studies. After deduplication and removal of conference abstracts, 84 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 39 studies and the further review of 45 full articles. Of the 45 full articles evaluated, five systematic reviews and nine RCTs were included at this update.
Additional information
The condition has for many years been known as 'plantar fasciitis', but there was a move away from this name about 10 years ago because research indicated that it wasn't an inflammatory condition. Hence, the term 'plantar fasciosis' was suggested, which means 'degeneration' of the plantar fascia. Since then, some authors have also referred to it as 'plantar fasciopathy', which simply means pathology of the plantar fascia. However, recent imaging studies are increasingly demonstrating that the condition affects more than just the plantar fascia (e.g., the heel bone and surrounding tissues), so the general term 'plantar heel pain' is more appropriate. Medical imaging may subsequently allow use of specific terms that relate to the tissues/structures involved (e.g., delamination of the plantar fascia, a tear of the plantar fascia, bone marrow oedema of the calcaneus).
About this condition
Definition
Plantar heel pain, also known as plantar fasciitis, is soreness or tenderness of the heel that is restricted to the sole of the foot. It often radiates from the central part of the heel pad or the medial tubercle of the calcaneus, but may extend along the plantar fascia into the medial longitudinal arch of the foot. Severity may range from tenderness at the origin of the plantar fascia, which is noticeable on rising after rest, to an incapacitating pain. This overview excludes clinically evident underlying disorders (e.g., calcaneal fracture and nerve entrapment, which may be distinguished clinically [a calcaneal fracture may present after trauma, and calcaneal nerve entrapment gives rise to shooting pains and feelings of 'pins and needles']). The condition has for many years been known as 'plantar fasciitis', but there was a move away from this name about 10 years ago because research indicated that it was not an inflammatory condition, particularly in its chronic form. As a result of this research, the term 'plantar fasciosis' was suggested, which means 'degeneration' of the plantar fascia. Since then, some authors have also referred to the condition as 'plantar fasciopathy', which simply means pathology of the plantar fascia. However, recent imaging studies are increasingly demonstrating that the condition affects more than just the plantar fascia (e.g., the heel bone and surrounding tissues), so the general term 'plantar heel pain' is more appropriate. Medical imaging may subsequently allow use of specific terms that relate to the tissues/structures involved (e.g., delamination of the plantar fascia, a tear of the plantar fascia, bone marrow oedema of the calcaneus). In this overview we have used the term 'plantar heel pain'; although, when referring to particular studies we have used the authors' terminology
Incidence/ Prevalence
The incidence and prevalence of plantar heel pain are uncertain. However, it has been estimated that 7% of people aged over 65 years in the US report tenderness in the region of the heel, and that plantar heel pain accounts for a quarter of all foot injuries relating to running. In the North West Adelaide Health Study, a population-based study of 3206 people aged 20 years or older, about 4% of the sample indicated that they had pain underneath their heel. A further study from the UK that collected data from 12 primary care settings found that plantar fasciitis accounted for about 8% of musculoskeletal foot and ankle consultations in general practice. In the US from 1995 to 2000, the diagnosis and treatment of plantar heel pain accounted for more than 1 million visits per year to physicians. The condition affects both athletic and sedentary people, and does not seem to be influenced by sex.
Aetiology/ Risk factors
Aetiology is largely unknown. Suggested risk factors include being overweight, older age, prolonged standing, and having a reduced range of motion in the ankle and first metatarsophalangeal joint. A pronated foot posture has also been linked with the condition, but this has not been consistently found to be a risk factor.
Prognosis
One systematic review found that almost all of the included trials reported an improvement in discomfort regardless of the intervention received (including placebo), suggesting that the condition is at least partially self-limiting. A telephone survey of 100 people treated conservatively (average follow-up 47 months) found that 82 people had resolution of symptoms, 15 had continued symptoms but no limitations of activity or work, and three had persistent bilateral symptoms that limited activity or changed work status. Thirty-one people said that they would have seriously considered surgical treatment at the time that medical attention was sought. In addition, one RCT has observed marked improvement in pain and function over time in 45 people with plantar fasciitis who were randomised to a sham intervention. Notwithstanding these findings, some people who have plantar heel pain can experience pain and disability for long periods (i.e., years), and these cases are frustrating to treat both from the patient's and practitioner's perspective.
Aims of intervention
To reduce pain and disability, with minimal adverse effects.
Outcomes
Pain reduction (often measured using visual analogue scales); improvement in function (e.g., walking distance); health-related quality of life; adverse effects.
Methods
Search strategyBMJ Clinical Evidence search and appraisal November 2013. Databases used to identify studies for this systematic review include: Medline 1966 to November 2013, Embase 1980 to November 2013, The Cochrane Database of Systematic Reviews 2013, Issue 10, the Database of Abstracts of Reviews of Effects (DARE), and the Health Technology Assessment (HTA) database. Inclusion criteria Study design criteria for evaluation in this review were systematic reviews and RCTs published in English, at least single-blinded, and containing more than 20 individuals (10 in each arm), of whom more than 80% were followed up. There was no minimum length of follow-up. We excluded all studies described as 'open', 'open label', or not blinded unless blinding was impossible. BMJ Clinical Evidence does not necessarily report every study found (e.g., every systematic review). Rather, we report the most recent, relevant and comprehensive studies identified through an agreed process involving our evidence team, editorial team, and expert contributors. Evidence evaluation A systematic literature search was conducted by our evidence team, who then assessed titles and abstracts, and finally selected articles for full text appraisal against inclusion and exclusion criteria agreed a priori with our expert contributors. In consultation with the expert contributors, studies were selected for inclusion and all data relevant to this overview extracted into the benefits and harms section of the overview. In addition, information that did not meet our predefined criteria for inclusion in the benefits and harms section, may have been reported in the 'Further information on studies' or 'Comment' section. Adverse effects All serious adverse effects, or those adverse effects reported as statistically significant, were included in the harms section of the overview. Pre-specified adverse effects identified as being clinically important were also reported, even if the results were not statistically significant. Although BMJ Clinical Evidence presents data on selected adverse effects reported in included studies, it is not meant to be, and cannot be, a comprehensive list of all adverse effects, contraindications, or interactions of included drugs or interventions. A reliable national or local drug database must be consulted for this information. Comment and Clinical guide sections In the Comment section of each intervention, our expert contributors may have provided additional comment and analysis of the evidence, which may include additional studies (over and above those identified via our systematic search) by way of background data or supporting information. As BMJ Clinical Evidence does not systematically search for studies reported in the Comment section, we cannot guarantee the completeness of the studies listed there or the robustness of methods. Our expert contributors add clinical context and interpretation to the Clinical guide sections where appropriate. Data and quality To aid readability of the numerical data in our overviews, we round many percentages to the nearest whole number. Mean differences taken from systematic reviews may be taken from raw data from an RCT and, as a consequence, may not exactly reflect the actual mean differences reported in that RCT if the authors of the RCT employed any adjustment (e.g., ANCOVA) when calculating between-group differences. Readers should be aware of this when relating percentages to summary statistics such as relative risks (RRs) and odds ratios (ORs). BMJ Clinical Evidence does not report all methodological details of included studies. Rather, it reports by exception any methodological issue or more general issue that may affect the weight a reader may put on an individual study, or the generalisability of the result. These issues may be reflected in the overall GRADE analysis. We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table). The categorisation of the quality of the evidence (high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com).
Table
GRADE Evaluation of interventions for Plantar heel pain and plantar fasciitis.
| Important outcomes | Functional improvement, Health-related quality of life, Pain relief | ||||||||
| Studies (Participants) | Outcome | Comparison | Type of evidence | Quality | Consistency | Directness | Effect size | GRADE | Comment |
| What are the effects of conservative treatments for plantar heel pain? | |||||||||
| 1 (89) | Pain relief | Customised foot orthoses versus placebo/sham or no treatment | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and weak methods |
| 1 (89) | Functional improvement | Customised foot orthoses versus placebo/sham or no treatment | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and weak methods |
| 2 (at least 206) | Pain relief | Customised foot orthoses versus prefabricated orthoses | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for weak methods (incomplete reporting of statistical analysis in one RCT); directness point deducted for use of co-interventions by some participants |
| 1 (at least 88) | Functional improvement | Customised foot orthoses versus prefabricated orthoses | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and weak methods |
| 1 (25) | Pain relief | Customised foot orthoses versus night splints | 4 | –2 | 0 | 0 | 0 | Low | Quality point deducted for sparse data and weak methods |
| 1 (25) | Functional improvement | Customised foot orthoses versus night splints | 4 | –2 | 0 | 0 | 0 | Low | Quality point deducted for sparse data and weak methods |
| 1 (25) | Health-related quality of life | Customised foot orthoses versus night splints | 4 | –2 | 0 | 0 | 0 | Low | Quality point deducted for sparse data and weak methods |
| 1 (170) | Pain relief | Customised orthoses plus taping versus night splints | 4 | –3 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data, weak methods, and lack of statistical assessment of between-group differences; directness point deducted for high attrition rate |
| 2 (at least 20) | Pain relief | Stretching exercises versus placebo or no treatment | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results; directness point deducted for difference in stretching exercise (weight bearing v non-weight bearing) |
| 2 (at least 20) | Functional improvement | Stretching exercises versus placebo or no treatment | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results; directness point deducted for difference in stretching exercise (weight bearing v non-weight bearing) |
| 1 (21) | Pain relief | Stretching exercises versus taping | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (21) | Functional improvement | Stretching exercises versus taping | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 2 (at least 31) | Pain relief | Taping versus placebo/sham or no treatment | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 2 (at least 31) | Functional improvement | Taping versus placebo/sham or no treatment | 4 | –2 | 0 | 0 | 0 | Low | Quality point deducted for sparse data and incomplete reporting of results |
| What are the effects of non-conservative treatments for plantar heel pain? | |||||||||
| 2 (122) | Pain relief | Corticosteroid injections versus placebo or no treatment (short-term) | 4 | –3 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data, weak methods, and incomplete reporting of results in one RCT; directness point deducted for inconsistency between interventions (different corticosteroid injections, and ultrasound-guided versus unguided injections) |
| 1 (82) | Functional improvement | Corticosteroid injections versus placebo or no treatment (short-term) | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, weak methods, and incomplete reporting of results |
| 2 (122) | Pain relief | Corticosteroid injections versus placebo or no treatment (longer term) | 4 | –3 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data, weak methods, and incomplete reporting of results in one RCT; directness point deducted for inconsistency between interventions (different corticosteroid injections; and ultrasound-guided v unguided injections) |
| 1 (82) | Functional improvement | Corticosteroid injections versus placebo or no treatment (longer term) | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, weak methods, and incomplete reporting of results |
| 1 (unclear: <200) | Pain relief | Corticosteroid injection plus local anaesthetic injection versus local anaesthetic injection alone (short-term) | 4 | –3 | 0 | –2 | 0 | Very low | Quality points deducted for sparse data, lack of placebo controls, weak methods (no between-group statistical analysis), and poor follow-up; directness points deducted for uncertainty of clinical relevance and heterogeneity between interventions |
| 1 (unclear; <200) | Pain relief | Corticosteroid injection plus local anaesthetic injection versus local anaesthetic injection alone (longer-term) | 4 | –3 | 0 | –2 | 0 | Very low | Quality points deducted for sparse data, lack of placebo controls, weak methods (no between-group statistical analysis), and poor follow-up; directness points deducted for uncertainty of clinical relevance and heterogeneity between interventions |
| 13 (at least 1307) | Pain relief | Extracorporeal shock wave therapy versus placebo | 4 | –2 | –1 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results and unclear number of participants in analysis; consistency point deducted for statistical heterogeneity between RCTs |
| 5 (790) | Functional improvement | Extracorporeal shock wave therapy versus placebo | 4 | 0 | 0 | –1 | 0 | Moderate | Directness point deducted for different intensities of ESWT |
| 2 (53) | Pain relief | Low dose versus high dose extracorporeal shock wave therapy | 4 | –3 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data, weak methods, and incomplete reporting of results; directness point deducted for differences in interventions (different doses and devices used to generate ESWT) |
| 2 (110) | Functional improvement | Low dose versus high dose extracorporeal shock wave therapy | 4 | –3 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data, weak methods, and incomplete reporting; directness point deducted for differences in interventions (different doses and devices used to generate ESWT) |
| 2 (53) | Health-related quality of life | Low dose versus high dose extracorporeal shock wave therapy | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, weak methods, and incomplete reporting |
| 1 (62) | Pain relief | Extracorporeal shock wave therapy versus corticosteroid injection plus local anaesthetic injection | 4 | –3 | 0 | 0 | 0 | Very low | Quality point deducted for sparse data, incomplete reporting of results, and weak methods |
| 1 (60) | Pain relief | Extracorporeal shock wave therapy plus local anaesthetic injection versus corticosteroid injection plus local anaesthetic injection | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and weak methods |
| 1 (60) | Functional improvement | Extracorporeal shock wave therapy plus local anaesthetic injection versus corticosteroid injection plus local anaesthetic injection | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and weak methods |
| 1 (65) | Pain relief | Extracorporeal shock wave therapy versus surgery | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and weak methods |
| 1 (65) | Functional improvement | Extracorporeal shock wave therapy versus surgery | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and weak methods |
We initially allocate 4 points to evidence from RCTs, and 2 points to evidence from observational studies. To attain the final GRADE score for a given comparison, points are deducted or added from this initial score based on preset criteria relating to the categories of quality, directness, consistency, and effect size. Quality: based on issues affecting methodological rigour (e.g., incomplete reporting of results, quasi-randomisation, sparse data [<200 people in the analysis]). Consistency: based on similarity of results across studies. Directness: based on generalisability of population or outcomes. Effect size: based on magnitude of effect as measured by statistics such as relative risk, odds ratio, or hazard ratio.
