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Current Concepts Review: Plantar Fasciitis

Alan C. League
Foot Ankle Int 2008 29: 358
DOI: 10.3113/FAI.2008.0358

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FOOT & ANKLE INTERNATIONAL
Copyright  2008 by the American Orthopaedic Foot & Ankle Society
DOI: 10.3113/FAI.2008.0358

Current Concepts Review: Plantar Fasciitis

Alan C. League, M.D.

Maywood, IL

INTRODUCTION
Plantar fasciitis is the most common cause of inferior
heel pain. It is estimated that 11% to 15% of all foot
complaints requiring medical attention can be attributed to
this condition.27,29 In the United States, plantar fasciitis
affects two million individuals and accounts for one million
outpatient visits annually.35
Plantar fasciitis is considered a self-limited condition.
Symptoms resolve in 80% to 90% of cases within 10
months.10,22,26,45 However, this long interval is frustrating
for both patients and clinicians. Although there are numerous
reports describing operative and non-operative treatment
options that claim to hasten the resolution of symptoms,
few entail high-level evidence to substantiate their claims.
Without high-quality data to identify which treatments are
successful, the clinical decision-making in the management
of this condition is at times arbitrary and anecdotal. This
review summarizes the current literature and assesses perti-
nent data in order to provide evidence-based recommenda-
tions for the treatment of plantar fasciitis.
ANATOMY
which passively tensions the plantar fascia and elevates the
medial longitudinal arch.
Plantar fasciitis is defined as a localized inflammation
and degeneration of the proximal plantar aponeurosis. The
most common site of involvement is near the origin at the
medial tuberosity of the calcaneus. Similar to chronic tendon
disorders, pathological findings have included degenerative
changes in the plantar fascia with fibroblastic proliferation
and limited inflammatory tissue.19,23,25 General agreement in
the literature favors a process where mechanical overload and
excessive strain produce microtears within the fascia, which
eventually incites an inflammatory response.20,44 Repeated
heel strikes may hinder or prevent normal healing,16 resulting
in chronic inflammation followed by degeneration.24,39,41
CLINICAL MANIFESTATIONS
Plantar fasciitis typically presents with the insidious onset
of so-called “start-up pain.” This sharp, stabbing pain local-
ized to the plantarmedial aspect of the heel occurs when
arising out of bed in the morning or from a chair after
sitting for a long period. Start-up pain rapidly dissipates

The plantar fascia is a strong, fibrous aponeurosis that

originates from the plantar tuberosity of the calcaneus and
fans out into 3 bands that insert into the bases of the proximal
phalanges. The central band anatomically and structurally
dominates the medial and lateral bands. The thick plantar
fat pad protects and cushions the origin and insertion, while
the midsubstance can be palpated subcutaneously when the
plantar fascia is tensioned. Dorsiflexion of the toes, and
especially the hallux, activates the windlass mechanism

Corresponding Author:
Alan C. League, M.D.
Illinois Bone & Joint Institute, LLC
9000 Waukegan Road
Suite 200
Morton Grove, IL 60053
E-mail: a.league@yahoo.com
For information on prices and availability of reprints, call 410-494-4994 x226 Alan C. League, M.D.
358

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Foot & Ankle International/Vol. 29, No. 3/March 2008
Table 1: Level of evidence and grades of recommendation
Level of Evidence
— Level I: high quality prospective randomized clinical
trial
— Level II: prospective comparative study
— Level III: retrospective case control study
— Level IV: case series
— Level V: expert opinion
Grades of Recommendation (given to various
treatment options based on Level of Evidence
supporting that treatment)
— Grade A treatment options are supported by strong
evidence (consistent with Level I or II studies)
— Grade B treatment options are supported by fair
evidence (consistent with Level III or IV studies)
— Grade C treatment options are supported by either
conflicting or poor quality evidence (Level IV
studies)
— Grade I when insufficient evidence exists to make a
recommendation
once weightbearing is initiated. By the end of the day, a
dull, constant aching or throbbing pain typically develops
and may radiate into the arch or the forefoot. Rest, eleva-
tion, and massage of the foot often facilitate relief of this
pain. Overnight, this pain recedes and the patient awakens to
a stiff, painless foot until the first step out of bed.
