Stretching and trigger-point manual therapy are effective
The traditional primary treatment modality for PF has been early initiation of an Achilles-soleus (heel-cord) muscle–stretching program. However, studies have shown that plantar fascia–specific stretching (PFSS) (FIGURE) significantly diminishes or eliminates heel pain when compared with traditional stretching movements, and is useful in treating chronic recalcitrant heel pain.12,13 PFSS has also yielded results superior to low-dose shock wave therapy.14
In a 2011 study, adding myofascial trigger-point manual therapy to a PFSS routine improved self-reported physical function and pain vs stretching alone.15 This manual therapy technique is specialized and should be administered only by trained physical therapists. Data are limited and mixed regarding the effectiveness of deep tissue massage, iontophoresis, or eccentric stretching of the plantar fascia to alleviate plantar fascial pain. Support for therapies such as rest, ice, heat, and massage has largely been anecdotal.
NSAIDs for PF lack good evidence
Nonsteroidal anti-inflammatory drugs (NSAIDs) are often prescribed to treat PF, despite a lack of evidence supporting their use. A small randomized, placebo-controlled double-blind study established a trend toward improvement in pain and disability scores with the use of NSAIDs. However, no statistically significant difference was noted in the measures between the NSAID and placebo groups at 1, 2, and 6 months.16 We found no studies that demonstrate a significant reduction in pain or improvement in function with the use of NSAIDs alone.
Although NSAIDs carry their own risks, they may work for some patients. And studies showing a lack of significant pain reduction may have been underpowered. If patients are willing to accept the risks of NSAID use, it would be reasonable to prescribe a therapeutic trial.
Orthotics and night splints can help, depending on comfort and compliance
Foot orthotics help prevent overpronation and attenuate tensile forces on the plantar fascia. A 2009 meta-analysis confirmed that both prefabricated and custom-made foot orthotics can decrease pain.17 One prospective study showed that 95% of patients had improvement in PF symptoms after 8 weeks of treatment with prefabricated orthotics.18 A Cochrane review found no difference in pain reduction between custom and prefabricated foot orthotics.19 A recent study demonstrated that rocker sole shoes—a type of therapeutic footwear with a more rounded outsole contour—combined with custom orthotics significantly reduced pain during walking compared with either modality alone.20 More research needs to be conducted into the use of rocker sole shoes before recommending them to PF patients.
Night splints help keep the foot and ankle in a neutral position, or slightly dorsiflexed, while patients sleep. Several studies have shown a reduction in pain with the use of night splints alone.17,21,22 Patient comfort and compliance tend to be the limiting factors in their use. Anterior splints are better tolerated than posterior splints.23
Shock wave therapy has better long-term results than steroid injections
Shock waves used to treat PF are thought to invoke extracellular responses that cause neovascularization and induce tissue repair and regeneration. A 2012 review article concluded that most research confirms that extracorporeal shock wave therapy (ESWT) reduces PF pain and improves function in 34% to 88% of cases.24 ESWT is comparable to surgical plantar fasciotomy without the operative risks, and yields better long-term effects in recalcitrant PF compared with corticosteroid injections (CSI).24 Many studies are underway to validate the effectiveness of ESWT. Currently, expense or lack of availability limits its use in some communities.
Invasive treatments
Corticosteroid injections may be used for more than just refractory pain
CSI have historically been reserved for recalcitrant heel pain. However, one systematic review cites evidence in support of CSI for the short-term management of plantar fascia pain.25 Compared with placebo, CSI reduces pain at both 6 and 12 weeks and decreases plantar fascia thickness.26 Additionally, the American College of Foot and Ankle Surgeons lists CSI as an acceptable first-line treatment for PF.4
The most common complication of CSI is postinjection pain. Other complications, such as fat pad atrophy, rarely occur.27 While the evidence is limited, CSI may be part of an initial approach to treating PF in addition to heel-cord or plantar fascia-specific stretching, particularly for patients who desire an expedited return to normal activity.
Platelet-rich plasma therapy holds promise
Platelet-rich plasma (PRP) has been gaining popularity as a treatment for PF pain. PRP is a component of whole blood that is centrifuged to a concentrated state, treated with an activating agent, and injected into the affected area. Theoretically, injected PRP increases the release of reparative growth factors, enhancing the healing process.28 PRP has been shown to be as effective in reducing pain scores as CSI at 3 weeks and 6 months.29 PRP also decreases plantar fascia thickness and improves pain scores and functional ability.30