Disclaimer
The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients. To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.
Benefits and harms
Customised foot orthoses versus placebo/sham or no treatment:
We found one systematic review (search date 2007), that identified one RCT comparing customised foot orthoses with sham orthoses in people with plantar fasciitis.
Pain relief
Customised foot orthoses compared with placebo/sham or no treatment We don’t know whether customised orthoses are more effective than sham orthoses at relieving pain (assessed using the Foot Health Status Questionnaire) at 3 and 12 months in people with plantar fasciitis (low-quality evidence).
Functional improvement
Customised foot orthoses compared with placebo/sham or no treatment Customised orthoses may be more effective than sham orthoses at improving function (assessed using the Foot Health Status Questionnaire) at 3 and 12 months in people with plantar fasciitis (low-quality evidence).
Customised foot orthoses versus prefabricated orthoses:
We found one systematic review (search date 2007), which identified one RCT meeting BMJ Clinical Evidence inclusion criteria comparing customised orthoses with prefabricated orthoses in people with plantar fasciitis. We found one subsequent RCT evaluating pain relief with customised orthoses versus prefabricated orthoses in adults with plantar fasciitis (see Further information on studies).
Pain relief
Customised foot orthoses compared with prefabricated orthoses Customised orthoses may be no more effective than prefabricated orthoses at reducing pain at up to 12 months in people with plantar fasciitis (low-quality evidence).
Functional improvement
Customised foot orthoses compared with prefabricated orthoses Customised orthoses may be no more effective than prefabricated orthoses at improving function at 3 and 12 months in people with plantar fasciitis; however, the evidence is limited (low-quality evidence).
Customised foot orthoses versus night splints:
We found one systematic review (search date 2007), which identified one RCT meeting BMJ Clinical Evidence inclusion criteria comparing the effects of customised orthoses with night splints in people with plantar fasciitis.
Pain relief
Customised foot orthoses compared with night splints We don’t know whether customised orthoses are more effective than night splints at reducing pain at 6 and 12 weeks in people with plantar fasciitis (low-quality evidence).
Functional improvement
Customised foot orthoses compared with night splints We don’t know whether customised orthoses are more effective than night splints at improving function or reducing disability at 6 and 12 weeks in people with plantar fasciitis (low-quality evidence).
Health-related quality of life
Customised foot orthoses compared with night splints We don’t know whether customised orthoses are more effective than night splints at improving health-related quality of life at 6 and 12 weeks in people with plantar fasciitis (low-quality evidence).
Adverse effects
Customised orthoses plus taping versus night splints:
We found one systematic review (search date 2007), that identified one RCT evaluating customised orthoses plus taping compared with night splints in people with plantar fasciitis.
Pain relief
Customised orthoses plus taping compared with night splints We don’t know whether custom-made orthoses plus taping are more effective than night splints in reducing pain at 12 weeks in people with plantar fasciitis (very low-quality evidence).
Further information on studies
The systematic review reported that none of the included trials blinded the investigator (i.e., therapist). However, the review did highlight that investigator blinding in RCTs assessing orthoses would be difficult to achieve, as the investigator would need to fit the orthoses and they would easily be able to differentiate between the different interventions. This is different to assessor blinding, which should be able to be achieved. In one RCT comparing custom-made orthoses with sham orthoses, the study protocol stipulated that other treatments, such as anti-inflammatory drugs or corticosteroid injections, were not permitted. Although some participants broke protocol and took other interventions, there was no significant difference between the two groups at 3 months (4% v 9%; RR 0.65, 95% CI 0.11 to 3.71) or 12 months (18% v 26%; RR 0.69, 95% CI 0.31 to 1.56) in the proportion of participants self-reporting this break in protocol.
Participants in this RCT were permitted to use a co-intervention, if required. Co-interventions were used by 67% of participants; the majority (40%) carrying out stretching exercises for the Achilles’ tendon, and the remainder (28%) using, for example, ice and anti-inflammatory treatment. The RCT reported that there were no differences between the groups in use of co-intervention, but it was highlighted as a potential confounding factor.
The RCT reported by the systematic review did not blind participants to treatment, and treatment allocation was not concealed. The dropout rate was 62/255 (24%) overall; no breakdown of attrition per arm was reported.
Customised foot orthoses versus placebo/sham or no treatment:
We found one systematic review (search date 2007), that identified one RCT comparing customised foot orthoses with sham orthoses in people with plantar fasciitis.
Pain relief
Customised foot orthoses compared with placebo/sham or no treatment We don’t know whether customised orthoses are more effective than sham orthoses at relieving pain (assessed using the Foot Health Status Questionnaire) at 3 and 12 months in people with plantar fasciitis (low-quality evidence).
Functional improvement
Customised foot orthoses compared with placebo/sham or no treatment Customised orthoses may be more effective than sham orthoses at improving function (assessed using the Foot Health Status Questionnaire) at 3 and 12 months in people with plantar fasciitis (low-quality evidence).
Health-related quality of life
Adverse effects
Pain relief
Customised foot orthoses compared with placebo/sham or no treatment We don’t know whether customised orthoses are more effective than sham orthoses at relieving pain (assessed using the Foot Health Status Questionnaire) at 3 and 12 months in people with plantar fasciitis (low-quality evidence).
Functional improvement
Customised foot orthoses compared with placebo/sham or no treatment Customised orthoses may be more effective than sham orthoses at improving function (assessed using the Foot Health Status Questionnaire) at 3 and 12 months in people with plantar fasciitis (low-quality evidence).
Health-related quality of life
No data from the following reference on this outcome.
Adverse effects
No data from the following reference on this outcome.
Customised foot orthoses versus prefabricated orthoses:
We found one systematic review (search date 2007), which identified one RCT meeting BMJ Clinical Evidence inclusion criteria comparing customised orthoses with prefabricated orthoses in people with plantar fasciitis. We found one subsequent RCT evaluating pain relief with customised orthoses versus prefabricated orthoses in adults with plantar fasciitis (see Further information on studies).
Pain relief
Customised foot orthoses compared with prefabricated orthoses Customised orthoses may be no more effective than prefabricated orthoses at reducing pain at up to 12 months in people with plantar fasciitis (low-quality evidence).
Functional improvement
Customised foot orthoses compared with prefabricated orthoses Customised orthoses may be no more effective than prefabricated orthoses at improving function at 3 and 12 months in people with plantar fasciitis; however, the evidence is limited (low-quality evidence).
Health-related quality of life
Adverse effects
Pain relief
Customised foot orthoses compared with prefabricated orthoses Customised orthoses may be no more effective than prefabricated orthoses at reducing pain at up to 12 months in people with plantar fasciitis (low-quality evidence).
Functional improvement
Customised foot orthoses compared with prefabricated orthoses Customised orthoses may be no more effective than prefabricated orthoses at improving function at 3 and 12 months in people with plantar fasciitis; however, the evidence is limited (low-quality evidence).
No data from the following reference on this outcome.
Health-related quality of life
No data from the following reference on this outcome.
Adverse effects
No data from the following reference on this outcome.
Customised foot orthoses versus night splints:
We found one systematic review (search date 2007), which identified one RCT meeting BMJ Clinical Evidence inclusion criteria comparing the effects of customised orthoses with night splints in people with plantar fasciitis.
Pain relief
Customised foot orthoses compared with night splints We don’t know whether customised orthoses are more effective than night splints at reducing pain at 6 and 12 weeks in people with plantar fasciitis (low-quality evidence).
Functional improvement
Customised foot orthoses compared with night splints We don’t know whether customised orthoses are more effective than night splints at improving function or reducing disability at 6 and 12 weeks in people with plantar fasciitis (low-quality evidence).
Health-related quality of life
Customised foot orthoses compared with night splints We don’t know whether customised orthoses are more effective than night splints at improving health-related quality of life at 6 and 12 weeks in people with plantar fasciitis (low-quality evidence).
Adverse effects
Pain relief
Customised foot orthoses compared with night splints We don’t know whether customised orthoses are more effective than night splints at reducing pain at 6 and 12 weeks in people with plantar fasciitis (low-quality evidence).
Functional improvement
Customised foot orthoses compared with night splints We don’t know whether customised orthoses are more effective than night splints at improving function or reducing disability at 6 and 12 weeks in people with plantar fasciitis (low-quality evidence).
Health-related quality of life
Customised foot orthoses compared with night splints We don’t know whether customised orthoses are more effective than night splints at improving health-related quality of life at 6 and 12 weeks in people with plantar fasciitis (low-quality evidence).
Adverse effects
Customised orthoses plus taping versus night splints:
We found one systematic review (search date 2007), that identified one RCT evaluating customised orthoses plus taping compared with night splints in people with plantar fasciitis.
Pain relief
Customised orthoses plus taping compared with night splints We don’t know whether custom-made orthoses plus taping are more effective than night splints in reducing pain at 12 weeks in people with plantar fasciitis (very low-quality evidence).
Functional improvement
Health-related quality of life
Adverse effects
Pain relief
Customised orthoses plus taping compared with night splints We don’t know whether custom-made orthoses plus taping are more effective than night splints in reducing pain at 12 weeks in people with plantar fasciitis (very low-quality evidence).
Functional improvement
No data from the following reference on this outcome.
Health-related quality of life
No data from the following reference on this outcome.
Adverse effects
No data from the following reference on this outcome.
Further information on studies
The systematic review reported that none of the included trials blinded the investigator (i.e., therapist). However, the review did highlight that investigator blinding in RCTs assessing orthoses would be difficult to achieve, as the investigator would need to fit the orthoses and they would easily be able to differentiate between the different interventions. This is different to assessor blinding, which should be able to be achieved. In one RCT comparing custom-made orthoses with sham orthoses, the study protocol stipulated that other treatments, such as anti-inflammatory drugs or corticosteroid injections, were not permitted. Although some participants broke protocol and took other interventions, there was no significant difference between the two groups at 3 months (4% v 9%; RR 0.65, 95% CI 0.11 to 3.71) or 12 months (18% v 26%; RR 0.69, 95% CI 0.31 to 1.56) in the proportion of participants self-reporting this break in protocol.
Participants in this RCT were permitted to use a co-intervention, if required. Co-interventions were used by 67% of participants; the majority (40%) carrying out stretching exercises for the Achilles’ tendon, and the remainder (28%) using, for example, ice and anti-inflammatory treatment. The RCT reported that there were no differences between the groups in use of co-intervention, but it was highlighted as a potential confounding factor.
The RCT reported by the systematic review did not blind participants to treatment, and treatment allocation was not concealed. The dropout rate was 62/255 (24%) overall; no breakdown of attrition per arm was reported.
The systematic review reported that none of the included trials blinded the investigator (i.e., therapist). However, the review did highlight that investigator blinding in RCTs assessing orthoses would be difficult to achieve, as the investigator would need to fit the orthoses and they would easily be able to differentiate between the different interventions. This is different to assessor blinding, which should be able to be achieved. In one RCT comparing custom-made orthoses with sham orthoses, the study protocol stipulated that other treatments, such as anti-inflammatory drugs or corticosteroid injections, were not permitted. Although some participants broke protocol and took other interventions, there was no significant difference between the two groups at 3 months (4% v 9%; RR 0.65, 95% CI 0.11 to 3.71) or 12 months (18% v 26%; RR 0.69, 95% CI 0.31 to 1.56) in the proportion of participants self-reporting this break in protocol.
The systematic review reported that none of the included trials blinded the investigator (i.e., therapist). However, the review did highlight that investigator blinding in RCTs assessing orthoses would be difficult to achieve, as the investigator would need to fit the orthoses and they would easily be able to differentiate between the different interventions. This is different to assessor blinding, which should be able to be achieved. In one RCT comparing custom-made orthoses with sham orthoses, the study protocol stipulated that other treatments, such as anti-inflammatory drugs or corticosteroid injections, were not permitted. Although some participants broke protocol and took other interventions, there was no significant difference between the two groups at 3 months (4% v 9%; RR 0.65, 95% CI 0.11 to 3.71) or 12 months (18% v 26%; RR 0.69, 95% CI 0.31 to 1.56) in the proportion of participants self-reporting this break in protocol.
