Plantar Fasciitis Treatment – A Complete Guide

Guide to Plantar Fasciitis Treatment

The most common cause of heel and arch pain is a condition called plantar fasciitis although there are many other causes of heel pain.

This page and it’s links will provide you with a complete guide to the current best treatments for plantar fasciitis. The information is based on the current best evidence available.

Plantar fasciitis is an inflammation and/or degeneration of a thick band of tissue that runs along the arch of your feet from your heel to your toes and aids in stabilization of your arch while you walk and run.

Plantar Fasciitis vs. Plantar Fasciosis

What is usually called “plantar fasciitis” (which simply means that the plantar fascia is inflamed) is actually “plantar fasciosis” (degeneration of the fascia) in most cases.  Plantar fasciitis, however,  has become the term commonly known to most people so we will use the terms interchangeably.

Evidence Based Treatment Protocol for Plantar Fasciitis

Our protocol for treating plantar fasciitis is based on what the best studies tell us are the best treatment options.

Levels of Evidence

The quality of  medical research is graded on “Levels of Evidence”.

• Level I is the best evidence and comes from a systematic review of all relevant studies that were run to the best standards.
• Level  VII evidence is based only on expert opinion and not on any studies.

There are, of course, five levels between those two.

We always try to use the best available evidence when designing our treatment plans and the information on this page will provide you with our best recommendations for treatment of plantar fasciitis.

Treatment Plan for Plantar Fasciitis

Below is a summary of our standard treatment plan for plantar fasciitis. There are links to more detailed explanations of each portion.

First: Reduce the Load on the Plantar Fascia

For tissue to heal you must first stop damaging it so it has a chance to heal.

There are two types of force that affect the plantar fascia:

• Tension: When the arch of the foot flattens out, it gets longer. As it gets longer, tension increases on the fascia. To allow the plantar fascia to heal you have to stop tugging on it.

• Pressure:  Every step you take puts 3 – 5 times your body weight through your heel. To allow the plantar fascia to heal you have to stop pounding on it.

We can reduce the tension on the plantar fascia and pressure on the heel in a number of ways:

• Orthotics and Arch Supports: Custom orthotics or prefabricated arch supports that conform close to the arch of the foot will both reduce tension on the plantar fascia AND transfer pressure off of the heel onto the mid-portion of the arch. You can read here how orthotics should be made to best treat plantar fasciitis / heel pain.

• Proper Shoes: Some shoes will reduce force on the plantar fascia while others can increase it. The best shoe for your foot will vary with your foot type and your activities. We will guide you to the best shoes to reduce force on the plantar fascia.  You can download our list of recommended shoes here.

• Walking Boots and Ankle Braces:  Boots and braces can be used in the short-term (usually a couple weeks) to maximally reduce force on the plantar fascia to allow the tissue to rest and jump start healing.

• Taping: There are taping techniques that can reduce tension on the plantar fascia. We often teach our patients to tape in order to facilitate healing.  Learn about taping for plantar fasciitis here.

• Modification of Activity: If you are athletic or exercise a lot we absolutely want to keep you active and we will work with you so you can maintain your fitness. You will, however, often need to modify activity so you are not pounding so hard on your heel and arch. You can read here our page on how to exercise when you have a foot injury.

• Weight Loss: Being overweight can dramatically increase force on the heel. Losing weight will almost always help plantar fasciitis heal. Learn more about how being overweight can affect your feet.

Second: Facilitate Healing and/or Reduce Inflammation

Once we reduce the load on the plantar fascia we want to help it to heal.  There are several treatments that have been shown to speed healing of the plantar fascia or at least speed pain relief by reducing inflammation.

• Stretching: There is high level evidence that specific stretches can help heal the plantar fascia. You can learn about the three stretches you should do to heal plantar fasciitis here.

• Shockwave Therapy: There is also high level evidence that shockwave therapy can help heal plantar fasciitis. Detailed information on shockwave therapy for plantar fasciitis is here.
  • The pros of shockwave therapy are that studies show it to be very effective at helping to heal plantar fasciitis and there are no side effects.
    • Many studies show shockwave to be the most effective treatment for plantar fasciitis and plantar fasciosis and recommend it as the primary treatment for any plantar fasciitis over one-month duration.
    • Shockwave is particularly good if athletes wish to remain active as the beneficial effects do not seem to be affected by activity.⁷
  • The downside of shockwave is that it takes 16 – 20 weeks to see maximum results and it is not covered by insurance (cost is $450 for the recommended three sessions).