Physical examination reveals localized tenderness to
palpation of the plantar fascia at its origin on the plantarme-
dial tubercle of the calcaneal tuberosity. An evaluation of the
range of motion may demonstrate restricted dorsiflexion of
the ankle, indicating a contracture of the gastrocnemius fascia
or Achilles tendon. A thorough assessment should include a
complete neurovascular examination to check for paresthe-
sias, a Tinel’s sign, and motor weakness. Inspection of the
heel pad for atrophy, trauma or open wounds may identify or
eliminate other possible diagnoses. If manually squeezing the
tuberosity elicits pain, the patient should be further evaluated
for a stress fracture of the calcaneus.
WHO IS AT RISK FOR PLANTAR FASCIITIS?
Although mechanical overload is frequently implicated as
a primary factor, the etiology of plantar fasciitis is thought
to be multi-factorial. Intrinsic factors such as advanced age,
abnormal foot posture, elevated Body-Mass Index, and tight
Achilles tendon, as well as extrinsic factors such as the use
of poor footwear, the type and intensity of daily activity, and
incidence of isolated or repetitive trauma have been proposed
as risk factors in development of plantar fasciitis. However,
no single factor has been reliably identified across multiple
studies. Static and dynamic cadaveric studies have linked
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PLANTAR FASCIITIS 359
Achilles tendon tension and plantar fascia loading and the
clinical significance of this relationship continues to draw
investigative interest.6,14 Riddle and colleagues34 conducted
a retrospective case-control study (Level II-1 prognostic
evidence) to evaluate three factors commonly thought to
predispose an individual to plantar fasciitis. Fifty patients
clinically diagnosed with unilateral plantar fasciitis were
enrolled in the study. Two controls were matched to each
patient on the basis of age and gender. Analysis of data
reported as an adjusted odds ratio revealed that individuals
who stand the majority of their workday had a significantly
increased risk of plantar fasciitis than those that did not
stand. The authors also determined that the risk of plantar
fasciitis increases in a “dose-response” relationship as the
amount of ankle dorsiflexion decreases or as the body-mass
index increases. Each of these 3 variables was found to be an
independent risk factor with reduced ankle dorsiflexion being
the most important. Recreational jogging did not increase the
risk of plantar fasciitis; however, only 8 subjects were joggers
in this study. The authors advised against generalizing this
particular finding to all athletic populations.
IMAGING
Imaging rarely plays a role in the diagnosis of plantar
fasciitis. It may rule out other diagnoses and confirm the
diagnosis in complicated cases. Plain radiographs may reveal
arthritis, neoplasm or other lesions in the bone or soft tissues
secondary to trauma, infection or prior surgery. Radiographs
may also reveal plantar calcaneal spurs; however, their
clinical relevance to plantar fasciitis has not been established.
While bone scans have 60% to 98% sensitivity and up to
86% specificity when used to diagnose plantar fasciitis, they
are more helpful to detect the presence of a calcaneal stress
fractures.17 Magnetic resonance imaging may demonstrate
thickening of the plantar fascia. The fascia of patients with
plantar fasciitis has been measured at 7.40 mm ± 1.17, while
in asymptomatic volunteers it measured 3.22 mm ± 0.44.
The differences were consistent for measurements taken in
the sagittal and coronal planes.4
Recently, ultrasonography has received increased atten-
tion for its diagnostic capabilities and its role in guiding
the location of extracorporeal shock wave treatment. With
ultrasound, the fascia can easily be differentiated from the
superficial fat pad and the underlying calcaneus. The normal
thickness of the plantar fascia thickness has been reported as
between two and four mm, whereas a thickness between five
and seven mm is found in patients with plantar fasciitis.15,17
NONOPERATIVE MANAGEMENT
Previous clinical studies evaluating the efficacy of nonop-
erative treatment have lacked high-level evidence. The
quality of recent research has improved, however, and data
360 LEAGUE
from high-quality, randomized, controlled trials are available
to assess the efficacy of specific treatment options.1,5,8,11 – 13,
18,21,28 – 32,36,37
Some investigations compare two or more
types of treatments, while others compare one treatment to a
sham or placebo control. Initiation of treatment within the
first 6 weeks of symptoms is thought to speed recovery,
however this remains unproven.40,46 Despite this progress,
considerable debate remains regarding the optimal manage-
ment of plantar fasciitis.