Participants in this RCT were permitted to use a co-intervention, if required. Co-interventions were used by 67% of participants; the majority (40%) carrying out stretching exercises for the Achilles’ tendon, and the remainder (28%) using, for example, ice and anti-inflammatory treatment. The RCT reported that there were no differences between the groups in use of co-intervention, but it was highlighted as a potential confounding factor.
Participants in this RCT were permitted to use a co-intervention, if required. Co-interventions were used by 67% of participants; the majority (40%) carrying out stretching exercises for the Achilles’ tendon, and the remainder (28%) using, for example, ice and anti-inflammatory treatment. The RCT reported that there were no differences between the groups in use of co-intervention, but it was highlighted as a potential confounding factor.
The RCT reported by the systematic review did not blind participants to treatment, and treatment allocation was not concealed. The dropout rate was 62/255 (24%) overall; no breakdown of attrition per arm was reported.
The RCT reported by the systematic review did not blind participants to treatment, and treatment allocation was not concealed. The dropout rate was 62/255 (24%) overall; no breakdown of attrition per arm was reported.
Clinical guide
Although the evidence is of low quality, it appears that customised foot orthoses are likely to be beneficial in the short and medium term. However, appropriate prefabricated foot orthoses (that are contoured to the heel and arch of the foot) appear to be as beneficial as customised foot orthoses, so prefabricated foot orthoses should be used first, unless a patient specifically requires a customised orthosis due to abnormal foot structure or function. In addition, customised foot orthoses may be as beneficial as night splints, but the evidence is of low quality. Night splints are also associated with a high frequency of adverse effects, so care is needed with their use. Accordingly, it is recommended that foot orthoses should be prescribed first, before night splints.
Substantive changes
Customised foot orthoses Two systematic reviews and one RCT added. Categorisation unchanged (likely to be beneficial).
Benefits and harms
Heel pads and heel cups versus placebo/sham or no treatment:
We found no RCTs or systematic reviews evaluating heel pads and heel cups compared with placebo or no treatment in people with plantar heel pain.
Heel pads and heel cups versus placebo/sham or no treatment:
We found no RCTs or systematic reviews evaluating heel pads and heel cups compared with placebo or no treatment in people with plantar heel pain.
Substantive changes
No new evidence
Benefits and harms
Night splints versus customised foot orthoses:
See option on Customised foot orthoses.
Night splints versus customised foot orthoses plus taping:
See option on Customised foot orthoses.
Night splints versus customised foot orthoses:
See option on Customised foot orthoses.
Night splints versus customised foot orthoses plus taping:
See option on Customised foot orthoses.
Clinical guide
Night splints are occasionally used for plantar heel pain, particularly in cases that are resistant to other conservative treatment. Night splints may be as beneficial as customised foot orthoses, but the evidence is of low quality. Night splints are also associated with a high frequency of adverse effects, such as sleep disturbance, so care is needed with their use. Accordingly, it is recommended that foot orthoses and taping should be used first before night splints.
Substantive changes
Night splints Two systematic reviews added. Categorisation unchanged (unknown effectiveness).
Benefits and harms
Stretching exercises versus placebo or no treatment:
We found one systematic review (search date 2010), which identified two RCTs evaluating stretching exercises compared with no treatment in people with plantar fasciitis. The review did not present the between-group results from the RCTs in full; therefore, we have reported directly from the RCTs where appropriate.
Pain relief
Stretching exercises compared with placebo or no treatment We don’t know whether stretching exercises are more effective than no treatment at reducing pain at 1 and 2 weeks in people with plantar heel pain (very low-quality evidence).
Functional improvement
Stretching exercises compared with placebo or no treatment We don’t know whether stretching exercises are more effective than no treatment at improving function at 1 and 2 weeks in people with plantar heel pain (very low-quality evidence).
Stretching exercises versus taping:
We found one systematic review (search date 2010), which identified one small RCT evaluating non-weight-bearing stretching exercises compared with calcaneal taping in people with plantar heel pain.
Pain relief
Stretching exercises compared with taping We don’t know whether non-weight-bearing stretching exercises are more effective than calcaneal taping at reducing pain at 1 week in people with plantar heel pain as the evidence is from a small RCT (low-quality evidence).
Functional improvement
Stretching exercises compared with taping We don’t know how non-weight-bearing stretching exercises and calcaneal taping compare in improving function at 1 week in people with plantar heel pain (low-quality evidence).
Stretching exercises versus placebo or no treatment:
We found one systematic review (search date 2010), which identified two RCTs evaluating stretching exercises compared with no treatment in people with plantar fasciitis. The review did not present the between-group results from the RCTs in full; therefore, we have reported directly from the RCTs where appropriate.
Pain relief
Stretching exercises compared with placebo or no treatment We don’t know whether stretching exercises are more effective than no treatment at reducing pain at 1 and 2 weeks in people with plantar heel pain (very low-quality evidence).
Functional improvement
Stretching exercises compared with placebo or no treatment We don’t know whether stretching exercises are more effective than no treatment at improving function at 1 and 2 weeks in people with plantar heel pain (very low-quality evidence).
Health-related quality of life
Adverse effects
Pain relief
Stretching exercises compared with placebo or no treatment We don’t know whether stretching exercises are more effective than no treatment at reducing pain at 1 and 2 weeks in people with plantar heel pain (very low-quality evidence).
Functional improvement
Stretching exercises compared with placebo or no treatment We don’t know whether stretching exercises are more effective than no treatment at improving function at 1 and 2 weeks in people with plantar heel pain (very low-quality evidence).
Health-related quality of life
No data from the following reference on this outcome.
Adverse effects
No data from the following reference on this outcome.
Stretching exercises versus taping:
We found one systematic review (search date 2010), which identified one small RCT evaluating non-weight-bearing stretching exercises compared with calcaneal taping in people with plantar heel pain.
Pain relief
Stretching exercises compared with taping We don’t know whether non-weight-bearing stretching exercises are more effective than calcaneal taping at reducing pain at 1 week in people with plantar heel pain as the evidence is from a small RCT (low-quality evidence).
Functional improvement
Stretching exercises compared with taping We don’t know how non-weight-bearing stretching exercises and calcaneal taping compare in improving function at 1 week in people with plantar heel pain (low-quality evidence).
Health-related quality of life
Adverse effects
Pain relief
Stretching exercises compared with taping We don’t know whether non-weight-bearing stretching exercises are more effective than calcaneal taping at reducing pain at 1 week in people with plantar heel pain as the evidence is from a small RCT (low-quality evidence).
Functional improvement
Stretching exercises compared with taping We don’t know how non-weight-bearing stretching exercises and calcaneal taping compare in improving function at 1 week in people with plantar heel pain (low-quality evidence).
Health-related quality of life
No data from the following reference on this outcome.
Adverse effects
No data from the following reference on this outcome.
Clinical guide
Although stretching is commonly used in practice, the evidence for it is weak and inconsistent. Essentially, we don’t know whether stretching exercises are more effective than no treatment or taping at reducing pain or improving function in people with plantar heel pain. Stretching may also be associated with some adverse effects, such as muscle pain; however, these are generally short-lived. Nevertheless, because stretching has no cost to a patient, other than the time taken to do it, it can still be recommended for plantar heel pain under the proviso that patients are made aware that we don’t know if it is effective and that there may be some adverse effects.
Substantive changes
Stretching exercises One systematic review added. Categorisation unchanged (unknown effectiveness).
Benefits and harms
Taping versus placebo/sham or no treatment:
We found one systematic review (search date 2007), that identified two RCTs comparing taping in the short term (1 week) with no treatment or sham taping in people with plantar fasciitis. The review did not present the results from the RCTs in full, nor did it perform a meta-analysis; therefore, we have reported directly from the RCTs.
Pain relief
Taping compared with placebo/sham or no treatment Taping may be more effective than no treatment or sham taping at reducing first-step pain at 1 week in people with plantar heel pain or fasciitis (low-quality evidence).
Functional improvement
Taping compared with placebo/sham or no treatment We don’t know whether taping is more effective than no treatment or sham taping at improving function at 1 week in people with plantar heel pain or fasciitis (low-quality evidence).
Adverse effects
Taping versus stretching exercises:
See option on Stretching exercises.
Taping plus customised orthoses (custom-made insoles) versus night splints:
See option on Customised foot orthoses.
Further information on studies
The RCT did not state whether the results were based on an intention-to-treat analysis. The study did not measure outcomes beyond 1 week.
Taping versus placebo/sham or no treatment:
We found one systematic review (search date 2007), that identified two RCTs comparing taping in the short term (1 week) with no treatment or sham taping in people with plantar fasciitis. The review did not present the results from the RCTs in full, nor did it perform a meta-analysis; therefore, we have reported directly from the RCTs.
Pain relief
Taping compared with placebo/sham or no treatment Taping may be more effective than no treatment or sham taping at reducing first-step pain at 1 week in people with plantar heel pain or fasciitis (low-quality evidence).
Functional improvement
Taping compared with placebo/sham or no treatment We don’t know whether taping is more effective than no treatment or sham taping at improving function at 1 week in people with plantar heel pain or fasciitis (low-quality evidence).
Health-related quality of life
Adverse effects
Pain relief
Taping compared with placebo/sham or no treatment Taping may be more effective than no treatment or sham taping at reducing first-step pain at 1 week in people with plantar heel pain or fasciitis (low-quality evidence).
Functional improvement
Taping compared with placebo/sham or no treatment We don’t know whether taping is more effective than no treatment or sham taping at improving function at 1 week in people with plantar heel pain or fasciitis (low-quality evidence).
Health-related quality of life
No data from the following reference on this outcome.
Adverse effects
No data from the following reference on this outcome.
Taping versus stretching exercises:
See option on Stretching exercises.
Taping plus customised orthoses (custom-made insoles) versus night splints:
See option on Customised foot orthoses.
Further information on studies
The RCT did not state whether the results were based on an intention-to-treat analysis. The study did not measure outcomes beyond 1 week.
The RCT did not state whether the results were based on an intention-to-treat analysis. The study did not measure outcomes beyond 1 week.
The RCT did not state whether the results were based on an intention-to-treat analysis. The study did not measure outcomes beyond 1 week.
Clinical guide
Taping is frequently used for the early treatment of plantar heel pain, particularly while waiting for customised foot orthoses to be made. Although the evidence is of low quality, it appears that taping is likely to be beneficial in the short term for pain relief. However, it is associated with some minor, short-lived adverse effects, such as potential tightness and skin irritation.
Substantive changes
Taping (low-Dye or antipronatory taping) Two systematic reviews added. Categorisation unchanged (likely to be beneficial).
Benefits and harms
Corticosteroid injections versus placebo or no treatment (short-term):
We found two RCTs evaluating the short-term effects of corticosteroid injections compared with placebo or no treatment in people with plantar fasciitis.
Pain relief
Corticosteroid injections compared with placebo or no treatment (short-term) Corticosteroid injections may be more effective than placebo at reducing pain at 4 and 6 weeks in people with plantar fasciitis (very low-quality evidence).
Functional improvement
Corticosteroid injections alone compared with placebo or no treatment (short-term) We don’t know whether corticosteroid injections are more effective than placebo at improving function at 4 weeks in people with plantar fasciitis (very low-quality evidence).
Further information on studies
To minimise pain during heel injection, both groups received an ultrasound-guided posterior tibial nerve block with 2% lidocaine hydrochloride. The recruitment method for the trial involved advertising in major daily newspapers, which may have led to a sample of participants not fully representative of those seen in general practice. Proportionally, there were more male participants in the RCT (52%) compared with female participants, which is not typical of other plantar fasciitis studies. Participants in both groups were also given a daily stretching programme for 8 weeks to ensure appropriate ethical management and that the trial better represented normal practice. There was no statistically significant difference between treatment groups in adherence to the stretching programme (P = 0.60).
The RCT had unclear method of allocation concealment. The RCT found no statistically significant difference between ultrasound-guided and unguided corticosteroid injection in reduction in pain at 6 or 12 weeks (P = 0.58).
Corticosteroid injections versus placebo or no treatment (short-term):
We found two RCTs evaluating the short-term effects of corticosteroid injections compared with placebo or no treatment in people with plantar fasciitis.
Pain relief
Corticosteroid injections compared with placebo or no treatment (short-term) Corticosteroid injections may be more effective than placebo at reducing pain at 4 and 6 weeks in people with plantar fasciitis (very low-quality evidence).
Functional improvement
Corticosteroid injections alone compared with placebo or no treatment (short-term) We don’t know whether corticosteroid injections are more effective than placebo at improving function at 4 weeks in people with plantar fasciitis (very low-quality evidence).
