EVIDENCE-BASED ANSWER
Mechanical therapies—such as taping, tension night splinting, and rigid arch support—are the most effective treatment for plantar fasciitis (strength of recommendation: A, based on randomized controlled trials). If limited or no improvement is observed after 6 months of mechanical therapy, extracorporeal shock wave therapy (Orthotripsy) is the next treatment of choice (strength of recommendation [SOR]: A, based on meta-analysis of randomized controlled trials). When mechanical therapies and extracorporeal shock wave therapy have failed for more than 1 year, surgical treatment may be considered (SOR: C, based on a case-series study).
Evidence summary
In a prospective, observer-blinded study, 103 subjects were randomized to 1 of 3 treatment categories: anti-inflammatory (etodolac plus corticosteroid injections); accommodative (viscoelastic heel cup); or mechanical (low-dye tapping for 1 month followed by rigid custom orthosis for 2 months).1 After 3 months of treatment, 70% of patients in the mechanical treatment group rated their functional outcome as excellent, compared with only 33% of the anti-inflammatory group and 30% of the accommodative group (P=.005). Additionally, the mechanically treated group was less likely to terminate treatment early because of treatment failure (P<.001).
Several of the same researchers then went a step further to find out which specific mechanical treatment is best. They found no statistically significant difference among treatment with tension night splinting ( Figure 1 ), custom rigid orthosis, and over-the-counter arch supports.2 A retrospective study of 237 subjects also concluded that mechanical treatment is better than anti-inflammatory or accommodative treatments.3
Another prospective, observer-blinded study randomized 116 patients to 1 of 2 groups for 3 months.4 The first group of patients were treated with a nonsteroidal anti-inflammatory drug (piroxicam) and Achilles tendon stretching 3 times a day. The second group received the same treatment but also wore plastic tension night splints in 5° of dorsiflexion. After 3 months, in an intention-to-treat analysis, no statistically significant difference was detected in subjective pain between the 2 groups. In this study, patient compliance with the tension night splinting was poor, and this likely affected the outcome.
From 1993–1995 an observer-blinded randomized controlled trial of 112 patients compared standard with sham extracorporeal shock wave therapy.5 The main outcome measure was patient satisfaction on a 4-step score at 6 months and 5 years. At 6 months, the treatment group had a significantly better 4-step score than the placebo group (P<.0001). In fact, 51% of treatment-group patients were pain-free, while none of the 48 placebo-group patients were painfree. After 5 years, the 4-step score only demonstrated a trend in favor of the treatment group (P<.071) because of a high rate of good results from subsequent surgery in the placebo group. Thirteen percent of the treatment-group patients had undergone a heel operation, compared with 58% of placebo-group patients.
A controlled and observer-blinded study of 302 patients with plantar fasciitis compared standard extracorporeal shock wave therapy with sham treatment.6 The treated patients had significantly lower pain scores (as measured on a visual analog scale) than the placebo group (1.9 vs 4.7). Three months post-treatment, half as many treated patients were taking pain medication when compared with placebo patients. After 1 year of follow-up, 94% of the treatment group patients were still pain-free, with a pain score of <2.
One randomized controlled study of 166 patients found no evidence to support a beneficial effect on pain, function, and quality of life of extracorporeal shock wave therapy over a sham treatment.7 Of note, this study enrolled patients who had a minimum of 6 weeks of symptoms. All recommendations in the US are to reserve extracorporeal shock wave therapy for patients with more than 6 months of symptoms.