Stretching
Although frequently utilized as a simple and inexpensive
treatment for plantar fasciitis, recommendations for the
optimal duration and frequency of stretching exercise have
not been established unanimously. In an attempt to improve
outcomes, several new stretching techniques and protocols
have been investigated for their efficacy in alleviating the
symptoms of plantar fasciitis.11,12,30,33
Porter and colleagues30 prospectively randomized 94
patients with plantar fasciitis (Level II evidence) to a program
of sustained or intermittent stretching of the Achilles tendon.
The sustained group stretched 3 times a day for 3 minutes
during each session. The intermittent group stretched twice
a day and performed five 20-second stretches during each
session. The two groups performed their respective stretching
routine for four months. Demographic, psychometric and
physical data collected from 41 volunteers without foot pain
served as a control. There were no significant differences
found in the range of motion, pain or function of the ankle
between the two groups after completing their respective
program of stretching. The authors observed a correlation
between stretching and an improvement in measures of foot
and ankle function for both groups. Difficulties with the
retention of subjects, compliance with the prescribed program
and the lack of an untreated control group limit the capacity
of this study to determine if variations in stretching tech-
niques affect the natural history of plantar fasciitis.
The effect of stretching the Achilles tendon versus
stretching of the plantar fascia in patients with plantar fasci-
itis has been investigated. DiGiovanni and colleagues11,12
prospectively compared stretching the Achilles tendon to a
plantar fascia-specific stretching technique (Level I evidence).
All patients received prefabricated soft insoles, a 3-week
course of celecoxib, and an educational video on plantar
fasciitis. Eighty-two patients randomly assigned to either
technique were compared after 8 weeks, and again 2 years
later. At 8 weeks, the group performing the plantar fascia-
specific stretching demonstrated a significant improvement in
the pain subscale score of the Foot Function Index compared
to the group stretching only the Achilles tendon. At 2 years,
both groups had significantly improved pain scores compared
to their respective baselines; however, there was no longer
a difference in pain scores between both groups. Although
this study demonstrated a short-term advantage of the plantar
fascia-specific stretching over Achilles stretching, it could not
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Foot & Ankle International/Vol. 29, No. 3/March 2008
determine if either technique provided a long-term benefit
because of the lack of an untreated or sham control group.
Radford and colleagues33 incorporated a sham control
group when they evaluated the effectiveness of stretching
in the treatment of plantar fasciitis. Ninety-two subjects
were randomly allocated to two groups and participants were
blinded as to whether they were in the treatment group or the
sham group. The treatment group performed calf stretching
exercises and received sham ultrasound treatment while the
control group received sham ultrasound treatment alone
(Level I evidence). After 2 weeks, there was no difference
between the groups with respect to pain, general foot health,
“first-step” pain, or foot function. Since these groups were
only followed for 2 weeks, it remains unclear whether a
longer treatment period would have shown improved results
in the stretching group.
Although previous investigations and general consensus
have supported the use of stretching exercises in the treat-
ment of plantar fasciitis, the evidence from these recent
studies is insufficient (Grade I recommendation) to support
their proposed modifications in the timing and technique of
stretching. The work of DiGiovanni and colleagues suggests
that a plantar fascia-specific stretching may be advantageous
to Achilles tendon stretching alone for the short term relief
of pain. Overall, larger, well controlled studies are necessary
to determine the ideal program of stretching in the treatment
of plantar fasciitis.
Nocturnal Dorsiflexion Splints
Several prospective, randomized studies have investigated
the effectiveness of ankle dorsiflexion splints. Lying supine
or even prone allows the foot and ankle to remain plan-
tarflexed throughout sleep. As such, these devices are worn at
night to keep the ankle at neutral and thereby prevent contrac-
ture of the plantar fascia and gastrocnemius-soleus complex.
The absence of plantarmedial heel pain upon arising from
bed in the morning is considered a direct benefit of nocturnal
splinting.
Batt et al.1 prospectively evaluated the effect of ankle
dorsiflexion night splinting in 33 patients with plantar
fasciitis (Level II evidence). The controls wore viscoelastic
heel lifts, took non-steroidal anti-inflammatory medication,
and stretched their Achilles tendon. The treatment group
followed the same regimen and also wore a custom ankle-
foot-orthosis (AFO) designed to hold the ankle in near
maximum dorsiflexion during sleep. All 17 patients in the
treatment group experienced substantial clinical relief. The
average time to resolution of pain in this group was 12.5
weeks. The control group was assessed at a different interval,
and after 8.8 weeks, only six of the 17 patients had substantial
clinical relief. The 11 failures in the control group then
crossed over to the treatment arm and began sleeping in the
custom AFO. Eight of these 11 patients then experienced
relief of their pain. Although 30 of 33 cases of plantar
fasciitis resolved with the use of an AFO, a direct comparison
Foot & Ankle International/Vol. 29, No. 3/March 2008
of the groups was confounded by the decision to use different
intervals of time for treatment.