Health-related quality of life
Adverse effects
Pain relief
Corticosteroid injections compared with placebo or no treatment (short-term) Corticosteroid injections may be more effective than placebo at reducing pain at 4 and 6 weeks in people with plantar fasciitis (very low-quality evidence).
Functional improvement
Corticosteroid injections alone compared with placebo or no treatment (short-term) We don’t know whether corticosteroid injections are more effective than placebo at improving function at 4 weeks in people with plantar fasciitis (very low-quality evidence).
No data from the following reference on this outcome.
Health-related quality of life
No data from the following reference on this outcome.
Adverse effects
No data from the following reference on this outcome.
Further information on studies
To minimise pain during heel injection, both groups received an ultrasound-guided posterior tibial nerve block with 2% lidocaine hydrochloride. The recruitment method for the trial involved advertising in major daily newspapers, which may have led to a sample of participants not fully representative of those seen in general practice. Proportionally, there were more male participants in the RCT (52%) compared with female participants, which is not typical of other plantar fasciitis studies. Participants in both groups were also given a daily stretching programme for 8 weeks to ensure appropriate ethical management and that the trial better represented normal practice. There was no statistically significant difference between treatment groups in adherence to the stretching programme (P = 0.60).
The RCT had unclear method of allocation concealment. The RCT found no statistically significant difference between ultrasound-guided and unguided corticosteroid injection in reduction in pain at 6 or 12 weeks (P = 0.58).
To minimise pain during heel injection, both groups received an ultrasound-guided posterior tibial nerve block with 2% lidocaine hydrochloride. The recruitment method for the trial involved advertising in major daily newspapers, which may have led to a sample of participants not fully representative of those seen in general practice. Proportionally, there were more male participants in the RCT (52%) compared with female participants, which is not typical of other plantar fasciitis studies. Participants in both groups were also given a daily stretching programme for 8 weeks to ensure appropriate ethical management and that the trial better represented normal practice. There was no statistically significant difference between treatment groups in adherence to the stretching programme (P = 0.60).
To minimise pain during heel injection, both groups received an ultrasound-guided posterior tibial nerve block with 2% lidocaine hydrochloride. The recruitment method for the trial involved advertising in major daily newspapers, which may have led to a sample of participants not fully representative of those seen in general practice. Proportionally, there were more male participants in the RCT (52%) compared with female participants, which is not typical of other plantar fasciitis studies. Participants in both groups were also given a daily stretching programme for 8 weeks to ensure appropriate ethical management and that the trial better represented normal practice. There was no statistically significant difference between treatment groups in adherence to the stretching programme (P = 0.60).
The RCT had unclear method of allocation concealment. The RCT found no statistically significant difference between ultrasound-guided and unguided corticosteroid injection in reduction in pain at 6 or 12 weeks (P = 0.58).
The RCT had unclear method of allocation concealment. The RCT found no statistically significant difference between ultrasound-guided and unguided corticosteroid injection in reduction in pain at 6 or 12 weeks (P = 0.58).
Clinical guide
Corticosteroid injections are frequently used for plantar heel pain, particularly if conservative interventions do not lead to the desired effect in a reasonable timeframe. Corticosteroid injections may be more effective than placebo at reducing pain in the short- to medium-term (at 4 and 6 weeks) in people with plantar heel pain, but this is based on weak evidence. There is limited evidence from a systematic review that ultrasound-guided corticosteroid injections are more effective than palpation-guided corticosteroid injections. Corticosteroid injections may be associated with a high rate of plantar fascia rupture and other complications, which may lead to chronic disability in some people; however, this is likely related to the solubility and duration of action of the corticosteroid being used.
Substantive changes
Corticosteroid injections (short-term effects) Two RCTs added. Categorisation changed from 'unknown effectiveness' to 'likely to be beneficial'.
Benefits and harms
Corticosteroid injections versus placebo or no treatment (longer term):
We found two RCTs evaluating the longer-term effects of corticosteroid injections compared with placebo or no treatment in people with plantar fasciitis.
Pain relief
Corticosteroid injections compared with placebo or no treatment (longer term) We don’t know how corticosteroid injections compare with placebo at reducing pain at 8 and 12 weeks in people with plantar fasciitis, as the evidence is weak and inconsistent (very low-quality evidence).
Functional improvement
Corticosteroid injections compared with placebo or no treatment (longer term) We don’t know whether ultrasound-guided corticosteroid injections are more effective than placebo at improving function at 8 and 12 weeks in people with plantar fasciitis (very low-quality evidence).
Adverse effects
Further information on studies
To minimise pain during heel injection, both groups received an ultrasound posterior tibial nerve block with 2% lidocaine hydrochloride. The recruitment method for the trial involved advertising in major daily newspapers, which may have led to a sample of participants not fully representative of those seen in general practice. Proportionally, there were more male participants in the RCT (52%) compared with female participants, which is not typical of other plantar fasciitis studies. Participants in both groups were also given a daily stretching programme for 8 weeks to ensure appropriate ethical management, and that the trial better represented normal practice. There was no statistically significant difference between treatment groups in adherence to the stretching programme (P = 0.60). Regarding the lack of adverse events, the authors noted that "trial supports the use of dexamethasone as a safe treatment option, and that the same safety outcome may not have been achieved with acetate compounds".
The RCT had unclear method of allocation concealment. The RCT found no statistically significant difference between ultrasound-guided and unguided corticosteroid injection in reduction in pain at 6 or 12 weeks (P = 0.58).
Corticosteroid injections versus placebo or no treatment (longer term):
We found two RCTs evaluating the longer-term effects of corticosteroid injections compared with placebo or no treatment in people with plantar fasciitis.
Pain relief
Corticosteroid injections compared with placebo or no treatment (longer term) We don’t know how corticosteroid injections compare with placebo at reducing pain at 8 and 12 weeks in people with plantar fasciitis, as the evidence is weak and inconsistent (very low-quality evidence).
Functional improvement
Corticosteroid injections compared with placebo or no treatment (longer term) We don’t know whether ultrasound-guided corticosteroid injections are more effective than placebo at improving function at 8 and 12 weeks in people with plantar fasciitis (very low-quality evidence).
Health-related quality of life
Adverse effects
Pain relief
Corticosteroid injections compared with placebo or no treatment (longer term) We don’t know how corticosteroid injections compare with placebo at reducing pain at 8 and 12 weeks in people with plantar fasciitis, as the evidence is weak and inconsistent (very low-quality evidence).
Functional improvement
Corticosteroid injections compared with placebo or no treatment (longer term) We don’t know whether ultrasound-guided corticosteroid injections are more effective than placebo at improving function at 8 and 12 weeks in people with plantar fasciitis (very low-quality evidence).
No data from the following reference on this outcome.
Health-related quality of life
No data from the following reference on this outcome.
Adverse effects
Further information on studies
To minimise pain during heel injection, both groups received an ultrasound posterior tibial nerve block with 2% lidocaine hydrochloride. The recruitment method for the trial involved advertising in major daily newspapers, which may have led to a sample of participants not fully representative of those seen in general practice. Proportionally, there were more male participants in the RCT (52%) compared with female participants, which is not typical of other plantar fasciitis studies. Participants in both groups were also given a daily stretching programme for 8 weeks to ensure appropriate ethical management, and that the trial better represented normal practice. There was no statistically significant difference between treatment groups in adherence to the stretching programme (P = 0.60). Regarding the lack of adverse events, the authors noted that "trial supports the use of dexamethasone as a safe treatment option, and that the same safety outcome may not have been achieved with acetate compounds".
The RCT had unclear method of allocation concealment. The RCT found no statistically significant difference between ultrasound-guided and unguided corticosteroid injection in reduction in pain at 6 or 12 weeks (P = 0.58).
To minimise pain during heel injection, both groups received an ultrasound posterior tibial nerve block with 2% lidocaine hydrochloride. The recruitment method for the trial involved advertising in major daily newspapers, which may have led to a sample of participants not fully representative of those seen in general practice. Proportionally, there were more male participants in the RCT (52%) compared with female participants, which is not typical of other plantar fasciitis studies. Participants in both groups were also given a daily stretching programme for 8 weeks to ensure appropriate ethical management, and that the trial better represented normal practice. There was no statistically significant difference between treatment groups in adherence to the stretching programme (P = 0.60). Regarding the lack of adverse events, the authors noted that "trial supports the use of dexamethasone as a safe treatment option, and that the same safety outcome may not have been achieved with acetate compounds".
To minimise pain during heel injection, both groups received an ultrasound posterior tibial nerve block with 2% lidocaine hydrochloride. The recruitment method for the trial involved advertising in major daily newspapers, which may have led to a sample of participants not fully representative of those seen in general practice. Proportionally, there were more male participants in the RCT (52%) compared with female participants, which is not typical of other plantar fasciitis studies. Participants in both groups were also given a daily stretching programme for 8 weeks to ensure appropriate ethical management, and that the trial better represented normal practice. There was no statistically significant difference between treatment groups in adherence to the stretching programme (P = 0.60). Regarding the lack of adverse events, the authors noted that "trial supports the use of dexamethasone as a safe treatment option, and that the same safety outcome may not have been achieved with acetate compounds".
The RCT had unclear method of allocation concealment. The RCT found no statistically significant difference between ultrasound-guided and unguided corticosteroid injection in reduction in pain at 6 or 12 weeks (P = 0.58).
The RCT had unclear method of allocation concealment. The RCT found no statistically significant difference between ultrasound-guided and unguided corticosteroid injection in reduction in pain at 6 or 12 weeks (P = 0.58).
Clinical guide
Corticosteroid injections into the plantar heel can be painful. Complications observed from local corticosteroid injection throughout the body include infection, subcutaneous fat atrophy, skin pigmentation changes, fascial rupture, peripheral nerve injury, and muscle damage, among others. Observational studies have reported rupture of the plantar fascia in people receiving corticosteroid injections. One study reported a 10% incidence of rupture among 122 injected heels. A second study examined 37 people with a presumptive diagnosis of plantar fascia rupture, all of whom had received corticosteroid injections for plantar fasciitis. Their history revealed that in 13/37 (35%) people the rupture had been a sudden event, whereas in the remainder it seemed to be gradual. The study reported that most had resolution of symptoms, but this often took 6 to 12 months to occur.
The evidence from observational studies does not allow us to state with certainty whether plantar fascia rupture is caused by corticosteroid injection, or whether it is coincidental. It is also difficult to define the clinical importance of rupture of the plantar fascia from the evidence provided by observational studies. Two recent RCTs had no ruptures recorded; although, one used dexamethasone sodium phosphate, and the other used methylprednisolone acetate as the corticosteroid. Rupture may be related to the duration of action of the corticosteroid used, with ruptures more likely with less soluble, longer acting corticosteroids. Rupture may relieve the original heel pain, but may cause arch and mid-foot strain, lateral plantar nerve dysfunction, stress fracture, deformity, and swelling, all of which may persist. Plantar fascia rupture is not necessarily a harmful phenomenon, as it may be clinically silent in some people.
Substantive changes
Corticosteroid injections (longer-term effects) Two RCTs added. Categorisation unchanged (likely to be ineffective or harmful).
Benefits and harms
Corticosteroid injection plus local anaesthetic injection versus local anaesthetic injection alone (short-term):
We found one four-armed RCT that compared a single injection of corticosteroid plus local anaesthetic injection with local anaesthetic injection alone, either with or without tibial nerve block, in people with plantar fasciitis.
Pain relief
Corticosteroid injection plus local anaesthetic injection compared with local anaesthetic injection alone (short-term) We don’t know whether a single injection of corticosteroid plus local anaesthetic injection is more effective than local anaesthetic injection alone (with or without tibial nerve block) at improving pain in the short term (at 1 month) in people with plantar fasciitis (very low-quality evidence).
Adverse effects
Corticosteroid injection plus local anaesthetic injection versus extracorporeal shock wave therapy:
See option on Extracorporeal shock wave therapy.
Corticosteroid injection plus local anaesthetic injection versus extracorporeal shock wave therapy plus local anaesthetic injection:
See option on Extracorporeal shock wave therapy.
Further information on studies
The RCT reported a dropout rate of more than 20% at 3 months and more than 45% at 6 months, and no intention-to-treat analysis was carried out. Participants’ perception of pain from corticosteroid injection did not appear to be affected by prior administration of tibial nerve block (P = 0.5). Participants were permitted to continue using orthoses, insoles, pads, or painkillers throughout the study.
Corticosteroid injection plus local anaesthetic injection versus local anaesthetic injection alone (short-term):
We found one four-armed RCT that compared a single injection of corticosteroid plus local anaesthetic injection with local anaesthetic injection alone, either with or without tibial nerve block, in people with plantar fasciitis.
