Plantar Fasciitis Treatment: What the Guidelines and Trials Actually Support

Key Takeaways

Plantar fasciitis contributes to approximately 15% of foot pathology in the general population and occurs most commonly in those between 40 and 60 years of age.[1]
The course can be long, at least in more severe cases: in a follow-up study of patients with severe plantar fasciitis, the risk of still having it was 80.5% after 1 year and 50.0% after 5 years from the onset of symptoms.[2]
A BJSM best practice guide concluded that core treatment for people with plantar heel pain should include taping, stretching and individualised education.[3]
The 2023 JOSPT guideline states that clinicians should prescribe therapeutic exercise that includes resistance training.[1]
In a meta-analysis, corticosteroid injection was not shown to be more effective than placebo injection for reducing pain in the short or medium term.[4]
For recalcitrant cases, a meta-analysis recommended high-energy shockwave therapy as a remedial measure after failure of traditional conservative treatment and ahead of surgical intervention.[5]
In a randomised trial, referral to a podiatrist for a custom-made insole did not lead to a better outcome compared to sham insoles or GP-led usual care.[6]
In my clinical experience, plantar fasciitis is very often the cause when a patient has pain in the sole around the heel, and many of my patients stand a lot at work.
In my practice, I am used to referring patients to a physiotherapist fairly quickly, as I have noticed that many are reluctant to take up active treatments such as stretching and rehabilitation.

Introduction: Plantar Fasciitis Treatment

Heel pain that is most noticeable with the first steps after a period of inactivity is the typical picture of plantar fasciitis.[1] Plantar heel pain affects 4%–7.0% of the community,[3] and among runners, plantar fasciitis incidence ranges from 4.5% to 10.0%, with prevalence ranging from 5.2% to 17.5%.[7]

As a physician and former world champion in Taekwon-Do, I look at plantar fasciitis from two directions: as a medical diagnosis and as a load problem that interrupts training.

Plantar fasciitis is a fairly common reason for visits in my practice. In my experience, when a patient has pain in the sole of the foot, especially around the heel, it is very often plantar fasciitis.

This article goes through what current guidelines and randomised trials say about plantar fasciitis treatment: first-line self-management, stretching and strength training, injections, shockwave therapy and insoles, and what the research shows about recovery time.

How Plantar Fasciitis Is Recognised

The 2023 clinical practice guideline from the Journal of Orthopaedic & Sports Physical Therapy describes plantar fasciitis as characterized by medial plantar heel pain with tenderness at the medial calcaneal tubercle. The pain is most noticeable with initial steps after a period of inactivity.[1]

The same guideline lists limited ankle dorsiflexion range of motion, high body mass index in nonathletic individuals, running, and work-related weight-bearing activities as risk factors.[1]

Many of my patients with plantar fasciitis stand a lot at work, sometimes in fairly static positions for long periods; nurses, for example, are often among them. Interestingly, I have noticed that many also have flat feet (pes planus) at the same time. I do not know whether this is directly linked; it is simply my own general observation. I also often see Achilles tendinopathy at the same time, which in my view may sometimes point to shared biomechanical factors, although I cannot establish such a link from these observations alone.

That said, I have also seen other causes of pain in the sole, such as a wart or a callus, and sometimes a ganglion. In some patients, pain from the tibialis tendons, such as enthesopathy, tendinitis or tenosynovitis, has been felt around the sole. Around the ball of the foot, I keep in mind bone stress injuries, Morton’s neuroma and intermetatarsal bursitis, and under the heel, fat pad damage, which I have seen resemble plantar fasciitis. In my experience, plantar fasciitis is usually tender in a typical spot: on the plantar side of the heel, perhaps a couple of centimetres from the insertion, and often slightly medially.

Plantar Fasciitis Treatment Starts With Self-Management

A best practice guide published in the British Journal of Sports Medicine combined a systematic review of 51 trials with 4,351 participants, expert interviews and a patient survey.[3] The review reported a short-term benefit for first step pain from low-dye taping plus sham ultrasound compared with sham ultrasound alone (SMD: 0.47, 95% CI 0.05 to 0.88), and found plantar fascia stretching superior to radial shockwave therapy for first step pain in the short term (SMD: 1.21, 95% CI 0.78 to 1.63). The guide is a best practice synthesis of trials, expert opinion and patient feedback, not a single trial that tested the whole treatment sequence.[3]

