Dr. Yi-Cheng Wu
中文

Plantar Fasciitis Explained: From Basic to Advanced Treatment

By Dr. Yi-Cheng Wu · Reviewed September 17, 2023

Plantar fasciitis accounts for 80% of heel-pain patients and is common in adults aged 40-60, runners, and people who stand for long periods. Sharp pain with the first steps in the morning is a typical symptom, and ultrasound is the main diagnostic tool today. Most patients improve with 6-12 months of conservative treatment (rest, stretching, orthotic insoles, shockwave, PRP), and only a few need surgery.

Plantar fasciitis is a degenerative inflammation of the plantar fascia at its attachment on the calcaneus, caused by repeated overload. Its hallmark is sharp pain on the medial heel with the first steps after getting up in the morning or after prolonged sitting. Diagnosis relies mainly on history and ultrasound. Treatment centers on conservative rehabilitation: calf and plantar fascia stretching, a night splint, orthotic insoles, and shockwave or PRP injection. Studies show more than 90% of patients improve within 6-12 months, and only a few need surgery. The actual treatment plan should be decided by a physician based on the individual situation.

Stages of conservative treatment for plantar fasciitis

  1. Adjust activity and lifestyle

    First avoid activities that trigger or worsen pain, switch to low-impact exercise (such as cycling or swimming), and avoid walking barefoot or wearing flat shoes, so as to reduce repeated overload on the plantar fascia.

  2. Do home calf stretches

    Stand facing a wall with both hands on it. Keep the knee of the affected leg straight with the heel on the floor behind you, and place the other leg forward with the knee bent. Push your hips toward the wall to feel a strong stretch along the back of the calf, hold for about 10 seconds, then relax, and repeat about 20 times.

  3. Use insoles and massage to release tension

    Combine soft heel pads, silicone, or custom orthotic insoles to spread out heel pressure, and use ice massage and deep plantar massage to release tight tissue, along with resistance-band and foot strengthening exercises.

  4. Use a night splint

    During sleep the foot often points downward, which makes the first step in the morning especially painful; a night splint keeps the plantar fascia stretched through the night. It takes time to get used to, and the article notes it can be used for about 8-10 weeks.

  5. Clinic physical therapy and injection assessment if needed

    If home measures give limited improvement, a physician can assess and arrange physical therapy such as shockwave, or injection options; each injection approach has its own characteristics and risks (for example, corticosteroids may cause fat-pad atrophy), and suitability should be decided after discussing your individual history and imaging with your physician.

  6. Reassess for surgery only after enough time

    Conservative treatment is advised for at least 6-12 months; the article notes that more than 90% of patients respond to non-surgical care. Surgery is only considered, after physician assessment, if there is still no improvement over 1-2 years.

Basic introduction

  • The plantar fascia absorbs the high pressure and tension placed on the foot during walking, running, and other activities such as sports. Sometimes excessive pressure damages or tears the tissue, leading to heel pain and inflammation of the plantar fascia.
  • Heel pain that extends more toward the medial side and less toward the lateral side.
  • The pain may be described as throbbing, burning, or stabbing, and it is usually worst during the first few steps after getting up in the morning.
  • The pain may ease as activity gradually increases, worsen in the evening, and also worsen after prolonged standing or inactivity.

Epidemiology

  • Plantar fasciitis accounts for 80% of patients with heel pain, and up to 33% of patients have it on both sides.
  • The estimated prevalence is as high as 10% of the general population.
  • Among runners, plantar fasciitis accounts for 10% of running injuries.
  • Onset peaks between ages 40 and 60, but it can occur in adults of all ages.

Risk factors

  • 50% of patients with plantar fasciitis have a heel bone spur, though about 19% of patients without plantar fasciitis also have a heel spur. A heel spur may appear together with plantar fasciitis, but the spur is not the sole cause of plantar fasciitis.
  • New or increased exercise volume (running, dancing, and so on).
  • Poorly supportive shoes with excessive twisting and pronation.
  • High arches or flat feet with poor shock absorption.
  • Anterior pelvic tilt.
  • Hindfoot valgus with a pronation deformity.
  • Limited ankle dorsiflexion.
  • Varus knee.
  • Obesity.
  • Prolonged standing (nurses, factory workers, and teachers).

History

  • Tenderness localized to the anteromedial heel, with a tight Achilles tendon.
  • If a complete tear occurs, an obvious defect or loss of arch height may be seen.
  • Gait assessment: the calcaneus everts when the heel lifts off.