Pain relief
Corticosteroid injection plus local anaesthetic injection compared with local anaesthetic injection alone (short-term) We don’t know whether a single injection of corticosteroid plus local anaesthetic injection is more effective than local anaesthetic injection alone (with or without tibial nerve block) at improving pain in the short term (at 1 month) in people with plantar fasciitis (very low-quality evidence).
Functional improvement
Health-related quality of life
Adverse effects
Pain relief
Corticosteroid injection plus local anaesthetic injection compared with local anaesthetic injection alone (short-term) We don’t know whether a single injection of corticosteroid plus local anaesthetic injection is more effective than local anaesthetic injection alone (with or without tibial nerve block) at improving pain in the short term (at 1 month) in people with plantar fasciitis (very low-quality evidence).
Functional improvement
No data from the following reference on this outcome.
Health-related quality of life
No data from the following reference on this outcome.
Adverse effects
Corticosteroid injection plus local anaesthetic injection versus extracorporeal shock wave therapy:
See option on Extracorporeal shock wave therapy.
Corticosteroid injection plus local anaesthetic injection versus extracorporeal shock wave therapy plus local anaesthetic injection:
See option on Extracorporeal shock wave therapy.
Further information on studies
The RCT reported a dropout rate of more than 20% at 3 months and more than 45% at 6 months, and no intention-to-treat analysis was carried out. Participants’ perception of pain from corticosteroid injection did not appear to be affected by prior administration of tibial nerve block (P = 0.5). Participants were permitted to continue using orthoses, insoles, pads, or painkillers throughout the study.
The RCT reported a dropout rate of more than 20% at 3 months and more than 45% at 6 months, and no intention-to-treat analysis was carried out. Participants’ perception of pain from corticosteroid injection did not appear to be affected by prior administration of tibial nerve block (P = 0.5). Participants were permitted to continue using orthoses, insoles, pads, or painkillers throughout the study.
The RCT reported a dropout rate of more than 20% at 3 months and more than 45% at 6 months, and no intention-to-treat analysis was carried out. Participants’ perception of pain from corticosteroid injection did not appear to be affected by prior administration of tibial nerve block (P = 0.5). Participants were permitted to continue using orthoses, insoles, pads, or painkillers throughout the study.
Substantive changes
Corticosteroid injection plus local anaesthetic injection (short-term effects) Three RCTs added (they appear in option on ESWT). Categorisation unchanged (unknown effectiveness).
Benefits and harms
Corticosteroid injection plus local anaesthetic injection versus local anaesthetic injection alone (longer-term):
We found one four-armed RCT that compared a single injection of corticosteroid plus local anaesthetic injection with local anaesthetic injection alone, either with or without tibial nerve block, in people with plantar fasciitis.
Pain relief
Corticosteroid injection plus local anaesthetic injection compared with local anaesthetic injection alone (longer-term) We don’t know how a single injection of corticosteroid plus local anaesthetic compares with local anaesthetic alone (with or without tibial nerve block) at improving pain in the medium to long term (at 3 to 6 months) in people with plantar fasciitis (very low-quality evidence).
Adverse effects
Corticosteroid injection plus local anaesthetic injection versus extracorporeal shock wave therapy:
See option on Extracorporeal shock wave therapy.
Corticosteroid injection plus local anaesthetic injection versus extracorporeal shock wave therapy plus local anaesthetic injection:
See option on Extracorporeal shock wave therapy.
Further information on studies
The RCT reported a dropout rate of more than 20% at 3 months and more than 45% at 6 months, and no intention-to-treat analysis was carried out. Participants’ perception of pain from corticosteroid injection did not appear to be affected by prior administration of tibial nerve block (P = 0.5). Participants were permitted to continue using orthoses, insoles, pads, or analgesics throughout the study.
Corticosteroid injection plus local anaesthetic injection versus local anaesthetic injection alone (longer-term):
We found one four-armed RCT that compared a single injection of corticosteroid plus local anaesthetic injection with local anaesthetic injection alone, either with or without tibial nerve block, in people with plantar fasciitis.
Pain relief
Corticosteroid injection plus local anaesthetic injection compared with local anaesthetic injection alone (longer-term) We don’t know how a single injection of corticosteroid plus local anaesthetic compares with local anaesthetic alone (with or without tibial nerve block) at improving pain in the medium to long term (at 3 to 6 months) in people with plantar fasciitis (very low-quality evidence).
Functional improvement
Health-related quality of life
Adverse effects
Pain relief
Corticosteroid injection plus local anaesthetic injection compared with local anaesthetic injection alone (longer-term) We don’t know how a single injection of corticosteroid plus local anaesthetic compares with local anaesthetic alone (with or without tibial nerve block) at improving pain in the medium to long term (at 3 to 6 months) in people with plantar fasciitis (very low-quality evidence).
Functional improvement
No data from the following reference on this outcome.
Health-related quality of life
No data from the following reference on this outcome.
Adverse effects
Corticosteroid injection plus local anaesthetic injection versus extracorporeal shock wave therapy:
See option on Extracorporeal shock wave therapy.
Corticosteroid injection plus local anaesthetic injection versus extracorporeal shock wave therapy plus local anaesthetic injection:
See option on Extracorporeal shock wave therapy.
Further information on studies
The RCT reported a dropout rate of more than 20% at 3 months and more than 45% at 6 months, and no intention-to-treat analysis was carried out. Participants’ perception of pain from corticosteroid injection did not appear to be affected by prior administration of tibial nerve block (P = 0.5). Participants were permitted to continue using orthoses, insoles, pads, or analgesics throughout the study.
The RCT reported a dropout rate of more than 20% at 3 months and more than 45% at 6 months, and no intention-to-treat analysis was carried out. Participants’ perception of pain from corticosteroid injection did not appear to be affected by prior administration of tibial nerve block (P = 0.5). Participants were permitted to continue using orthoses, insoles, pads, or analgesics throughout the study.
The RCT reported a dropout rate of more than 20% at 3 months and more than 45% at 6 months, and no intention-to-treat analysis was carried out. Participants’ perception of pain from corticosteroid injection did not appear to be affected by prior administration of tibial nerve block (P = 0.5). Participants were permitted to continue using orthoses, insoles, pads, or analgesics throughout the study.
Substantive changes
Corticosteroid injection plus local anaesthetic injection (longer-term effects) Three RCTs added (they appear in option on ESWT). Categorisation unchanged (likely to be ineffective or harmful).
Benefits and harms
Extracorporeal shock wave therapy versus placebo:
We found three systematic reviews (search dates 2004; 2010; and 2013), which identified 19 RCTs between them. The reviews included different RCTs in individual meta-analysis and presented data for different outcomes. For these reasons, we have reported results from the three reviews as we think appropriate. None of the reviews reported on adverse effects in detail. For adverse effects, we have reported directly from some RCTs.
Pain relief
ESWT compared with placebo ESWT without local anaesthetic may be more effective than placebo at reducing overall pain at 12 weeks in people with chronic plantar fasciitis. However, we don’t know how effective low to high intensity ESWT is compared with placebo at reducing overall pain in people with heel pain at 12 weeks. ESWT may be more effective than placebo at reducing morning pain in people with plantar heel pain at 12 weeks (very low-quality evidence).
Functional improvement
ESWT versus placebo ESWT seems to be more effective than placebo at decreasing limitation of activity duration in people with heel pain (moderate-quality evidence).
Adverse effects
Low dose versus high dose extracorporeal shock wave therapy:
We found two RCTs evaluating low dose versus high dose ESWT in adults with chronic heel pain.
Pain relief
Low dose compared with high dose ESWT We don’t know how low dose and high dose ESWT compare at reducing pain in people with chronic heel pain as the evidence is weak (very low-quality evidence).
Functional improvement
Low dose compared with high dose ESWT We don’t know how low dose and high dose ESWT compare at improving function in people with chronic heel pain as the evidence is weak (very low-quality evidence).
Health-related quality of life
Low dose compared with high dose ESWT We don’t know how low dose and high dose ESWT compare at improving quality of life (as assessed using the SF-36) in people with plantar fasciitis and pain lasting at least 6 months (very low-quality evidence).
Adverse effects
Extracorporeal shock wave therapy versus corticosteroid injection plus local anaesthetic injection:
We found one RCT that compared ultrasound-guided ESWT with ultrasound-guided injection of corticosteroid plus local anaesthetic people with plantar fasciitis with or without perifascial oedema.
Pain relief
ESWT compared with corticosteroid injection plus local anaesthetic injection We don’t know how ESWT compares with injection of corticosteroid plus local anaesthetic at reducing pain in people with plantar fasciitis with or without perifascial oedema (very low-quality evidence).
Extracorporeal shock wave therapy plus local anaesthetic injection versus corticosteroid injection plus local anaesthetic injection:
We found two RCTs that compared ESWT plus local anaesthetic injection with injection of corticosteroid plus local anaesthetic in people with plantar fasciitis (duration of symptoms of longer than 6 months).
Pain relief
ESWT plus local anaesthetic injection compared with corticosteroid injection plus local anaesthetic injection We don’t know how ESWT plus local anaesthetic injection compares with injection of corticosteroid plus local anaesthetic at reducing pain in people with plantar fasciitis (very low-quality evidence).
Functional improvement
ESWT plus local anaesthetic injection compared with corticosteroid injection plus local anaesthetic injection We don’t know how ESWT plus local anaesthetic injection compares with injection of corticosteroid plus local anaesthetic at improving function in people with plantar fasciitis (very low-quality evidence).
Adverse effects
Extracorporeal shock wave therapy versus surgery:
We found one RCT comparing ESWT with endoscopic plantar fasciotomy (partial release) in adults with plantar fasciitis.
Pain relief
ESWT compared with surgery ESWT may be equally effective as endoscopic plantar fasciotomy (partial release) at reducing pain at 1 year in adults with recalcitrant plantar heel pain (fasciopathy), but this is based on limited evidence (very low-quality evidence).
Functional improvement
ESWT compared with surgery ESWT may be equally effective as endoscopic plantar fasciotomy (partial release) at improving function (assessed using the AOFAS total score) at 1 year in adults with recalcitrant plantar heel pain (fasciopathy), but this is based on limited evidence (very low-quality evidence).
Further information on studies
Randomisation, allocation concealment, and blinding were unclear in the RCT. In the study, ESWT was given as a single treatment of 3000 shock waves; prilocaine hydrochloride was administered before ESWT. A single injection of corticosteroid plus local anaesthetic comprised betamethasone dipropionate, betamethasone sodium phosphate, and prilocaine hydrochloride.
Randomisation, allocation concealment, and blinding were unclear in the RCT. In the study, ESWT was given at 0.28 mJ/mm over two sessions (2 weeks apart); lidocaine hydrochloride gel was administered before ESWT. Injection of corticosteroid plus local anaesthetic comprised betamethasone diproprionate, betamethasone sodium phosphate, and zylocaine hydrochloride.
In the RCT, people were initially stratified into two groups based on presence or absence of perifascial oedema. People in each group were then randomly allocated to ultrasound-guided ESWT or ultrasound-guided injection of corticosteroid plus local anaesthetic. Methods for allocation concealment and maintenance of masking were unclear.
In the RCT, allocation concealment and maintenance of blinding were unclear. In the 'fixed' energy density group (high dose), a starting energy density of 0.05 mJ/mm was used, which was gradually increased in a 'stepped' manner until the maximum tolerable dose was reached. This dose was then recorded and used in subsequent sessions. The ‘maximum tolerable’ energy density group (high dose) also had a starting energy density of 0.05 mJ/mm. However, in contrast to the 'fixed' energy group, increases in dose were 'staircased' to the person’s maximum tolerable level after every 200 impulse application. The low dose group received ESWT at a frequency of 3 Hz with a total of 30 impulses with an energy density fixed at the lowest level of 0.03 mJ/mm. ESWT was applied once a week for 3 weeks with a follow-up session 3 weeks later (i.e., at 6 weeks). The RCT identified that the results of the study cannot be generalised to ESWT generated by mechanisms other than a pneumatic-generating system because the physical properties of the generated shock waves and the spatial distribution of the energy density or focus pressure are dependent on the sound source and the focusing device used.
In the RCT, methods to maintain blinding were unclear. The low-dose energy group received 0.12 mJ/mm compared with a dose of 0.56 mJ/mm applied in the high-energy group. Both groups received three sessions of ESWT (2000 shock waves/session) at weekly intervals.
Blinding was unclear in the RCT. People in the ESWT group were given conscious sedation anaesthesia (no local anaesthetic given), and surgery (fasciotomy) was performed under general or spinal anaesthesia. People in the ESWT group received 100 graded shocks (14–18 kV; 0.12–0.22 mJ/mm) to assess the effectiveness of the anaesthesia, followed by 1400 shock waves at 18 kV (0.22 mJ/mm), for a total of 1500 shock waves, applied at 4 shocks/second. For the median change from baseline in morning pain scores, between-group comparisons were also non-significant at 3 and 12 weeks (P = 0.45 and 0.71, respectively). For the median change from baseline in total AOFAS scores, non-significant between group differences were observed for all time points (3, 12, and 52 weeks) and for all AOFAS subscales (pain, activity limitation, walking surface, sagittal motion, hindfoot motion, ankle/hind foot instability, alignment) except maximum walking distance (significant at 3 weeks, ESWT 4 [4–5] v fasciotomy 4 [2–4], P = 0.005) and gait abnormality (significant at 3 weeks, ESWT 4 [4–8] v fasciotomy 4 [4–4], P = 0.002).
