A quick search on the internet can lead to you being overwhelmed with information about treatments for plantar fasciitis. Thankfully a new systematic review provides a comprehensive evidence-based summary.
Plantar fasciitis or plantar heel pain, is a common musculoskeletal injury which affects people of all ages and physical activity levels. The condition is characterised by pain in the medial heel which is made worse by weight-bearing activity and often follows a a trajectory towards chronicity.
Over the past decade we have seen an unprecedented influx of articles about plantar fasciitis. This is demonstrated by the fact that across five of the most popular medicine journals plantar fasciitis was the second most commonly published topic. this means there is a constant change in what is being advised from both an assessment and treatment perspective.
Thankfully a new systematic review published in Life summarises the findings from systematic reviews which focus on any aspect of plantar fasciitis assessment and management. We’ve taken that article and summarised the findings in around a thousand words for you.
This systematic review was pre-registered on PROSPERO and used the search terms plantar fasciitis, plantar heel pain OR plantar fasciopathy in combination with systematic review or meta-analysis on four databases. The full search strategy is available to read.
Two authors performed the search independently of each other with a third author being available to reach consensus about inclusion. All systematic reviews or meta-analyses about plantar fasciitis were eligible for inclusion. Narrative reviews were excluded so too were articles that weren’t published in English.
As this systematic review’s aim was to evaluate and synthesise the current state of knowledge about plantar fasciitis the only information extracted from the included reviews were:
- author and year of publication
- the type of plantar fasciitis topic
- the number and type of included studies in the systematic review
- the results of the meta-analysis if present
- summary findings of the systematic review
- limitations of the systematic review
The quality of the reviews included within this synthesis was evaluated by two authors by using AMSTAR 2. Any disagreement was resolved through consensus or by including a third author.
Results – Summary of Current Understanding of Plantar Fasciitis Assessment and Treatment
In total 96 systematic reviews were included within this review with the overall confidence of included reviews being low. 75% of the reviews rated as critically low, 17% as low, 3% as moderate and 4% as high.
Epidemiology & Risk Factors
Plantar fasciitis is most common between the ages of 40 and 60 and is thought to contribute to 25% of foot injuries in the general population with incidence being highest in runners. Other common proven risk factors include raised BMI, increased plantar flexion range of motion and the presence of a calcaneal spur.
Five reviews investigated the use of imaging tools in the assessment of plantar fasciitis which included ultrasound, MRI and x-ray. Ultrasound was the most commonly used and reliable diagnostic tool with plantar fascia thickness being the primary diagnostic indicator. Meta-analysis showed that patients with PF has 2.16mm thicker fascia and tended to have absolute fascia thickness of 4.00mm or more.
It is commonly thought that the presence of a calcaneal spur is a diagnostic indicator of fasciitis and whilst the odds ratio is 16.11 a causal relationship has yet to be established so caution should be used in interpreting presence.
The use of corticosteroids in the treatment of plantar fasciitis is common in clinical practice however there is little evidence to suggest it is beneficial beyond the short-term (4-6 weeks) and in fact in some cases the adverse effects outweigh the benefits.
Evidence does support using injections to reduce pain and some evidence demonstrates injection may be better at improving function than conservative physiotherapy treatments, however this evidence is methodologically weak with high risk of bias. If injection is to be used then ultrasound guided injections improve the effectiveness markedly but still not beyond short term benefits only.
Platelet-rich plasma injections are being used more commonly in the treatment of plantar fasciitis however evidence to support its use is currently inconclusive. Early evidence suggests improvement in pain and AOFAS score at 12 months however comparisons of PRP and corticosteroids show no difference.
Multiple studies demonstrate that using high-focused extracorporeal shockwave therapy (ESWT) improves pain at 3 and 6 months and also reduces the thickness of the plantar fascia itself. There is disagreement about which settings should be used and wether radial or focussed ESWT is more effective. This disagreement about protocol means current evidence isn’t conclusive with other RCTs showing no difference compared to commonly used treatments. that being said there is consensus that ESWT is more effective than corticosteroids.
Mechanical treatments (i.e insoles, taping, orthotics, night split and shoes) are commonly used in clinical practice and often people living with plantar heel pain use these interventions themselves without seeking advice first. For some insoles may be a useful treatment however pre-fabricated or custom insoles appear more effective at reducing pain and improving function than shame or some models of off the shelf insoles. Overall there is inconclusive evidence and personal trial-and-error may be the best way forward.
From an exercise perspective stretching alone is more effective than strengthening alone however combination offers the most benefit. The best stretches are a combination of calf and plantar fascia specific stretches.
There is no evidence to support the use of manual therapy alone in the treatment of plantar fasciitis however there is evidence to support its use in combination with stretching over a 4 week period. However it is unclear what type of manual therapy is most effective and what protocols should be followed.
Low Dye and calcaneal taping are the most commonly used taping techniques used however they are likely to only offer around a week of pain reduction and combination of stretching and tapping is more effective than taping alone.
There is limited evidence to support the use of acupuncture, dry needling or low-level laser therapy but the latter is likely to be most effective of the three. It is unclear which protocols are most effective for each of these treatments.