• Cortico-steroid Injections: There is medium level evidence that steroid (cortisone) injections can help relieve the pain of plantar fasciitis. An advantage of steroid injections is that when they work they tend to give very rapid relief. We often use ultrasound to help guide the injection to the most inflamed or damaged portion of the plantar fascia.
  • The pros of steroid injections are that they can provide very rapid relief. If you have a vacation coming up and need to be pain free for the trip or are having trouble walking because of the pain we can use steroid injections to help give you almost immediate relief.
  • The downside of steroid injections is that they do not help heal the tissue (as shockwave does). Also, there are some potential complications of the injections including thinning of the fat pad under the heel, degeneration of the plantar fascia and an increased chance of a rupture of the plantar fascia.

• Ultrasound Guided Steroid Injections vs. Palpation Guided Steroid Injections
  • We use ultrasound guidance for most of our heel injections. Multiple studies have shown that both short term and long-term outcomes are better when ultrasound is used to guide the injection. The only downside is that the use of ultrasound increases the cost of the injection. Below is information from the studies and additional details on cost.
    • In a meta-analysis (review of multiple studies) of using ultrasound to guide the injection vs. injection without using ultrasound (“palpation method”), the ultrasound guided injections were found to be more effective ¹⁰. This is likely because we are able to guide the steroid at the thickest and most inflamed portion of the plantar fascia.
    • A 2013 study showed better therapeutic outcomes at 3 months for those patients that received ultrasound guided steroid injection compared to those that had palpation guided. In addition there was less thinning of the fat pad – a potential complication of these injections.¹¹
    • A study by Tsai et al. involving 25 patients who received either Ultrasound-guided or Palpation-guided injection were followed up to assess pain intensity, thickness, and echogenicity of the proximal plantar fascia at 2 weeks, 2 months, and a year after the injection. The results revealed that pain, plantar fascia thickness, and recurrence was less when ultrasound was used to give the injection.¹²

      • Cost of Ultrasound Guided Injections

        • There is an additional charge for use of the ultrasound. This is usually covered by insurance after your deductible is met.
        • We are certainly able to do the injection without the ultrasound if the patient prefers.
        • The billed amount if we are billing insurance is $136 for the injection and $195 for ultrasound guidance.
        • If you are paying out of pocket we do offer discounted prices of $109 for the injection and an additional $152 for the ultrasound guidance. This discount is available only if insurance is not billed. If insurance is billed and the service is not covered by the insurance then the patient is responsible for the non-discounted price.
        • Our insurance and self-pay discounted prices for most of our services can be found here.

• Often we will use a steroid injection to get patients over the initial severe pain and then use shockwave therapy to help the tissue heal in order to prevent return of the symptoms. You must wait 6 weeks after an injection before starting shockwave therapy
  • A 2017 study compared corticosteroid injection and shockwave therapy in the treatment of plantar fasciitis. Both treatments were shown to provide pain relief, but by 6 months the pain had returned in the group who received injection while the group that had shockwave therapy did not show a return of the pain.¹³
  • A 2018 study found  shockwave therapy achieves better medium- and long-term outcomes than ultrasound-guided injection in the treatment of plantar fasciitis.¹⁴
  • Another 2018 study looked at the pain level at the 12th week after treatment and found that extracorporeal shockwave therapy (ESWT) was more efficient than corticosteroid injection (CSI) on chronic plantar fasciitis.¹⁵

• Icing: Ice can help with the initial inflammation but won’t help if you have plantar fasciosis.

• Anti-inflammatory Medications: There is low level evidence that NSAIDs help, except with the initial inflammation.

Third: Prevent the Plantar Fascia Pain from Returning

Once the pain of plantar fasciitis / fasciosis has been relieved, the next goal is to allow the patient to participate in any activity they want without having the plantar fascia pain return.

Two important concepts help prevent return of plantar fasciitis / fasciosis.

• Prevent Excessive Load on the Plantar Fascia: Continued use of orthotics or arch supports and the use of proper shoes will reduce load on the fascia to help prevent return of plantar fasciitis.

• Improve the Ability of the Plantar Fascia to Handle Increased Load without Becoming Injured:  Our goal here is to slowly and progressively increase the load the plantar fascia can handle. Essentially this means we want to increase the strength of the connection between the plantar fascia and the heel bone.
  • This is a long term treatment and requires commitment from the patient to every other day exercises. Often we find competitive athletes are better at doing the required exercises long term.
  • Read about how to increase the ability of the plantar fascia to handle load

Surgery Should be the Last Resort for Treatment of Plantar Fasciitis

We advise you not to let anyone perform surgery on your heel unless you have seen us first for a consultation.