Extracorporeal shock wave therapy versus placebo:
We found three systematic reviews (search dates 2004; 2010; and 2013), which identified 19 RCTs between them. The reviews included different RCTs in individual meta-analysis and presented data for different outcomes. For these reasons, we have reported results from the three reviews as we think appropriate. None of the reviews reported on adverse effects in detail. For adverse effects, we have reported directly from some RCTs.
Pain relief
ESWT compared with placebo ESWT without local anaesthetic may be more effective than placebo at reducing overall pain at 12 weeks in people with chronic plantar fasciitis. However, we don’t know how effective low to high intensity ESWT is compared with placebo at reducing overall pain in people with heel pain at 12 weeks. ESWT may be more effective than placebo at reducing morning pain in people with plantar heel pain at 12 weeks (very low-quality evidence).
Functional improvement
ESWT versus placebo ESWT seems to be more effective than placebo at decreasing limitation of activity duration in people with heel pain (moderate-quality evidence).
Health-related quality of life
Adverse effects
Pain relief
ESWT compared with placebo ESWT without local anaesthetic may be more effective than placebo at reducing overall pain at 12 weeks in people with chronic plantar fasciitis. However, we don’t know how effective low to high intensity ESWT is compared with placebo at reducing overall pain in people with heel pain at 12 weeks. ESWT may be more effective than placebo at reducing morning pain in people with plantar heel pain at 12 weeks (very low-quality evidence).
Functional improvement
ESWT versus placebo ESWT seems to be more effective than placebo at decreasing limitation of activity duration in people with heel pain (moderate-quality evidence).
No data from the following reference on this outcome.
Health-related quality of life
No data from the following reference on this outcome.
Adverse effects
No data from the following reference on this outcome.
Low dose versus high dose extracorporeal shock wave therapy:
We found two RCTs evaluating low dose versus high dose ESWT in adults with chronic heel pain.
Pain relief
Low dose compared with high dose ESWT We don’t know how low dose and high dose ESWT compare at reducing pain in people with chronic heel pain as the evidence is weak (very low-quality evidence).
Functional improvement
Low dose compared with high dose ESWT We don’t know how low dose and high dose ESWT compare at improving function in people with chronic heel pain as the evidence is weak (very low-quality evidence).
Health-related quality of life
Low dose compared with high dose ESWT We don’t know how low dose and high dose ESWT compare at improving quality of life (as assessed using the SF-36) in people with plantar fasciitis and pain lasting at least 6 months (very low-quality evidence).
Adverse effects
Pain relief
Low dose compared with high dose ESWT We don’t know how low dose and high dose ESWT compare at reducing pain in people with chronic heel pain as the evidence is weak (very low-quality evidence).
Functional improvement
Low dose compared with high dose ESWT We don’t know how low dose and high dose ESWT compare at improving function in people with chronic heel pain as the evidence is weak (very low-quality evidence).
Health-related quality of life
Low dose compared with high dose ESWT We don’t know how low dose and high dose ESWT compare at improving quality of life (as assessed using the SF-36) in people with plantar fasciitis and pain lasting at least 6 months (very low-quality evidence).
No data from the following reference on this outcome.
Adverse effects
No data from the following reference on this outcome.
Extracorporeal shock wave therapy versus corticosteroid injection plus local anaesthetic injection:
We found one RCT that compared ultrasound-guided ESWT with ultrasound-guided injection of corticosteroid plus local anaesthetic people with plantar fasciitis with or without perifascial oedema.
Pain relief
ESWT compared with corticosteroid injection plus local anaesthetic injection We don’t know how ESWT compares with injection of corticosteroid plus local anaesthetic at reducing pain in people with plantar fasciitis with or without perifascial oedema (very low-quality evidence).
Functional improvement
Health-related quality of life
Adverse effects
Pain relief
ESWT compared with corticosteroid injection plus local anaesthetic injection We don’t know how ESWT compares with injection of corticosteroid plus local anaesthetic at reducing pain in people with plantar fasciitis with or without perifascial oedema (very low-quality evidence).
Functional improvement
No data from the following reference on this outcome.
Health-related quality of life
No data from the following reference on this outcome.
Adverse effects
Extracorporeal shock wave therapy plus local anaesthetic injection versus corticosteroid injection plus local anaesthetic injection:
We found two RCTs that compared ESWT plus local anaesthetic injection with injection of corticosteroid plus local anaesthetic in people with plantar fasciitis (duration of symptoms of longer than 6 months).
Pain relief
ESWT plus local anaesthetic injection compared with corticosteroid injection plus local anaesthetic injection We don’t know how ESWT plus local anaesthetic injection compares with injection of corticosteroid plus local anaesthetic at reducing pain in people with plantar fasciitis (very low-quality evidence).
Functional improvement
ESWT plus local anaesthetic injection compared with corticosteroid injection plus local anaesthetic injection We don’t know how ESWT plus local anaesthetic injection compares with injection of corticosteroid plus local anaesthetic at improving function in people with plantar fasciitis (very low-quality evidence).
Health-related quality of life
Adverse effects
Pain relief
ESWT plus local anaesthetic injection compared with corticosteroid injection plus local anaesthetic injection We don’t know how ESWT plus local anaesthetic injection compares with injection of corticosteroid plus local anaesthetic at reducing pain in people with plantar fasciitis (very low-quality evidence).
No data from the following reference on this outcome.
Functional improvement
ESWT plus local anaesthetic injection compared with corticosteroid injection plus local anaesthetic injection We don’t know how ESWT plus local anaesthetic injection compares with injection of corticosteroid plus local anaesthetic at improving function in people with plantar fasciitis (very low-quality evidence).
No data from the following reference on this outcome.
Health-related quality of life
No data from the following reference on this outcome.
Adverse effects
No data from the following reference on this outcome.
Extracorporeal shock wave therapy versus surgery:
We found one RCT comparing ESWT with endoscopic plantar fasciotomy (partial release) in adults with plantar fasciitis.
Pain relief
ESWT compared with surgery ESWT may be equally effective as endoscopic plantar fasciotomy (partial release) at reducing pain at 1 year in adults with recalcitrant plantar heel pain (fasciopathy), but this is based on limited evidence (very low-quality evidence).
Functional improvement
ESWT compared with surgery ESWT may be equally effective as endoscopic plantar fasciotomy (partial release) at improving function (assessed using the AOFAS total score) at 1 year in adults with recalcitrant plantar heel pain (fasciopathy), but this is based on limited evidence (very low-quality evidence).
Health-related quality of life
Adverse effects
Pain relief
ESWT compared with surgery ESWT may be equally effective as endoscopic plantar fasciotomy (partial release) at reducing pain at 1 year in adults with recalcitrant plantar heel pain (fasciopathy), but this is based on limited evidence (very low-quality evidence).
Functional improvement
ESWT compared with surgery ESWT may be equally effective as endoscopic plantar fasciotomy (partial release) at improving function (assessed using the AOFAS total score) at 1 year in adults with recalcitrant plantar heel pain (fasciopathy), but this is based on limited evidence (very low-quality evidence).
Health-related quality of life
No data from the following reference on this outcome.
Adverse effects
No data from the following reference on this outcome.
Further information on studies
Randomisation, allocation concealment, and blinding were unclear in the RCT. In the study, ESWT was given as a single treatment of 3000 shock waves; prilocaine hydrochloride was administered before ESWT. A single injection of corticosteroid plus local anaesthetic comprised betamethasone dipropionate, betamethasone sodium phosphate, and prilocaine hydrochloride.
Randomisation, allocation concealment, and blinding were unclear in the RCT. In the study, ESWT was given at 0.28 mJ/mm over two sessions (2 weeks apart); lidocaine hydrochloride gel was administered before ESWT. Injection of corticosteroid plus local anaesthetic comprised betamethasone diproprionate, betamethasone sodium phosphate, and zylocaine hydrochloride.
In the RCT, people were initially stratified into two groups based on presence or absence of perifascial oedema. People in each group were then randomly allocated to ultrasound-guided ESWT or ultrasound-guided injection of corticosteroid plus local anaesthetic. Methods for allocation concealment and maintenance of masking were unclear.
In the RCT, allocation concealment and maintenance of blinding were unclear. In the 'fixed' energy density group (high dose), a starting energy density of 0.05 mJ/mm was used, which was gradually increased in a 'stepped' manner until the maximum tolerable dose was reached. This dose was then recorded and used in subsequent sessions. The ‘maximum tolerable’ energy density group (high dose) also had a starting energy density of 0.05 mJ/mm. However, in contrast to the 'fixed' energy group, increases in dose were 'staircased' to the person’s maximum tolerable level after every 200 impulse application. The low dose group received ESWT at a frequency of 3 Hz with a total of 30 impulses with an energy density fixed at the lowest level of 0.03 mJ/mm. ESWT was applied once a week for 3 weeks with a follow-up session 3 weeks later (i.e., at 6 weeks). The RCT identified that the results of the study cannot be generalised to ESWT generated by mechanisms other than a pneumatic-generating system because the physical properties of the generated shock waves and the spatial distribution of the energy density or focus pressure are dependent on the sound source and the focusing device used.
In the RCT, methods to maintain blinding were unclear. The low-dose energy group received 0.12 mJ/mm compared with a dose of 0.56 mJ/mm applied in the high-energy group. Both groups received three sessions of ESWT (2000 shock waves/session) at weekly intervals.
Blinding was unclear in the RCT. People in the ESWT group were given conscious sedation anaesthesia (no local anaesthetic given), and surgery (fasciotomy) was performed under general or spinal anaesthesia. People in the ESWT group received 100 graded shocks (14–18 kV; 0.12–0.22 mJ/mm) to assess the effectiveness of the anaesthesia, followed by 1400 shock waves at 18 kV (0.22 mJ/mm), for a total of 1500 shock waves, applied at 4 shocks/second. For the median change from baseline in morning pain scores, between-group comparisons were also non-significant at 3 and 12 weeks (P = 0.45 and 0.71, respectively). For the median change from baseline in total AOFAS scores, non-significant between group differences were observed for all time points (3, 12, and 52 weeks) and for all AOFAS subscales (pain, activity limitation, walking surface, sagittal motion, hindfoot motion, ankle/hind foot instability, alignment) except maximum walking distance (significant at 3 weeks, ESWT 4 [4–5] v fasciotomy 4 [2–4], P = 0.005) and gait abnormality (significant at 3 weeks, ESWT 4 [4–8] v fasciotomy 4 [4–4], P = 0.002).
Randomisation, allocation concealment, and blinding were unclear in the RCT. In the study, ESWT was given as a single treatment of 3000 shock waves; prilocaine hydrochloride was administered before ESWT. A single injection of corticosteroid plus local anaesthetic comprised betamethasone dipropionate, betamethasone sodium phosphate, and prilocaine hydrochloride.
Randomisation, allocation concealment, and blinding were unclear in the RCT. In the study, ESWT was given as a single treatment of 3000 shock waves; prilocaine hydrochloride was administered before ESWT. A single injection of corticosteroid plus local anaesthetic comprised betamethasone dipropionate, betamethasone sodium phosphate, and prilocaine hydrochloride.
Randomisation, allocation concealment, and blinding were unclear in the RCT. In the study, ESWT was given at 0.28 mJ/mm over two sessions (2 weeks apart); lidocaine hydrochloride gel was administered before ESWT. Injection of corticosteroid plus local anaesthetic comprised betamethasone diproprionate, betamethasone sodium phosphate, and zylocaine hydrochloride.
Randomisation, allocation concealment, and blinding were unclear in the RCT. In the study, ESWT was given at 0.28 mJ/mm over two sessions (2 weeks apart); lidocaine hydrochloride gel was administered before ESWT. Injection of corticosteroid plus local anaesthetic comprised betamethasone diproprionate, betamethasone sodium phosphate, and zylocaine hydrochloride.
In the RCT, people were initially stratified into two groups based on presence or absence of perifascial oedema. People in each group were then randomly allocated to ultrasound-guided ESWT or ultrasound-guided injection of corticosteroid plus local anaesthetic. Methods for allocation concealment and maintenance of masking were unclear.
In the RCT, people were initially stratified into two groups based on presence or absence of perifascial oedema. People in each group were then randomly allocated to ultrasound-guided ESWT or ultrasound-guided injection of corticosteroid plus local anaesthetic. Methods for allocation concealment and maintenance of masking were unclear.
