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Review Article

Plantar Fasciitis: A Review
Nitin Ajitkumar Menon, Jitendra Jain
Department of Pain Medicine, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India

Abstract
Plantar fasciitis, though a common condition seen by pain specialists, occasionally presents diagnostic dilemmas and very often
the management of this condition suffers from lack of awareness of the varied treatment modalities and progressive escalation of
treatment options. For this purpose, we searched through all articles with key words of plantar fasciitis or heel pain in the last ten years
for which full text was available and compiled a narrative review to guide clinical decision making. An appreciation of pathomechanics
of involved structures, possible differential diagnoses and a review of all treatment modalities presented in this article may perhaps
help in simplifying matters. Treatment options consist of non-invasive physical therapy modalities, footwear modification, exercise
program and newer modalities like shock-wave therapy, minimally invasive treatments like steroid or platelet-rich plasma injections and
surgery in recalcitrant cases. Resorting to combining treatment modalities, step-wise escalation of treatment depending on duration of
the condition and using our suggested step-ladder approach maybe an appropriate way of treating this condition.

Keywords: Extracorporeal shock wave therapy, heel pain, orthotics, platelet-rich plasma, stepladder treatment

Introduction
Plantar fasciitis is the most common cause of heel pain.
Approximately 15% of all foot complaints coming to the
attention of health-care professionals can be attributed
to this cause.[1] This condition also accounts for 8% of
all injuries in athletes in running-related sports.[2] Hence,
it can be said that this condition is common in both
sedentary and athletic population. It is attributed to
chronic weight bearing and repeated overload of the foot
in daily activities or sports. As a result, some workers have
suggested the term “fasciosis” rather than fasciitis because
of the chronicity of the condition and the presence of
degeneration rather than inflammation.[3]
when bearing weight, and rigid and tense during push off.
These opposite functions are carried out to a large extent
by the plantar fascia, which acts as a truss during force
absorption and as a taut beam to provide rigidity during
propulsion.[4] It does this in two ways—by providing
stretch tension to support the medial longitudinal arch
during weight bearing to prevent its collapse and by
acting as a “windlass” similar to tightening of a rope or
a cable during propulsive phase to provide tension and
keep the foot rigid.[5] Demands on this structure, which are
substantial in normal health, may be greatly enhanced in
an anatomically abnormal foot, during the performance
of activities such as running, or in overweight individuals.

The origin of the problem is nearly always traced

to anatomical abnormalities of the foot leading to
biomechanical stress on the joints and supporting
soft tissue structures, which fail to adjust due to either
long-standing and repetitive nature of such demands
or supraphysiological loads on them. The human foot
has to subserve two important functions:  (a) to provide
propulsive force during latter part of the stance phase and
(b)  to absorb the impact of the body weight during the
early part. This requires the foot to be soft and flexible
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Clinical Features
Most patients present with heel pain, which develops
insidiously, characteristically affecting the medial part,
which may radiate into the medial arch of the foot. Pain
tends to be worse in the morning or after a period of
rest, with maximal discomfort reported during the initial
Address for correspondence: Dr. Nitin Ajitkumar Menon,
3/361A Tambe Building, Dr. Ambedkar Road, Matunga (E),
Mumbai, Maharashtra 400019, India.
E-mail: nitinam@gmail.com
This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows
­appropriate credit is given and the new creations are licensed under the identical terms.

For reprints contact: reprints@medknow.com

DOI:
10.4103/ijpn.ijpn_3_18 How to cite this article: Menon NA, Jain J. Plantar fasciitis: A review.
Indian J Pain 2018;32:24-9.