A crossover, prospective study performed by Powell and
colleagues31 employed night splints as the sole modality of
treatment for chronic plantar fasciitis (Level II evidence).
Thirty-seven patients randomized into 2 groups were follow-
ed for 6 months. One group wore splints for the first month
of the study, while the other group wore splints during
the second month. Neither group wore splints during the
last 4 months of the study. After the first month of the
study, the group sleeping in splints demonstrated significant
improvements in two different clinical scoring systems,
while the untreated group remained at baseline. At the
conclusion of the second month, the group that crossed
over to splinting demonstrated significant improvement in
the average scores. After 6 months, both groups maintained
the improvement in their scores observed with the use of the
night splints. Although neither the subjects nor the evaluators
were blinded, the results of this study support the efficacy of
night splinting.
Probe et al.32 performed a prospective, randomized study
to evaluate the effect of night splinting in patients receiving
other therapeutic modalities (Level I evidence). One hundred
sixteen patients were randomly assigned to 2 groups. The
members of the first group took anti-inflammatory medica-
tion, stretched their Achilles tendons, and made changes in
their shoewear. The other group followed the same regimen
and also used a dorsiflexion night splint for 3 months.
Blinded evaluation of the 2 groups was performed at 4, 6, and
12 weeks. The authors did not detect any significant differ-
ences between the results of the groups. The author could
not attribute any benefit to use of night splints in their study.
Overall the body of evidence regarding the use of night
splints supports a Grade B recommendation for the use of
this modality in the management of plantar fasciitis.
Orthoses
A wide variety of prefabricated and custom-made orthoses,
including heel cups, arch supports, and foot orthoses have
been used to treat plantar fasciitis. Many studies evaluating
the effects of orthotics on plantar fasciitis have compared
multiple orthotic designs.
Pfeffer et al.29 reported a multicenter study that enrolled
236 patients with plantar fasciitis and randomly allocated
them to 5 groups (Level II evidence). All patients performed
plantar fascia and Achilles tendon stretching. One group
performed stretching alone while the four remaining groups
each wore one of following orthoses: silicone heel pad,
felt pad, rubber heel cup, or a custom-made polypropylene
orthotic device. The Foot Function Index (FFI) was assessed
at baseline and at 8 weeks. The authors found no signifi-
cant differences in FFI scores among the groups. However,
a subgroup of patients who stood more than 8 hours daily
had significantly worse results wearing custom orthotics than
those who wore the prefabricated inserts. Additionally, the
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PLANTAR FASCIITIS 361
results were significantly better when the data from the
three groups wearing prefabricated orthoses were pooled for
comparison to the group wearing the custom orthoses. The
authors theorized the better results with the prefabricated
inserts may have been due to the superior cushioning proper-
ties of these materials compared to the firmer polypropylene
used to fabricate the custom orthoses.
Roos et al.37 compared subjects who wore a custom-
molded orthosis to those who slept in a night splint in
a recent prospective, randomized trial (Level II evidence).
Forty-three patients with plantar fasciitis were randomized
to receive custom orthoses alone, night splint alone, or both
custom orthoses and a night splint. Patients were evaluated
at up to 1 year and compliance was monitored with daily
logs. All groups had significant improvement at 12 weeks
and this was maintained at 1 year. No significant differences
were observed between the three groups at any point. When
the data from the two groups wearing an orthosis (alone or
in combination with splint) were pooled and compared to
the group using only the splints, a significant reduction in
pain was noted. Nineteen of 23 patients were still wearing
their orthotics at 12 months, while only a single patient
continued sleeping in a night splint. The authors concluded
that although both treatments reduced pain, the higher rate
of compliance with the orthotics offers a distinct advantage
to this method of treatment.
Landorf et al.21 prospectively randomized 135 patients
with plantar fasciitis to receive a non-therapeutic orthosis
(soft, thin foam), a prefabricated orthosis (firm foam), or a
customized orthosis (semi-rigid plastic) (Level I evidence).
Pain and function were assessed at 3 and 12 months.