When plantar fasciitis is treated correctly, surgery is almost never necessary. We can’t emphasize that enough – surgery is almost never necessary to treat your plantar fasciitis. If surgery has been recommended for your plantar fasciitis, see us for a second opinion first.

If surgery should be necessary, we will provide you with comprehensive, state-of-the-art care but you should first give conservative treatment at least six months to work.

Although rarely necessary, when it is needed surgery is about 85% successful. People who are overweight do not respond as well to surgery.

Summary of Treatments for Plantar Fasciitis with Level of Evidence

Treatment	Level of Evidence
Reduce Load
Over the counter arch supports	Medium level evidence
Custom orthotics	Medium level evidence
	.
Facilitate Healing and Reduce Inflammation
Stretching of arch and calf	High level evidence
Shockwave / EWST	High level evidence
Cryotherapy (Icing)	Medium level evidence
Cortico-steroid injection	Medium level evidence
Night splints	Medium level evidence
Platelet rich plasma	Low level evidence
Physical therapy (ultrasound & iontophoresis)	Low level evidence
NSAIDs (Advil, etc)	Low level evidence
Needling, accupuncture, massage, Cold LASER	Experimental / Not well studied
	.
Surgery
Endoscopic plantar fasciotomy	High / medium evidence
Open and percutaneous fasciotomy	Low level evidence
Gastrocnemius recession	Low level evidence
TOPAZ	Low level evidence

 

Table adapted from: Saxena, A, Fullem, B “Plantar Fascial Injuries” in  Foot and Ankle in Sports Medicine ( editors: David W. Altchek, M.D., Jonathan T. Deland, M.D., Christopher DiGiovanni, M.D.,Rock G. Positano, DPM, MSC, MPH, and Joshua Dines, M.D.) Lippincott 2012 and from an excellent article by Dr. Amol Saxena.

See Us in Our Seattle Heel Pain Clinic

If you have heel pain due to plantar fasciitis or other causes, contact us for an appointment.

Try Home Treatment of Plantar Fasciitis

If you would like to try home treatment of plantar fasciitis before seeing a professional, our plantar fasciitis home treatment plan can be found here.

FAQs About Plantar Fasciitis

#1 What causes plantar fasciitis?

Plantar fasciitis is usually the result of faulty biomechanics (walking gait abnormalities) that put too much tension on the plantar fascia, causing inflammation and pain. The most common cause of increased stress is “over-pronation” which means that your feet roll inward too much when you walk. As they roll inward, the arch of the foot flattens and the arch lengthens increasing tension on the plantar fascia.

#2 What are the symptoms of plantar fasciitis?

Plantar fasciitis symptoms involve two areas – the arch and the inside heel area (the latter is more common). It can cause severe pain especially in the morning when you get up. Common symptoms of plantar fasciitis include:

• Pain in the morning when you first get out of bed.
• Pain and stiffness when you start to walk after sitting for a while.
• Increasing pain in your heel or arch towards the end of the day.
• Tired feet at the end of the day.

#3 Why does plantar fasciitis cause heel pain first thing in the morning?

Morning heel pain is most often caused by plantar fasciitis though other heel conditions may cause this pain from damage to tissue that connects to the heel.

This damage causes inflammation but when you walk around during the day, the act of walking and your muscles contracting plus pressure from the ground pressing on the heel acts like a massage and prevents inflammation from building up in the heel.

Once you lie down at night or sit down during the day, you stop these actions that prevent the build-up of inflammation. The inflammation builds up and when you stand up again, you have a sharp pain in your heel due to the inflammatory fluid in the area. After you walk around for a few minutes, the inflammatory fluid is pumped out of the area and you feel better – at least for a while.

 #4 How do orthotics help with plantar fasciitis?

To avoid continued tension on the plantar fascia that causes ongoing pain, it is critical to support the arch and prevent it from collapsing. Several studies have shown that the most effective way to accomplish this is to use custom foot orthotics that conform extremely closely to the arch of the foot.5-6 These are known as total contact orthotics.

#5 Will prefabricated over-the-counter orthotics work?

Most typical orthotics fail because they do not hug the arch of the foot tightly. This allows the foot to flatten and increases tension on the plantar fascia. Many patients come into our office who have orthotics that do not provide enough support to cure plantar fasciitis. Dr. Hale and Dr. Huppin are experts at prescribing, casting and troubleshooting foot orthotics, including total contact foot orthotics.

#6 How are custom orthotics different than prefabricated?