Diagnostic tools

  • X-ray: may show soft-tissue calcification around the heel or a heel spur. The heel spur is not the main cause of plantar fasciitis, so the spur does not need to be removed to treat the pain of plantar fasciitis.
  • Ultrasound (US): shows a thickened plantar fascia and is the main diagnostic tool at present; it can also help assess other nearby soft-tissue or nerve problems.
  • Bone scan: distinguishes plantar fasciitis from a calcaneal stress fracture.
  • MRI: if heel pain does not improve after 4 to 6 months of non-surgical treatment, consider a bone scan or MRI.

Differential diagnosis

Skeletal

– Calcaneal stress fracture

– Bone bruise

– Subtalar arthritis

– Inflammatory arthropathy

– Infections (osteomyelitis / subtalar pyarthrosis)

– Tumor

Soft tissue

– Intrinsic muscle strain (abductor hallucis, flexor digitorum brevis, quadratus plantae)

– Plantar fibromatosis

– Plantar fascia rupture

– Achilles tendinitis

– Posterior tibial tendinitis

– Retrocalcaneal bursitis

– Fat-pad atrophy

Nervous system

– Compression of branches of the posterior tibial nerve as they pass through the tarsal tunnel (medial plantar nerve, lateral plantar nerve, or medial calcaneal nerve).

– Nerve-root compression symptoms from L4-S1 (sciatic nerve).

First-line treatment

  • Conservative treatment should be used for at least 6 months, ideally 12 months, because more than 90% of patients respond to non-surgical care.

  • Initial treatment is conservative and includes rest, pain control, activity modification, physical therapy, exercise training, footwear adjustment, and weight loss.

  • Lifestyle modification:

  • Avoid activities that cause or aggravate pain, and choose low-impact exercise (such as cycling or swimming).

  • Avoid wearing flat shoes and walking barefoot.

  • Medical interventions:

    • Anti-inflammatory drugs (NSAIDs).
    • Ultrasound therapy: iontophoresis of corticosteroid (Decadron) or acetic acid.
    • Night splint: most people sleep with the foot pointing downward, which is one reason for morning heel pain. A night splint stretches the plantar fascia during sleep, though it takes some getting used to and can be worn for 8-10 weeks.
    • Shockwave therapy: it is non-invasive and carries relatively little risk. There is no consensus in the research on the effect size of focused versus radial shockwave in plantar fasciitis, but compared with other treatments, the medium-to-long-term benefit of shockwave still tends to be favorable.
    • Corticosteroid injection: usually effective for pain relief, but the risk of fat-pad atrophy must be kept in mind, and the benefit may be limited to the short term (4 to 12 weeks).
    • PRP injection: research supports PRP over corticosteroid injection and shockwave therapy at the 3-month and 6-month follow-ups.

    On whether PRP is effective for plantar fasciitis, in 2019 I published a meta-analysis in the American journal of physical medicine and rehabilitation, which found that corticosteroid injection gave better short-term pain relief at 1.5 to 3 months, but beyond 6 months PRP performed better than corticosteroid for plantar fasciitis.

    The American Journal of Sports Medicine also published a study on plantar fasciitis with a longer treatment period. On the foot-function rating scale (AOFAS), PRP showed no difference from corticosteroid in the first three months, but from 6 months to 1 year PRP outperformed corticosteroid. For pain improvement, apart from the first month when the two showed no difference, from 3 months to 1 year of follow-up PRP outperformed corticosteroid.

    In addition, the American journal of physical medicine and rehabilitation published a study on prolotherapy for plantar fasciitis. Notably, it was a double-blind randomized controlled trial. The study enrolled 60 patients in total, mainly divided into a treatment group and a control group. The treatment group mainly received 15% dextrose (the formula was 5 cc of 30% dextrose, 4 cc of saline, and 1 cc of 2% lidocaine), and the control group received mainly 9 cc of saline plus 1 cc of lidocaine. Injections were given at five sites: the medial and lateral aspects of the plantar fascia attachment on the calcaneus, the attachments at the first and fifth metatarsals, and the mid-portion of the plantar fascia. Two injections were given in total, three weeks apart, and patients were followed at weeks 7 and 15. In this trial, more than half of the treatment-group patients reported little or no remaining pain, and about 80% showed plantar fascia thickness returning to normal on follow-up. These are results from a small study and do not predict any individual’s outcome.

    A network meta-analysis published in 2016 in BJSM, the leading journal in sports medicine, concluded that for reducing pain in the short term (0-2 months), injection therapies ranked in order as amniotic membrane, PRP, botulinum toxin injection, prolotherapy, and corticosteroid; and for improving pain over the 2-month to 1-year period, PRP ranked among the highest of the injection options.