Both parameters were improved in the prefabricated and
custom orthotic group when compared to the non-therapeutic
control group at three months; however, only the functional
difference was statistically significant. By 12 months, no
significant differences were observed among the groups. The
authors concluded that the short-term differences between
the treatment groups and the control group justify the use of
orthotics in the treatment of plantar fasciitis.
The results of these three trials demonstrate fair evidence
to support the short-term use of foot orthoses in the treatment
of plantar fasciitis (Grade B recommendation), with custom
orthoses providing no measureable benefit over prefabricated
orthoses.
Antinflammatory Agents
Anti-inflammatory agents, whether administered orally,
topically, or through an injection, have been a cornerstone
in the treatment of plantar fasciitis. Corticosteroids injected
into the origin of the plantar fascia provide an invasive,
but focused delivery of anti-inflammatory medication. The
risk of fascial rupture or fat pad atrophy weighs against
repeated or the immediate use of injections. Topically applied
steroid, propelled into the tissues with a small electric
charge (iontophoresis), may provide a safer alternative.
362 LEAGUE
The use of non-steroidal anti-inflammatory drugs (NSAIDs)
may decrease local inflammation, but difficult to tolerate
in patients with a gastric ulcers or a complex regimen of
medications. Although the histological changes observed in
diseased plantar fascia theoretically support the use of these
agents, high-quality trials investigating their effectiveness
have been lacking.
In a prospective, randomized controlled trial, Crawford
and colleagues8 investigated the effectiveness of corticos-
teroid injections for the treatment of plantar fasciitis (Level
II evidence). One hundred six patients were randomized
to one of 4 treatment groups: an injection containing 25
mg prednisolone and 1 ml lignocaine at the origin of the
plantar fascia, a tibial nerve block followed by an injec-
tion containing 25 mg prednisolone and 1 ml lignocaine,
an injection containing lignocaine only, and a tibial nerve
block followed by an injection of lignocaine. Pain, assessed
by visual analog scale, was the primary measure of outcome.
It was assessed prior to the intervention and at 1, 3, and 6
months after treatment. Reductions in the pain scores were
significantly greater at 1 month in the 2 groups that received
injections containing steroid. However, at 3 and 6 months, no
significant differences were detected. The tibial nerve block
did not have an effect on the overall pain relief or the percep-
tion of pain during the injection. A large number of the
subjects enrolled in this study were lost to followup: 25%
at 3 months and 48% at 6 months. However, there was no
statistical difference among the groups with respect to the
number of patients lost to followup. The authors concluded
that a single injection containing steroid provides effective
short-term relief from the pain associated with plantar fasci-
itis, but no long-term therapeutic benefit was observed.
Gudeman et al.18 reported on 36 patients with plantar
fasciitis randomized to receive iontophoresis with either
dexamethasone or a placebo (Level II evidence). Both groups
received 6 treatments over 2 weeks. At the conclusion of
treatment, the group receiving iontophoresis with dexam-
ethosone had significantly improved Maryland Foot Scores
compared to the group receiving iontophoresis with placebo.
However, 1 month after the treatments had ceased there was
no significant difference between the 2 groups. The authors
concluded that this treatment may not alter the natural history
of plantar fasciitis, although they suggested that iontophoresis
with dexamethasone may be considered for patients in whom
more immediate relief of pain is desired, such as competitive
athletes.
Donley et al.13 utilized a randomized controlled trial to
evaluate the effectiveness of NSAIDs in the treatment of
plantar fasciitis (Level II evidence). Twenty-nine patients
treated with stretching of the Achilles tendon, viscoelastic
heel cups and night splinting were randomly allocated to
receive 200 mg of celecoxib daily or a placebo for 30
days. The Foot Function Index measured disability and pain
at 1, 2, and 6 months from the initiation of treatment.
Consistent with many other trials evaluating the nonoperative
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Foot & Ankle International/Vol. 29, No. 3/March 2008
management of plantar fasciitis, pain and disability scores
improved significantly in both groups at all time points.
Although a trend toward increased efficacy was seen the
group receiving celecoxib, no statistically significant was
detected. The inclusion of a power analysis to confirm that
this study contained a sample size sufficient to avoid a beta
error would have strengthened the authors’ conclusions.