In the RCT, allocation concealment and maintenance of blinding were unclear. In the 'fixed' energy density group (high dose), a starting energy density of 0.05 mJ/mm was used, which was gradually increased in a 'stepped' manner until the maximum tolerable dose was reached. This dose was then recorded and used in subsequent sessions. The ‘maximum tolerable’ energy density group (high dose) also had a starting energy density of 0.05 mJ/mm. However, in contrast to the 'fixed' energy group, increases in dose were 'staircased' to the person’s maximum tolerable level after every 200 impulse application. The low dose group received ESWT at a frequency of 3 Hz with a total of 30 impulses with an energy density fixed at the lowest level of 0.03 mJ/mm. ESWT was applied once a week for 3 weeks with a follow-up session 3 weeks later (i.e., at 6 weeks). The RCT identified that the results of the study cannot be generalised to ESWT generated by mechanisms other than a pneumatic-generating system because the physical properties of the generated shock waves and the spatial distribution of the energy density or focus pressure are dependent on the sound source and the focusing device used.
In the RCT, allocation concealment and maintenance of blinding were unclear. In the 'fixed' energy density group (high dose), a starting energy density of 0.05 mJ/mm was used, which was gradually increased in a 'stepped' manner until the maximum tolerable dose was reached. This dose was then recorded and used in subsequent sessions. The ‘maximum tolerable’ energy density group (high dose) also had a starting energy density of 0.05 mJ/mm. However, in contrast to the 'fixed' energy group, increases in dose were 'staircased' to the person’s maximum tolerable level after every 200 impulse application. The low dose group received ESWT at a frequency of 3 Hz with a total of 30 impulses with an energy density fixed at the lowest level of 0.03 mJ/mm. ESWT was applied once a week for 3 weeks with a follow-up session 3 weeks later (i.e., at 6 weeks). The RCT identified that the results of the study cannot be generalised to ESWT generated by mechanisms other than a pneumatic-generating system because the physical properties of the generated shock waves and the spatial distribution of the energy density or focus pressure are dependent on the sound source and the focusing device used.
In the RCT, methods to maintain blinding were unclear. The low-dose energy group received 0.12 mJ/mm compared with a dose of 0.56 mJ/mm applied in the high-energy group. Both groups received three sessions of ESWT (2000 shock waves/session) at weekly intervals.
In the RCT, methods to maintain blinding were unclear. The low-dose energy group received 0.12 mJ/mm compared with a dose of 0.56 mJ/mm applied in the high-energy group. Both groups received three sessions of ESWT (2000 shock waves/session) at weekly intervals.
Blinding was unclear in the RCT. People in the ESWT group were given conscious sedation anaesthesia (no local anaesthetic given), and surgery (fasciotomy) was performed under general or spinal anaesthesia. People in the ESWT group received 100 graded shocks (14–18 kV; 0.12–0.22 mJ/mm) to assess the effectiveness of the anaesthesia, followed by 1400 shock waves at 18 kV (0.22 mJ/mm), for a total of 1500 shock waves, applied at 4 shocks/second. For the median change from baseline in morning pain scores, between-group comparisons were also non-significant at 3 and 12 weeks (P = 0.45 and 0.71, respectively). For the median change from baseline in total AOFAS scores, non-significant between group differences were observed for all time points (3, 12, and 52 weeks) and for all AOFAS subscales (pain, activity limitation, walking surface, sagittal motion, hindfoot motion, ankle/hind foot instability, alignment) except maximum walking distance (significant at 3 weeks, ESWT 4 [4–5] v fasciotomy 4 [2–4], P = 0.005) and gait abnormality (significant at 3 weeks, ESWT 4 [4–8] v fasciotomy 4 [4–4], P = 0.002).
Blinding was unclear in the RCT. People in the ESWT group were given conscious sedation anaesthesia (no local anaesthetic given), and surgery (fasciotomy) was performed under general or spinal anaesthesia. People in the ESWT group received 100 graded shocks (14–18 kV; 0.12–0.22 mJ/mm) to assess the effectiveness of the anaesthesia, followed by 1400 shock waves at 18 kV (0.22 mJ/mm), for a total of 1500 shock waves, applied at 4 shocks/second. For the median change from baseline in morning pain scores, between-group comparisons were also non-significant at 3 and 12 weeks (P = 0.45 and 0.71, respectively). For the median change from baseline in total AOFAS scores, non-significant between group differences were observed for all time points (3, 12, and 52 weeks) and for all AOFAS subscales (pain, activity limitation, walking surface, sagittal motion, hindfoot motion, ankle/hind foot instability, alignment) except maximum walking distance (significant at 3 weeks, ESWT 4 [4–5] v fasciotomy 4 [2–4], P = 0.005) and gait abnormality (significant at 3 weeks, ESWT 4 [4–8] v fasciotomy 4 [4–4], P = 0.002).
Clinical guide
ESWT is being increasingly used. Although there are few major side effects, patients may complain of pain upon application.
Substantive changes
Extracorporeal shock wave therapy Two systematic reviews and six RCTs added. Categorisation unchanged (unknown effectiveness).
Benefits and harms
Local anaesthetic injection alone versus corticosteroid injection plus local anaesthetic injection (short-term effects):
See option on Corticosteroid injection plus local anaesthetic injection (short-term effects).
Local anaesthetic injection alone versus corticosteroid injection plus local anaesthetic injection (longer-term effects):
See option on Corticosteroid injection plus local anaesthetic injection (longer-terms effects).
Local anaesthetic injection alone versus corticosteroid injection plus local anaesthetic injection (short-term effects):
See option on Corticosteroid injection plus local anaesthetic injection (short-term effects).
Local anaesthetic injection alone versus corticosteroid injection plus local anaesthetic injection (longer-term effects):
See option on Corticosteroid injection plus local anaesthetic injection (longer-terms effects).
Clinical guide
Local anaesthetic injection is not frequently used in clinical practice for plantar heel pain. However, the theory behind its use relates to hydrodilation and breaking the pain cycle. Most practitioners would use a corticosteroid injection (or a corticosteroid and local anaesthetic injection) in preference to a local anaesthetic injection alone.
Substantive changes
No new evidence
Benefits and harms
Surgery versus ESWT:
See option on Extracorporeal shock wave therapy.
Surgery versus ESWT:
See option on Extracorporeal shock wave therapy.
Clinical guide
Surgery for plantar heel pain is usually reserved for chronic cases where multiple other interventions have been tried without benefit. There are many potential adverse effects from surgery and because there is, essentially, no evidence that it is beneficial, it should be reserved for extreme cases.
Substantive changes
Surgery One RCT added. Categorisation unchanged (unknown effectiveness).
We would like to acknowledge the previous contributors to this review, Hylton B. Menz and Fay Crawford.
We would like to acknowledge the previous contributors to this review, Hylton B. Menz and Fay Crawford.
Abstract
Introduction
Plantar heel pain, also known as plantar fasciitis, causes soreness or tenderness of the sole of the foot under the heel, which sometimes extends into the medial arch. Pain associated with the condition may cause substantial disability and poor health-related quality of life. The prevalence and prognosis are unclear, but the symptoms seem to resolve over time in most people.
Methods and outcomes
We conducted a systematic overview, aiming to answer the following clinical questions: What are the effects of conservative treatments for plantar heel pain? What are the effects of non-conservative treatments for plantar heel pain? We searched: Medline, Embase, The Cochrane Library and other important databases up to November 2013 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review).
Results
At this update, searching of electronic databases retrieved 162 studies. After deduplication and removal of conference abstracts, 84 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 39 studies and the further review of 45 full articles. Of the 45 full articles evaluated, five systematic reviews and nine RCTs were included at this update. We performed a GRADE evaluation for 30 PICO combinations.
Conclusions
In this systematic overview, we categorised the efficacy for 12 interventions based on information relating to the effectiveness and safety of corticosteroid injection alone (both short-term and longer-term effects), corticosteroid injections plus local anaesthetic injection (both short-term and longer-term effects), customised foot orthoses, extracorporeal shock wave therapy, heel pads and cups, local anaesthetic injection alone, night splints, stretching exercises, surgery, and taping.
Key Points
Plantar heel pain causes soreness or tenderness of the sole of the foot under the heel, which sometimes extends into the medial arch.
Pain associated with the condition may cause substantial disability and poor health-related quality of life.
Those affected can experience significant limitations in their activities of daily living, ability to exercise, and work-related activities.
The prevalence and prognosis are unclear, but in most people the symptoms seem to resolve over time, although in some cases this can take years.
Conservative treatments for plantar heel pain:
Customised foot orthoses may be more effective than sham orthoses at improving function at up to 12 months in people with plantar heel pain, but we don’t know whether they are more effective at reducing pain.
Customised foot orthoses may be equally effective as prefabricated orthoses at reducing pain or improving function in people with plantar heel pain.
We don’t know whether customised foot orthoses (alone or with taping) are more effective than night splints at reducing pain or improving function or health-related quality of life in people with plantar heel pain as the evidence is weak.
We don't know whether heel pads and heel cups are effective in people with plantar heel pain as we found no evidence from RCTs meeting our inclusion criteria.
Taping may be more effective than no taping or sham taping at reducing pain in the short term (at 1 week) in people with plantar heel pain. However, we don’t know whether it is effective in the longer term or whether it is effective at improving function.
We don't know whether stretching exercises are more effective than no treatment or taping at reducing pain or improving function in people with plantar heel pain as the evidence is weak and inconsistent.
Non-conservative treatments for plantar heel pain:
Corticosteroid injections may be more effective than placebo at reducing pain in the short term (4 and 6 weeks) in people with plantar heel pain, but we don’t know whether they are more effective at reducing pain in the longer term (8 and 12 weeks). However, this is based on weak evidence.
We don’t know whether corticosteroid injections are more effective than placebo at improving function in the short or long term in people with plantar heel pain.
We don't know whether corticosteroid injection plus local anaesthetic injection are more effective than local anaesthetic injections alone at reducing pain in the short or long term in people with plantar heel pain.
There is limited evidence that ultrasound-guided corticosteroid injection may be more effective that palpation-guided corticosteroid injection.
Corticosteroid injections may be associated with a high rate of plantar fascia rupture and other complications, which may lead to chronic disability in some people. However, this is likely related to the solubility and duration of action of the corticosteroid being used.
Extracorporeal shock wave therapy (ESTW) may be more effective than placebo at reducing pain at 12 weeks in people with chronic heel pain, but this is based on limited evidence.
We don’t know how low-dose ESWT compares with high-dose ESWT or how ESWT (with or without local anaesthetic injections) compares with corticosteroid injection plus local anaesthetic injection, as the evidence is weak.
Surgery with endoscopic plantar fasciotomy (partial release) may be equally effective as ESWT at reducing pain and improving function at 1 year in adults with recalcitrant heel pain, but this is based on weak evidence.
We initially allocate 4 points to evidence from RCTs, and 2 points to evidence from observational studies. To attain the final GRADE score for a given comparison, points are deducted or added from this initial score based on preset criteria relating to the categories of quality, directness, consistency, and effect size. Quality: based on issues affecting methodological rigour (e.g., incomplete reporting of results, quasi-randomisation, sparse data [<200 people in the analysis]). Consistency: based on similarity of results across studies. Directness: based on generalisability of population or outcomes. Effect size: based on magnitude of effect as measured by statistics such as relative risk, odds ratio, or hazard ratio.
Glossary
| Achilles tendon stretching | A stretch achieved by either hanging the heel from a step while keeping the knee straight, or by leaning into the wall from a standing position with the affected leg placed behind the other leg. |
| Customised foot orthoses | Orthoses fabricated by moulding a thermoplastic or thermomouldable material over an impression (or negative cast) of a person’s foot with individual tailoring specific for each individual. |
| Extracorporeal shock wave therapy (ESWT) | Shock waves are pulsed acoustic waves that dissipate mechanical energy at the interface of two substances with different acoustic impedance. |
| Heel cups | Prefabricated rubber or silicone heel pads that contour the heel, thus surrounding and supporting the fibro fatty heel pad. |
| Heel pads | Padding underneath the heel that may be constructed from semi-compressed felt, sponge foam, rubber, or silicone. |
| Low-quality evidence | Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. |
| Moderate-quality evidence | Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. |
| Plantar fascia stretching | A stretch achieved by crossing the affected leg over the other leg from a seated position, placing the fingers of the affected side across the base of the toes (distal to the metatarsal phalangeal joints), and pulling the toes back until a stretch in the arch of the foot can be felt. |
| Prefabricated orthoses | Orthoses which are already made to a pre-determined size and shape, and which can be used immediately as there is no lengthy fabrication process. |
| Very low-quality evidence | Any estimate of effect is very uncertain. |
Notes
Disclaimer
The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients. To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.
Summary
Customised foot orthoses may be more effective than sham orthoses at improving function in people with plantar heel pain, but we don’t know whether they are more effective at reducing pain.