  • Rehabilitation and exercise training:

  • Calf stretch: lean forward with both hands on a wall, keep the knee of the painful leg straight with the heel on the floor, and place the other leg forward with the knee bent. To stretch the calf muscles and heel, push your hips toward the wall. Hold the position for 10 seconds, then relax, and repeat this exercise 20 times; you should feel a strong pull in the calf during the stretch.

  • Insoles: custom insoles (that is, soft heel pads / silicone), custom orthotic insoles, or medial heel insoles.

  • Ice massage and deep massage.

  • Resistance-band strength training and foot muscle training.

  • Taping during exercise.

  • High-load eccentric strength training may improve symptoms faster than stretching.

Surgical treatment

  • Plantar fascia release can be partial or complete, and it is a surgical procedure for refractory cases of plantar fasciitis.
  • Surgery can be considered after 1-2 years of failed conservative treatment.
  • Postoperative care includes 2 weeks of splinting, gentle stretching, and walking with crutches and a walking boot, 3 weeks of pool running, and return to activity after 3 to 4 months.

Complications

  • Lateral plantar nerve injury.
  • Complete release of the plantar fascia, with instability of the medial longitudinal arch.
  • Increased pressure over the dorsolateral midfoot.
  • Heel fat-pad atrophy.
  • Plantar fascia rupture.

Conclusion

In the past, corticosteroid was a common option for injection treatment of plantar fasciitis and could provide short-term pain relief. However, long-term use may lead to infection, fat atrophy, and even plantar fascia rupture in 2.4-10% of cases. As more related research has emerged, we now know that corticosteroid may be effective for short-term pain relief, but over the longer term of 2-6 months and beyond, PRP and other treatment options show different profiles in their clinical characteristics. Whichever treatment is used, early detection and assessment matter most.

This article is general medical health education, not individual medical advice, and makes no guarantee of any treatment outcome. The actual grading of an injury, its management, and whether medical care is needed still depend on a physician’s assessment of the individual situation.

References

  • Plantar Fasciitis and Bone Spurs - OrthoInfo - AAOS
  • Plantar Fasciitis - Foot & Ankle - Orthobullets
  • Am J Phys Med Rehabil. 2019 May;98(5):343-352. doi:10.1097/PHM.0000000000001070. Autologous Blood-Derived Products Compared With Corticosteroids for Treatment of Plantar Fasciopathy: A Systematic Review and Meta-Analysis
  • Am J Sports Med. 2021 Apr;49(5):1381-1393. doi:10.1177/0363546520937293. Epub 2020 Aug 21. Platelet-Rich Plasma Versus Corticosteroids for the Treatment of Plantar Fasciitis: A Systematic Review and Meta-analysis
  • Br J Sports Med. 2016 Nov;50(22):1367-1375. doi:10.1136/bjsports-2015-095437. Epub 2016 May 3. Injection therapies for plantar fasciopathy (‘plantar fasciitis’): a systematic review and network meta-analysis of 22 randomised controlled trials
  • Arch Phys Med Rehabil. 2012 Jul;93(7):1259-68. doi:10.1016/j.apmr.2012.02.023. Epub 2012 Mar 12. Comparative 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
  • Clin Rehabil. 2023 Jun;37(6):727-746. doi:10.1177/02692155221143865. Epub 2022 Dec 26. Effects of therapeutic interventions on pain due to plantar fasciitis: A systematic review and meta-analysis
  • Am J Phys Med Rehabil. 2020 Apr;99(4):318-324. doi:10.1097/PHM.0000000000001330. Effect of Dextrose Prolotherapy on Pain Intensity, Disability, and Plantar Fascia Thickness in Unilateral Plantar Fasciitis: A Randomized, Controlled, Double-Blind Study

Further reading

Frequently asked questions

Who is more likely to develop plantar fasciitis?

People who suddenly increase their running or dancing volume, wear poorly supportive shoes, have high arches or flat feet, have limited ankle dorsiflexion, are obese, or work standing for long periods (such as nurses, teachers, and factory workers) are at higher risk. Onset peaks between ages 40 and 60.

Does plantar fasciitis always require surgery?

Most patients improve with conservative treatment, and studies show more than 90% respond to non-surgical care. It is advisable to try at least 6-12 months of rest, rehabilitation exercises, orthotic insoles, and physical therapy; surgical assessment is only considered if there is still no improvement after 1-2 years.

How well does PRP injection work for plantar fasciitis?

Meta-analyses show corticosteroid injection relieves pain faster within 1.5-3 months, but from 6 months onward PRP and other treatment options show different profiles in clinical performance. Whether PRP is suitable depends on your individual history, imaging findings, and treatment considerations, so discuss it with your physician.

This article is also available in the original Chinese, with the full reference list.

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