In more difficult cases of plantar fasciitis, custom functional orthotics may be prescribed. Research indicates mechanically induced heel and arch pain are most effectively treated by prescription orthotics designed to take tension off the plantar fascia where over-the-counter prefabricated orthotics will fail. We use laser foot molds to ensure best function and comfort of your orthotics is 100% guaranteed.

#7 What if all conservative therapy fails?

If you have failed conservative therapy including total contact orthotic, dry needling, BK boot and extracorporeal shock wave therapy and symptoms have been present for over 1 year you may be a candidate for surgery. Prior to surgery, you may need to a nerve conduction study to rule out nerve issues and a rheumatology workup. Surgery is a last resort and less than 1% of our patients have heel surgery. We offer an endoscopic approach for patients that qualify.

Consult the Heel Pain Experts at the Foot and Ankle Center

We specialize in treating patients who have not had success with other doctors and treatments. Dr. Hale and Dr. Huppin have a better than 95% success rate. We can usually cure even the most chronic heel pain due to plantar fasciitis. Don’t live with pain in your heels, feet, and arches. Contact us to make an appointment for a foot pain consultation in our Seattle office.

Medical Literature on Treatments for Plantar Fasciitis

1. JE Martin, JC Bosch, WP Goforth, et al, “Mechanical Treatment of Plantar Fasciitis,” Journal of the American Podiatric Medical Association, 91(2) (Feb 2001): 55.
2. KB Langdorf, Am Keenan, RD Herbert, “Effectiveness of Foot Orthoses to Treat Plantar Fasciitis.” Archives of Internal Medicine, 166 (2006): 1305.
3. E Roos, M Engstrom, B Soderberg, “Foot Orthoses for the Treatment of Plantar Fasciitis,” Foot & Ankle International, 27(8) (2006): 606.
4. G Kogler, FB Veer, SE Solomonidis, “The Influence of Medial and Lateral Placement of Orthotic Wedges on Loading of the Plantar Aponeurosis,” Journal of Bone and Joint Surgery, 81A (1999): 1403-1413.
5. PR Scherer, et al, “Heel Spur Syndrome, Pathomechanics and Non-surgical Treatment,” Journal of the American Podiatric Medical Association, 81 (1991): 68-72.
6. WP Lynch, J Goforth, R Martin, R Odom, et al, “Conservative Treatment of Plantar Fasciitis, A Prospecitic Study, Journal of the American Podiatric Medical Association, 88 (1998): 375-380.Prospecitic Study, Journal of the American Podiatric Medical Association, 88 (1998): 375-380.
7. Saxena, A. Comparison between extracorporeal shockwave therapy, placebo ESWT and endoscopic plantar fasciotomy for the treatment of chronic plantar heel pain in the athlete. Muscles Ligaments Tendons J. 2012 Oct-Dec
8. Kudo P. Randomized, placebo-controlled, double-blind clinical trial evaluating the treatment of plantar fasciitis with an extracoporeal shockwave therapy (ESWT) device: a North American confirmatory study. J Orthop Res. 2006 Feb;24(2):115-23.
9. Chew KT. Comparison of Autologous Conditioned Plasma Injection, Extracorporeal Shockwave Therapy, and Conventional Treatment for Plantar Fasciitis: A Randomized Trial. nPM R. 2013 Aug 22.
10. Li Z1, et. al. Ultrasound- versus palpation-guided injection of corticosteroid for plantar fasciitis: a meta-analysis.  PLoS One. 2014
11. Chen CM1, et. al.  Effectiveness of device-assisted ultrasound-guided steroid injection for treating plantar fasciitis. Am J Phys Med Rehabil. 2013 Jul.
12. Tsai WC, et. al. Plantar fasciitis treated with local steroid injection: Comparison between sonographic and palpation guidance. J Clin Ultrasound. 2006
13. Sehriban Hocaoglu, et. al. Comparative Effectiveness of Radial Extracorporeal Shockwave Therapy and Ultrasound-Guided Local Corticosteroid Injection Treatment for Plantar Fasciitis.  Journal of the American Podiatric Medical Association: May 2017
14. Huo XL et al. Prognostic analysis of plantar fasciitis treated by pneumatic ballistic extracorporeal shock wave versus ultrasound guided intervention  Nan Fang Yi Ke Da Xue Xue Bao. 2018 Feb 20;38(2):135-140.
15. Lai TW, et. al. Ultrasonography and clinical outcome comparison of extracorporeal shock wave therapy and corticosteroid injections for chronic plantar fasciitis: A randomized controlled trial.  J Musculoskelet Neuronal Interact. 2018 Mar