Customised foot orthoses and prefabricated orthoses may be equally effective at reducing pain or improving function in people with plantar heel pain.
We don’t know whether customised foot orthoses (alone or with taping) are more effective than night splints at reducing pain, improving function, or improving health-related quality of life in people with plantar heel pain as the evidence is weak.
Summary
We found no direct evidence from RCTs on the effectiveness of heel pads and heel cups in people with plantar heel pain.
Summary
We don’t know how night splints compare with customised orthoses (alone or with taping) at reducing pain, improving function, or improving health-related quality of life in people with plantar heel pain as the evidence is weak.
Summary
We don’t know whether stretching exercises are more effective than no treatment or taping at reducing pain or improving function in people with plantar heel pain, as the evidence is weak and inconsistent.
Summary
Taping may be more effective than no taping or sham taping at reducing pain in the short term (at 1 week) in people with plantar heel pain or fasciitis. However, we don’t know whether it is effective in the longer term, or whether it is effective at improving function.
Summary
Corticosteroid injections may be more effective than placebo at reducing pain in the short-term (at 4 and 6 weeks) in people with plantar fasciitis.
We don’t know whether corticosteroid injections are more effective than placebo at improving function in the short-term in people with plantar fasciitis.
Corticosteroid injections may be associated with a high rate of plantar fascia rupture and other complications, which may lead to chronic disability in some people; however, this is likely related to the solubility and duration of action of the corticosteroid being used.
Summary
We don’t know whether corticosteroid injections are more effective than placebo at reducing pain or improving function in the longer term (at 8 and 12 weeks) in people with plantar fasciitis.
Corticosteroid injections may be associated with a high rate of plantar fascia rupture and other complications, which may lead to chronic disability in some people; however, this is likely related to the solubility and duration of action of the corticosteroid being used.
Summary
We don’t know whether corticosteroid injection plus local anaesthetic injection are more effective than local anaesthetic injection alone at reducing pain in the short term (at 1 month) in people with plantar heel pain.
Corticosteroid injections may be associated with a high rate of plantar fascia rupture and other complications, which may lead to chronic disability in some people; however, this is likely related to the solubility and duration of action of the corticosteroid being used.
Summary
We don’t know whether corticosteroid injection plus local anaesthetic injection are more effective than local anaesthetic injection alone at reducing pain in the longer term (3 and 6 months) in people with plantar fasciitis.
Corticosteroid injections may be associated with a high rate of plantar fascia rupture and other complications, which may lead to chronic disability in some people; however, this is likely related to the solubility and duration of action of the corticosteroid being used.
Summary
Extracorporeal shock wave therapy (ESWT) may be more effective than placebo at reducing pain at 12 weeks in people with chronic plantar heel pain, but this is based on limited evidence.
ESWT may be equally effective as endoscopic plantar fasciotomy (partial release) at reducing pain and improving function at 1 year in adults with recalcitrant plantar fasciopathy, but this is based on weak evidence.
We don’t know how low-dose ESWT compares with high-dose ESWT, or how ESWT (with or without local anaesthetic injections) compares with corticosteroid injection plus local anaesthetic injection, as the evidence is weak.
We found no direct evidence from RCTs comparing ESWT with corticosteroid injections alone.
Summary
We don’t know whether corticosteroid injection plus local anaesthetic injection are more effective than local anaesthetic injection alone at reducing pain or improving function in people with plantar fasciitis.
Summary
Endoscopic plantar fasciotomy (partial release) may be equally effective as extracorporeal shock wave therapy (ESWT) at reducing pain and improving function at 1 year in adults with recalcitrant heel pain, but this is based on weak evidence.
References
- 1. Dunn JE, Link CL, Felson DT, et alPrevalence of foot and ankle conditions in a multiethnic community sample of older adults. Am J Epidemiol 2004;159:491–498. [[PubMed]
- 2. Clement DBT, Taunton JE, Smart GW, et alA survey of overuse running injuries. Phys Sportsmed 1981;9:47–58. [[PubMed]
- 3. Hill CL, Gill TK, Menz HB, et alPrevalence and correlates of foot pain in a population-based study: the North West Adelaide health study. J Foot Ankle Res 2008;1:1–7.
- 4. Menz HB, Jordan KP, Roddy E, et alCharacteristics of primary care consultations for musculoskeletal foot and ankle problems in the UK. Rheumatology (Oxford) 2010;49:1391–1398.
- 5. Riddle DL, Schappert SMVolume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int 2004;25:303–310. [[PubMed]
- 6. Irving DB, Cook JL, Menz HB, et al. Factors associated with chronic plantar heel pain: a systematic review. [Review] [26 refs]. <em>J Sci Med Sport</em> 2006;9:11–22. [[PubMed]
- 7. Irving D, Cook J, Young M, et alObesity and pronated foot type may increase the risk of chronic plantar heel pain: a matched case-control study. BMC Musculoskeletal Disord 2007;8:41.
- 8. Pohl MB, Hamill J, Davis ISBiomechanical and anatomic factors associated with a history of plantar fasciitis in female runners. Clin J Sports Med 2009;19:372–376. [[PubMed]
- 9. Wearing SC, Smeathers JE, Yates B,et alSagittal movement of the medial longitudinal arch is unchanged in plantar fasciitis. Med Sci Sports Exerc 2004;36:1761–1767. [[PubMed]
- 10. Crawford F, Atkins D, Young P, et al. Steroid injection for heel pain: evidence of short term effectiveness. A randomised controlled trial. Rheumatology 1999;38:974–977. [[PubMed]
- 11. Wolgin M, Cook C, Graham C, et alConservative treatment of plantar heel pain: long term follow up. Foot Ankle Int 1994;15:97–102. [[PubMed]
- 12. Landorf KB, Keenan AM, Herbert RDEffectiveness of foot orthoses to treat plantar fasciitis: a randomized trial. Arch Intern Med 2006;166:1305–1310. [[PubMed]
- 13. Hawke F, Burns J, Radford JA, et al. Custom-made foot orthoses for the treatment of foot pain. In: The Cochrane Library, Issue 10, 2013. Chichester, UK: John Wiley & Sons, Ltd. Search date 2007. [PubMed]
- 14. Baldassin V, Gomes CR, Beraldo PSEffectiveness of prefabricated and customized foot orthoses made from low-cost foam for noncomplicated plantar fasciitis: a randomized controlled trial. Arch Phys Med Rehabil 2009;90:701–706. [[PubMed]
- 15. Roos E, Engstrom M, Soderberg BFoot orthoses for the treatment of plantar fasciitis. Foot Ankle Int 2006;27:606–611. [[PubMed]
- 16. van de Water AT, Speksnijder CMEfficacy of taping for the treatment of plantar fasciosis: a systematic review of controlled trials. J Am Podiatr Med Assoc 2010;100:41–51. Search date 2007. [[PubMed]
- 17. Martin J, Hosch J, Goforth W, et al. Mechanical treatment of plantar fasciitis. A prospective study. J Am Podiatr Med Assoc 2001;91:55–62. [[PubMed]
- 18. Turlik M, Donatelli T, Veremis MA comparison of shoe inserts in relieving mechanical heel pain. Foot 1999;9:84–87. [PubMed]
- 19. Sweeting D, Parish B, Hooper L, Chester RThe effectiveness of manual stretching in the treatment of plantar heel pain: a systematic review. J Foot Ankle Res 2011;4:19. Search date 2010.
- 20. Hyland MR, Webber-Gaffney A, Cohen L, et alRandomized controlled trial of calcaneal taping, sham taping, and plantar fascia stretching for the short-term management of plantar heel pain. J Orthop Sports Phys Ther 2006;36:364–371. [[PubMed]
- 21. Radford JA, Landorf KB, Buchbinder R, et alEffectiveness of calf muscle stretching for the short-term treatment of plantar heel pain: a randomised trial. BMC Musculoskelet Disord 2007;8:36.
- 22. DiGiovanni BF, Nawoczenski DA, Lintal ME, et alTissue-specific plantar fascia stretching exercises enhances outcomes in patients with chronic heel pain. J Bone Joint Surg 2003;85A:1270–1277. [[PubMed]
- 23. Radford JA, Landorf KB, Buchbinder R, et alEffectiveness of low-Dye taping for the short-term treatment of plantar heel pain: a randomised trial. BMC Musculoskeletal Disord 2006;7:64.
- 24. McMillan AM, Landorf KB, Gilheany MF, et alUltrasound guided corticosteroid injection for plantar fasciitis: randomised controlled trial. BMJ 2012;344:e3260. [[PubMed]
- 25. Ball EM, McKeeman HM, Patterson C, et alSteroid injection for inferior heel pain: a randomised controlled trial. Ann Rheum Dis 2013;72:996–1002. [[PubMed]
- 26. Li Z, Xia C, Yu A, et alUltrasound- versus palpation-guided injection of corticosteroid for plantar fasciitis: a meta-analysis. PLoS One 2014;9:e92671.
- 27. Fadale PD, Wiggins MDCorticosteroid injections: their use and abuse. J Am Acad Orthop Surg 1994;2:133–140. [[PubMed]
- 28. Sellman JRPlantar fascial rupture associated with corticosteroid injection. Foot Ankle Int 1994;15:376–381. [[PubMed]
- 29. Acevedo JI, Beskin JLComplications of plantar fascial rupture associated with steroid injection. Foot Ankle Int 1998;19:91–97. [[PubMed]
- 30. Crawford F, Thomson C. Interventions for treating plantar heel pain. In: The Cochrane Library, Issue 10, 2013. Chichester, UK: John Wiley & Sons, Ltd. Search date 2002. [PubMed]
- 31. Yucel I, Ozturan KE, Demiraran Y, et alComparison of high-dose extracorporeal shockwave therapy and intralesional corticosteroid injection in the treatment of plantar fasciitis. J Am Podiatr Med Assoc 2010;100:105–110. [[PubMed]
- 32. Saber N, Diabb H, Nassar W, et alUltrasound guided local steroid injection versus extracorporeal shockwave therapy in the treatment of plantar fasciitis. Alexandria J Med 2012;48:35–42. [PubMed]
- 33. Sorrentino F, Iovane A, Vetro A, et alRole of high-resolution ultrasound in guiding treatment of idiopathic plantar fasciitis with minimally invasive techniques. Radiol Med 2008;113:486–495. [[PubMed]
- 34. Thomson CE, Crawford F, Murray GDThe effectiveness of extra corporeal shock wave therapy for plantar heel pain: a systematic review and meta analysis. BMC Musculoskelet Disord 2005;6:19. Search date 2004; primary sources Medline, Embase, Cinahl, and The Cochrane Library.
- 35. Dizon JN, Gonzalez-Suarez C, Zamora MT, et alEffectiveness of extracorporeal shock wave therapy in chronic plantar fasciitis: a meta-analysis. Am J Phys Med Rehabil 2013;92:606–620. [[PubMed]
- 36. Aqil A, Siddiqui MR, Solan M, et alExtracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: a meta-analysis of RCTs. Clin Orthop Relat Res 2013;471:3645–3652. Search date January 2013.
- 37. Kudo P, Dainty K, Clarfield M, et al. Randomized, placebo-controlled, double-blind clinical trial evaluating the treatment of plantar fasciitis with an extracoporeal shockwave therapy (ESWT) device: a North American confirmatory study. <em>J Orthop Res</em> 2006;24:115–123. [[PubMed]
- 38. Malay DS, Pressman MM, Assili A, et alExtracorporeal Shockwave Therapy Versus Placebo for the Treatment of Chronic Proximal Plantar Fasciitis: Results of a Randomized, Placebo-Controlled, Double-Blinded, Multicenter Intervention Trial. J Foot Ankle Surg 2006;45:196–210. [[PubMed]
- 39. Chow IH, Cheing GLComparison of different energy densities of extracorporeal shock wave therapy (ESWT) for the management of chronic heel pain. Clinical Rehabilitation 2007;21:131–141. [[PubMed]
- 40. Liang HW, Wang TG, Chen WS, et alThinner plantar fascia predicts decreased pain after extracorporeal shock wave therapy. Clin Orthop Relat Res 2007;460:219–225. [[PubMed]
- 41. Radwan YA, Mansour AM, Badawy WSResistant plantar fasciopathy: shock wave versus endoscopic plantar fascial release. Int Orthop 2012;36:2147–2156.
- 42. Chang KV, Chen SY, Chen WS, et alComparative effectiveness of focused shock wave therapy of different intensity levels and radial shock wave therapy for treating plantar fasciitis: a systematic review and network meta-analysis. Arch Phys Med Rehabil 2012;93:1259–1268. Search date 2011. [[PubMed]
- 43. Kinley S, Frascone S, Calderone D, et alEndoscopic plantar fasciotomy versus traditional heel spur surgery: a prospective study. J Foot Ankle Surg 1993;32:595–603. [[PubMed]