The collective results of these investigations suggest that
the relief from pain provided by the use of anti-inflammatory
agents may be limited to the first month of treatment. Flaws
in the design and a lack of followup diminish the capacity
of these studies to assess the efficacy of these agents beyond
this time point. The quantity and quality of the evidence
offered by these studies preclude a recommendation for their
use (Grade I recommendation).
EXTRACORPOREAL SHOCK WAVE THERAPY
Proponents of extracorporeal shock wave therapy (ESWT),
also referred to as orthotripsy, claim it offers an effective
means of treatment for chronic plantar fasciitis that has been
non-responsive to other nonsurgical treatments. The mech-
anism of action of orthotripsy is similar to lithotripsy for
treatment of kidney stones, in which acoustic waves dissi-
pate mechanical energy at the interface of two substances of
differing acoustic impedance. An electrohydraulic, electro-
magnetic, or piezoelectric generator may be used to produce
the shock waves. Currently, all 3 techniques are available for
clinical use and ESWT has been classified as either high- or
low-energy treatments based on the magnitude of the shock
wave generated by the device. High-energy ESWT requires
local or general anesthesia and is administered in a single
session, while the low-energy treatment avoids anesthesia
and is usually administered in 3 weekly sessions.
Buchbinder et al.5 performed a double-blind, randomized,
placebo-controlled trial to assess the efficacy of ESWT
with a low-energy device (Level I evidence). One hundred
sixty patients with plantar fasciitis for at least 6 weeks
were randomly assigned to receive either weekly ultrasound-
guided ESWT for 3 weeks or an identically administered
protocol with a sham treatment. Patients continued to use
previously prescribed orthotics and acetaminophen; however,
other therapies were not allowed during the study. At 6 and
12 weeks, the authors measured pain on a visual analog scale
and assessed functional outcomes with the Maryland Foot
Score, the Short-Form-36 Health Survey (SF-36), and other
clinical rating scales. Both groups demonstrated significant
improvements in all outcome measures. However, there were
no significant differences between the treatment-dose and
placebo-dose groups for any of the measured outcomes.
Based on their findings, the authors concluded that there was
no evidence to support ESWT with this particular device
for treatment of plantar fasciitis. Although an otherwise well
designed study, this trial enrolled subjects with a very short
of duration of symptoms. Most other trials assess the efficacy
Foot & Ankle International/Vol. 29, No. 3/March 2008
of ESWT on subjects with at least 6 months of symptoms.
This variation in the inclusion criterion of this study may
limit the relevance of these results to the entire population
of patients with plantar fasciitis.
Rompe et al.36 prospectively evaluated the results of
ESWT with an electromagnetically generated low-energy
device in a randomized, observer-blinded trial that enrolled
112 patients with at least 6 months of symptoms due to
plantar fasciitis (Level I evidence.) Both groups underwent
ESWT once a week for 3 sessions; however, the treatment
group received 1000 low-energy impulses while the control
group received only 10 impulses during each session. The
authors measured patient satisfaction with a 4-step scale, pain
with a visual analog scale, and function by pain-free walking
intervals. At 6 months, the treatment group demonstrated
57% good to excellent results compared to only 10% in the
placebo group. VAS pain scores were found to be statistically
significant favoring the treatment group by a score of 19
compared to 77 in the placebo group. Fifty-one percent of
patients in the treatment group were able to walk pain-free
at 6 months compared to none in the placebo group. These
patients were reevaluated at 5 years. At this time, more
than one-half (58%) of the placebo group had undergone
surgical release of their plantar fascia, while only 13% of the
treatment group had undergone the procedure. Although the
results of this study would be strengthened by more objective
outcome measures, the author’s conclusion that ESWT is an
effective treatment for plantar fasciitis is supported by their
data.
Ogden et al.28 investigated the efficacy of ESWT with
a high-energy device in a randomized, placebo-controlled,
blinded, multi-center study (Level I evidence). All patients
had symptoms for a minimum of 6 months and had been
treated with at least 3 different modalities prior to enrollment
in this study. The patients were assessed with 4 primary
criteria: 50% improvement in investigator-assessed pain,
50% improvement in patient-assessed morning pain, an
improvement of 1 point on a 5-point patient-assessed activity
scale, and absence of analgesic use. The authors considered
the treatment successful if all four criteria had been met.