The guide’s conclusion was that core treatment for people with plantar heel pain should include taping, stretching and individualised education, and that patients who do not optimally improve may be offered shockwave therapy, followed by custom orthoses.[3]

The 2023 JOSPT guideline gives similar first-line recommendations. It states that clinicians should use plantar fascia-specific and gastrocnemius/soleus stretching, foot taping techniques (rigid or elastic) in conjunction with other physical therapy treatments, and manual therapy directed at the joints and soft tissue structures of the lower extremity.[1] For individuals who consistently have pain with the first step in the morning, the guideline recommends a 1- to 3-month program of night splints.[1]

In practice, I see stretching treatment in two forms: active stretching that patients do themselves, and more passive night splint treatment. There is a sock model and a frame model, similar to a walker boot, which we often use. In my experience, the sock model is usually easier and cheaper to get, and in Finland I have seen it widely available in pharmacies. Many of my patients have been helped by these measures. Rest can help too, but in my view it does not necessarily remove the underlying problem, which I see as tendinopathy-type change in the plantar fascia.

In my experience, patients may be reluctant to take up active treatments such as stretching and rehabilitation, and are often content with more passive measures, such as medication and rest. With many of my patients I have suggested stretching, and I am used to referring them to a physiotherapist fairly quickly, usually right after the first visit. I know how stubborn the condition can be, and I find it helpful that a physiotherapist can assess their ergonomics and rehabilitation exercises early.

Stretching and Strength Training for Plantar Fasciitis

Plantar fascia-specific stretching

The plantar fascia-specific stretch comes from a randomised trial of 101 patients who had chronic proximal plantar fasciitis.[8] The authors concluded that a program of non-weight-bearing stretching exercises specific to the plantar fascia is superior to the standard program of weight-bearing Achilles tendon-stretching exercises.[8]

High-load strength training

In a later trial, 48 patients with plantar fasciitis were randomised to shoe inserts with daily plantar-specific stretching or shoe inserts with high-load strength training based on heel raises.[9] The strength group had better foot function scores at 3 months, but there were no differences between the groups at 6 or 12 months. The authors concluded that high-load strength training may aid in a quicker reduction in pain and improvements in function.[9]

The 2023 JOSPT guideline states that clinicians should prescribe therapeutic exercise that includes resistance training.[1]

In my clinical experience, rehabilitation of plantar fasciitis differs here from many other tendinopathies: eccentric exercises have often not helped my patients with this condition as well as stretching has. This is my own clinical impression; the trial above tested high-load strength training rather than eccentric exercises alone.

Injections: Where Corticosteroids Fit in Plantar Fasciitis Treatment

Corticosteroid injection is a frequently used plantar fasciitis treatment, although there is limited high-quality evidence to support it.[4] A systematic review and meta-analysis of 47 trials (2989 participants) found that corticosteroid injection was more effective than some comparators for reducing pain and improving function. However, in placebo-controlled comparisons it did not show a statistically significant benefit for pain reduction in the short or medium term, and when trials considered to have high risk of bias were excluded, there were no significant findings.[4] In the longer term, corticosteroid injection was less effective than dry needling.[4]

The FIX-Heel trial randomised 180 adults with plantar fasciopathy to patient advice and a heel cup, the same plus heavy-slow resistance training, or both plus a corticosteroid injection.[10] There was a statistically significant difference in the primary pain outcome between advice alone and the injection group after 12 weeks, with an adjusted mean difference of 9.1 points, while the minimal important difference was 14.1 points. At no follow-up did the mean difference between groups exceed the pre-specified minimal important difference. An acceptable symptom state was reached within 12 weeks by 11 patients in the advice group, 8 in the exercise group and 21 in the injection group.[10] The authors concluded that combining a corticosteroid injection with exercise is not superior to exercise or no exercise.[10]

Some of my patients ask for a cortisone injection now and then. I have given them occasionally, but in my view it is not a first-line treatment, and in my experience there is no guarantee of the result. Sometimes the pain eases for a while, but the injection itself is often quite painful.

