Heel pain

Last evidence check March 2010

The majority of patients will resolve on non-surgical management. Sammarco and Helfrey (1996) found that only 3% of 870 patients with plantar fascitis required surgery. In Blackburn we have operated on four of over 500 patients.

Many non-surgical methods have been recommended, and there is no clear evidence that any modality is clearly better than others. There are a number of RCTs, but their methodological quality is poor and the results contradictory. We therefore recommend that treatment should begin simply and cheaply, using more costly and complex treatments for patients who fail initial treatment.

Initial management is aimed at symptom control and patient understanding of the problem and includes

Donley et al (2007) reported a small RCT comparing celecoxib with placebo. Although they reported more improvement in the treatment group, the Foot Function Index scores were very similar and there was a large loss to follow-up.

A number of other treatment methods have been described. Some have been examined in RCTs, although these are often of relatively low quality. Most trials have interventions other than those being studied, randomisation is rarely clearly described, and outcome assessment is not always independent.

Stretching exercises

Most series assume these as part of general management. Stretching of the Achilles tendon is aimed to improve the range of ankle dorsiflexion, which is often deficient in patients with plantar fascitis. A large multi-centre trial by Pfeffer et al (1999) found that other mechanical treatment added little in effectiveness to stretching. DiGiovanni et al (2006) found that plantar fascial stretching exercises were more effective than Achilles exercises at 8 weeks, but there was no difference at two years. Rompe reported an RCT comparing stretching to shockwave treatment as initial care for heel pain. Both groups improved markedly up to 15 months, but there was no difference between them.

Heel cups

Intended to reduce forces on the heel and also relax the Achilles tendon.

Dorsiflexion night splint

The rationale is that the Achilles tendon and plantar fascia normally contract at night in the relaxed equinus position, resulting in first-step pain when the tight foot hits the floor. If the ankle and toes are splinted in dorsiflexion this tightening is prevented. Some patients find the splint uncomfortable and stop using it.

Batt (1996) and Powell (1998) reported cross-over studies which offer some support for the use of night splintage, but Probe, in a RCT with longer follow-up and SF-36 generic health outcome measures, found that night splintage offered no advantage over Achilles stretching, NSAIDs and shoe advice. Probe’s patients had a much shorter duration of symptoms before entry into the trial and the natural history of improvement may be more significant in this group of patients than in the chronic patients in Powell’s trial. The place of the night splint requires further study.

Sheridan (2010) also found greater improvement in pain with a night splint added to a standard multimodal tratment programme.

Biomechanical treatment - strapping and orthotics

The use of custom moulded orthoses derives from the concept, particularly prevalent in sports medicine and podiatry circles, that plantar fascitis is caused by overpronation, which stretches the plantar fascia. The evidence for this is equivocal, particularly as general populations with plantar fascitis (as distinct from selected athletic populations) have relatively few overpronators. Some practitioners use taping of the heel as an initial or independent step in this biomechanical approach to treatment, and a number of recent trials have suggested this has an independent effect.

Lynch (1998) found biomechanical treatment to be superior to "anti-inflammatory" treatment with NSAIDs and steroid injections or "accommodative" treatment with a heel cup. Pfeffer (1999), however, found no advantage for biomechanical treatment over stretching or silicone heel cups, although this study has been criticised for its methods of orthotic prescription.

Steroid injections

Injections into the origin of the plantar fascia are intended to help resolve inflammation, although plantar fascitis is a non-inflammatory degenerative process. Blockley (1956) found no difference between lignocaine and lignocaine plus steroid, and Lynch (1998) found NSAIDs plus steroid injections inferior to biomechanical treatment, although both trials have significant methodological weaknesses. More recent studies have examined the use of ultrasonography to guide steroid injection. Only one small RCT (Kane et al 2001) has compared ultrasound with palpation guidance of injection, without showing any difference. Steroid injection carries a small risk of plantar fascial rupture or infection. We use it only for resistant cases. If injections are carried out, the medial approach seems less unpleasant for the patient than an approach through the heel.


The concept is of “resting” the plantar fascia; although there is only anecdotal evidence of efficacy, some resistant patients start to settle after a month in a below-knee walking cast. Whether a walker boot would be equally effective, or whether the “effect” is simply the natural history of resolution, can only be answered by trials which have not been done.

Extracorporeal shockwave treatment

This has been used in a number of degenerative soft-tissue conditions for its effects in stimulating tissue repair. Shockwave therapy appears to have different effects at different intensities and doses. High-energy shockwaves require local anaesthesia. There have been a number of RCTs comparing shockwaves of verying intensities with sham treatment. The results have been variable, with significant treatment effects reported in a majority of series, but no effect found in a minority of series. Several of these studies have had significant methodological problems, and there is potential for commercial bias. The method may be worth trying in patients who have failed simpler treatment, but it requires significant investment in instrumentation.