Two hundred ninety-three patients were randomized to either
a treatment arm consisting of a single session of high-
energy ESWT under an ankle block, or a sham group
where placebo anesthesia was administered and a foam pad
blocked the transmission of shock waves to the foot. After 3
months, patients from either group who were deemed failures
were offered active treatment, thereby allowing crossover
for failures in the placebo group. At 3 months, the authors
reported 47% success in the actively treated group and
30% in the placebo group. This difference was statistically
significant. Of the failures in the placebo group who elected
to crossover, 43% subsequently achieved success. Although
a treatment effect was found in this study, implementation
of more universal outcome measures would increase the
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PLANTAR FASCIITIS 363
generalizability of the results and allow clearer comparisons
to other trials.
Thomson et al.42 published a recent meta-analysis on the
efficacy of ESWT for plantar fasciitis (Level I evidence).
Their review of all randomized, controlled trials between
1966 and 2004 identified 15 studies. Six demonstrated
sufficient summary statistics to allow pooling of their data
and met their inclusion criteria. Their analysis included a total
of 897 patients and adverse effects attributable to ESWT were
relatively minor, including skin reddening, local swelling,
numbness, and burning sensations. Outcomes demonstrated
a significant effect of ESWT with respect to morning pain.
Although statistically significant (p = 0.04), the clinical
significance of the observed benefit is unclear since it equates
to less than one-half centimeter (0.42 mm 95% confidence
interval 0.02 to 0.83) on a 10-cm VAS at 12 weeks.
The evidence to support the use of ESWT delivered
by an electrohydraulic, electromagnetic, or piezoelectric
generator is fair yet conflicting, and the trials investigating
these techniques are flawed due to inconsistencies in their
methodology. For these reasons, ESWT receives a Grade C
recommendation in the management of plantar fasciitis.
OPERATIVE TREATMENT
Isolated partial or complete release of the plantar fascia
or a fascial release combined with resection of the plantar
calcaneal spur, excision of abnormal tissue, or nerve decom-
pression are surgical treatment options for recalcitrant plantar
fasciitis. These operations, performed either open or through
an endoscopic approach, are indicated for patients with
moderate to severe, persistent symptoms that have been
resistant to at least six months of conservative treatment.
To date, high level evidence from randomized controlled
trials regarding the efficacy of these procedures has not been
published. Potential complications include arch collapse,
injury to the posterior tibial nerve and its branches, complex
regional pain syndrome, and persistent or recurrent pain.
The use of endoscopic techniques to perform these proce-
dures arises from their perceived advantages of a more rapid
recovery and return to activity after surgery.
Tomczak and colleagues43 retrospectively compared the
complete, endoscopic release of the plantar fascia with open
fasciotomy and removal of the plantar calcaneal spur (Level
III evidence). At nine months followup, the endoscopic group
returned to work sooner. Of note, pain, function and satisfac-
tion after surgery were not reported. The inclusion of a bony
resection with the open release introduces additional surgical
manipulation not experienced by the group that underwent
an isolated endoscopic release. This design flaw undermines
the intended comparison of open versus endoscopic release.
Furthermore, concern that an endoscopic approach does not
allow decompression of the first branch of the lateral plantar
nerve (FBLPN), and may increase the risk of nerve injury
limits the widespread use of this technique.
364 LEAGUE
Baxter and Thigpen2 differentiated nerve entrapment pain
of the FBLPN from plantar fascia origin pain, and accord-
ingly performed nerve decompressions without plantar fascia
release. Histologic examination of the FBLPN has demon-
strated evidence of perineural fibrosis and hypertrophy
(Sammarco, Helfey).38 However, Conflitti and Tarquino7
commented on the difficulty in differentiating pain from these
2 sources and recommended partial plantar fascia release
with neurolysis. They reported their results with 23 patients
who underwent partial fasciectomy and neurolysis of the
FBLPN. In this case series (Level IV evidence), the mean
duration of nonsurgical treatment prior to surgical interven-
tion was more than twenty months. Through an oblique,
medial incision the deep and superficial fascia of the abductor
hallucis muscle was released to decompress the nerve. After
this, an 8-mm x 8-mm square section of the medial plantar
fascia was resected. The authors estimated two-thirds to
three-quarters of the width of the plantar fascia was excised,
with the remaining lateral fascia left intact to prevent arch
collapse. Postoperative telephone interviews at an average of
twenty-five months after surgery revealed an improvement in
pain from 9.2 to 1.7 on a visual analog scale. However, the
preoperative scores were obtained retrospectively. Fourteen
patients reported no residual heel pain and an additional
eight patients reported at least a 50% reduction in their pain.