Shockwave Therapy as a Plantar Fasciitis Treatment for Stubborn Heel Pain

A meta-analysis of five placebo-controlled and double-blinded clinical trials including 716 patients estimated the pooled OR at 2.25 (95% CI, 1.66–3.06; p <0.00001) at 12 weeks after active high-energy shockwave treatment.[5] The authors recommended high-energy shockwave therapy as a remedial measure after failure of traditional conservative treatment and ahead of surgical intervention.[5]

The BJSM best practice guide reached a similar stepped-care position, recommending focused shockwave for first step pain for patients who do not optimally improve with core treatment.[3]

Insoles, Orthoses and Other Plantar Fasciitis Treatments

In the STAP randomised trial, 176 of 185 randomised participants completed the 12-week follow-up, and there was no difference in pain or function between the insole and the sham groups.[6] Participants in the GP-led usual care group reported less pain during activity at 12 weeks than those in the custom insole group.[6]

The JOSPT guideline says clinicians should not use orthoses, either prefabricated or custom, as an isolated treatment for short-term pain relief, but may use them when combined with other treatments to reduce pain and improve function.[1] It also recommends dry needling to myofascial trigger points in the gastrocnemius, soleus and plantar muscles of the foot, and low-level laser therapy as part of a rehabilitation program. It advises against using ultrasound to enhance the benefits of stretching treatment.[1]

How Long Does Plantar Fasciitis Take to Heal?

A long-term follow-up of 174 patients with severe plantar fasciitis found that the risk of having plantar fasciitis was 80.5% after 1 year, 50.0% after 5 years, 45.6% after 10 years, and 44.0% after 15 years from the onset of symptoms.[2] The risk was significantly greater for women and patients with bilateral pain. The authors noted that these participants are not representative of all patients with plantar fasciitis.[2]

In my clinical experience, this can be a very difficult condition. Some of my patients have recurrent episodes and end up repeatedly on sick leave, because the pain tends to get worse with load and at work. By the time they reach my clinic, many have already tried better shoes, different insoles, heel raises, heel cushions, sometimes pronation support, and anti-inflammatory painkillers. It is usually in one foot, but I have also seen it in both, and the affected side can vary.

Plantar Fasciitis Treatment FAQ

Is stretching or strengthening better?

Both have trial support. Plantar fascia-specific stretching was superior to weight-bearing Achilles tendon stretching in a trial of 101 patients,[8] while high-load strength training produced better foot function scores than stretching at 3 months.[9]

Do I need expensive custom insoles?

In the STAP trial, referral to a podiatrist for a custom-made insole did not lead to a better outcome compared to sham insoles or compared to GP-led usual care at 12 weeks.[6] The JOSPT guideline advises against using orthoses as an isolated treatment for short-term pain relief, but allows them when combined with other treatments.[1]

Does a steroid injection fix it?

A meta-analysis of 47 trials found no statistically significant advantage of corticosteroid injection over placebo injection for pain reduction in the short or medium term,[4] and in the FIX-Heel trial the mean difference in the primary pain outcome did not reach the minimal important difference, although more patients in the injection group reached an acceptable symptom state.[10]

Who is most at risk of a long course?

In a follow-up of 174 patients with severe plantar fasciitis, the risk of persisting plantar fasciitis was significantly greater for women and patients with bilateral pain.[2]

Conclusion

Plantar fasciitis contributes to approximately 15% of foot pathology,[1] and in a long-term follow-up of patients with severe plantar fasciitis, the risk of still having it was 80.5% one year after onset.[2]

The BJSM best practice guide places taping, stretching and individualised education at the core of plantar fasciitis treatment, with shockwave therapy and then custom orthoses for those who do not improve.[3] The JOSPT guideline adds resistance training to the recommended exercise.[1] In the FIX-Heel trial, the mean improvement in the primary pain outcome with injection plus exercise, compared with advice and a heel cup alone, did not exceed the minimal important difference, although more patients in the injection group reached an acceptable symptom state,[10] and in the STAP trial, referral for custom-made insoles did not lead to a better outcome than sham insoles or GP-led usual care at 12 weeks.[6]

This matches what I see in practice: I have seen how stubborn plantar fasciitis can be. Some patients end up repeatedly on sick leave, and many have already tried several shoes, insoles and painkillers before they come to see me. In my experience, treatments such as stretching and night splints have helped many of them, while a cortisone injection has offered no guarantee of lasting relief.

In my view, current evidence supports several conservative options for plantar fasciitis, while the best order of treatments and their long-term benefits remain uncertain.

Plantar Fasciitis Treatment: What the Guidelines and Trials Actually Support

Table of Contents

Key Takeaways

Introduction: Plantar Fasciitis Treatment

How Plantar Fasciitis Is Recognised

Plantar Fasciitis Treatment Starts With Self-Management