Two patients incurred a surgical complication. One patient
partially dehisced the incision and another patient devel-
oped dorsal midfoot pain that required temporary use of a
walking boot.
In an effort to reduce complications and speed recovery,
Bazaz and Ferkel3 recently reviewed their results with
endoscopic release of the plantar fascia. Their case series
(Level IV evidence) included 20 patients with a minimum of
7 months of symptoms. All received treatment with multiple
nonoperative modalities before surgery. Their technique
utilized a 30-degree, 4.0-mm endoscope through a lateral
portal for visualization, and a medial portal for release of the
medial third to half of the plantar fascia with a hook blade.
They found significant improvement in both the AOFAS
Ankle-Hindfoot Scale (66 to 88) and Maryland Foot Score
(62 to 83). The author additionally concluded that women,
non-worker compensation patients, and patients with less
than 2 years of symptoms achieved better results; however
these claims did not have adequate statistical analysis to
support them. They reported one case of complex regional
pain syndrome that required pain management. The authors
reported no additional complications and no further surgery
for their series.
Currently, insufficient data (Grade I recommendation)
exists to support the various surgical procedures available
for use in the surgical treatment of plantar fasciitis. In
the future, well designed, prospective studies that directly
compare surgical techniques or comparing the effects of
surgical and nonsurgical treatments may provide valuable
evidence to guide clinical decision-making.
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Foot & Ankle International/Vol. 29, No. 3/March 2008
SUMMARY
Although recently published studies have started to clarify
the effectiveness of some of the numerous options available
for the treatment of plantar fasciitis, the conclusions of a
systemic review performed in 2003 remain relevant. Craw-
ford and Thomson9 reviewed all randomized trials assessing
the treatment of plantar heel pain in adults published between
1966 and 2002. Only 19 trials involving 1626 participants
met their inclusion criteria. The authors found the quality
of the trials to be generally poor and inadequate to yield
poolable data. As a result, they attempted to provide a limited
summary of nonoperative interventions. They were only able
to conclude that limited evidence existed to support the short-
term effectiveness of local steroid injections. All other treat-
ments could not be adequately judged for their effectiveness
due to the lack of randomized, controlled studies. The authors
encouraged the development of well-designed trials to assist
in clinical decision-making and to optimize patient care.
Despite these limitations, this review of the current liter-
ature has identified several concepts that may guide our
collective approach to the treatment of plantar fasciitis:
1. Plantar fasciitis is a common cause of inferior heel pain.
In most cases, its clinical course reflects a self-limited
process with the resolution of symptoms occurring
within one year.
2. The diagnosis of plantar fasciitis in made clinically in
most cases. A history of “start-up pain” and tenderness
at the plantar medial aspect of the calcaneus supports
the diagnosis. Additional findings after a thorough
interview and physical examination of the patient may
warrant the use of plain radiographs or advanced
imaging to rule out other possible diagnoses.
3. Due to the natural history of this condition and the lack
of high-quality evidence to support one particular inter-
vention, the initial treatment of plantar fasciitis should
be limited to nonoperative methods. This may include
the use of night splints, over-the-counter foot orthoses
and routine stretching of the plantar fascia and/or the
Achilles tendon. The use of anti-inflammatory agents
administered orally, topically or by injection may be
included in the initial management regimen. However,
the risk of fascial rupture or fat pad atrophy weighs
against repeated or the immediate use of injections.
Further, the capacity of these agents to relieve pain
has not been demonstrated to extend beyond the first
month of use.
4. The evidence currently available to assess the efficacy
of extracorporeal shock wave therapy lacks the quality
and consistency to support its unconditional use in the
management of plantar fasciitis. For those patients who
have complied with a monitored course of nonoperative
treatment and have failed to respond within six months,
the use of extracorporeal shock wave therapy may be
Foot & Ankle International/Vol. 29, No. 3/March 2008
considered. No study directly comparing the efficacy
of the ESWT devices currently available has been
published. Therefore, no high-quality evidence exists
to guide the choice of whether to employ a low or high
energy device to administer shock wave therapy.
5. High quality evidence to support the surgical release of
the plantar fascia alone or in combination with a neurol-
ysis of the posterior tibial nerve and its branches is
lacking. The absence of randomized, controlled trials in
a well-defined cohort prevents the clear determination
of the role, timing and effectiveness of these operations
in the treatment of plantar fasciitis.
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