24 © 2018 Indian Journal of Pain | Published by Wolters Kluwer - Medknow

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Table 1: Differential diagnosis
Originating structure
Plantar fascia
Soft tissues
Skeletal (bony tenderness)
Neurological (burning or numbness or tingling,
night symptoms)
Source: Modified from Roxas[7] and Cole et al.[8]
few steps, and progressive improvement as the person
continues to walk.[6] Pain may also be experienced during
chronic overuse conditions such as running. Clinical
examination reveals tender areas along the medial part of
heel or medial arch in most patients. However, foot should
be examined for the presence of anatomical abnormalities
such as cavus or planus deformities, restriction of motion
of the ankle–foot complex, scar tissue, and loss of heel
pad thickness, as well as document any neurological
abnormality—particularly, sensory or motor deficits and
the presence of Tinel’s sign. A  schema for differential
diagnosis of heel pain can be found in Table 1.[7,8]
Diagnostic Considerations
The diagnosis is generally made on clinical grounds.
Characteristic history and pain pattern is sufficient in
most cases. Imaging is useful if another diagnosis is
being seriously considered. Radiography may reveal
the presence of bony spur on the calcaneum. In Indian
population, the incidence of such a finding in patients
with heel pain is reported to be 59%.[9] Histological
analysis of the spur has revealed degeneration and
proliferation of fibrocartilaginous tissue along with areas
of ossification, further strengthening the argument that
this may be a degenerative rather than an inflammatory
condition.[10] It is hypothesized that these generate as a
result of body’s adaptive response to redistribute impact
forces away from calcaneal insertion site to surrounding
tissues. Use of diagnostic ultrasound is gaining more
favor among practitioners because of its simplicity to use
and ability to guide interventions, if required. Common
findings seen in ultrasound are increased signal intensity
of the plantar fascia, hypoechogenic plantar fascia, and
thickness of plantar fascia more than 4 mm.[11] [Figure 1]
Alteration of heel pad fat signals may also be picked up
Indian Journal of Pain  ¦  Volume 32  ¦  Issue 1  ¦  January‑April 2018
Menon and Jain: Plantar fasciitis
Condition Salient features
Plantar fasciitis Pain with first steps
Plantar fascia rupture Sudden, knifelike pain, ecchymosis
Fat pad syndrome Atrophy of heel pad
Heel bruise Acute impact injury history
Bursitis Swelling and erythema of heel
Tendinitis Pain with resisted motion of tendon
Calcaneal stress fracture Pain worsens with prolonged weight
bearing
Paget’s disease Whole skeletal abnormalities
Tumor Systemic manifestations
Calcaneal apophysitis (Sever’s disease) Adolescent patients
Tarsal tunnel syndrome Neuropathic pain, nerve conduction
abnormalities
Posterior tibial nerve entrapment As above
Abductor digiti quinti nerve entrapment As above
Lumbar spine disorders Pain in back, radiation to legs,
­abnormal reflexes
Neuropathies History of alcohol abuse or diabetes
on ultrasound, particularly in elderly individuals.[12] Real-
time sonoelastography is an upcoming technique that
helps in evaluating whether tissues are less or more elastic,
and it is shown to be useful in the diagnosis and planning
interventions in plantar fasciitis.[13] The superior ability of
magnetic resonance imaging (MRI) to provide soft tissue
contrast resolution may be used in doubtful cases, but
at an added expense and image acquisition time.[14] The
most common findings in MRI are calcaneal edema with
increased T2 signals in plantar fascia and thickening of
plantar fascia on T1 images.[15]
Management
The goal of treatment is to decrease pain, promote healing,
restore normal range of motion and flexibility of foot,
support tissues, correct any biomechanical abnormalities,
and institute correct training methods.[16] Stepladder
approach is a useful tool to guide clinical decision-making
in managing these patients.[17] [Figure 2] Accordingly, step
1 consists of physical therapy, orthoses, and medications
to manage pain for 6 weeks. If relief is inadequate, therapy
may be stepped up to level 2 comprising local injections,
advanced manipulation, and custom orthoses. Patients
who have received adequate conservative trial for 6 months
may be referred to a foot surgeon. Referral to a nutritional
counsellor should be considered in obese individuals.
Step 1
Initial physical therapy options include manual therapy,
which promotes normal joint and soft tissue motion;
stretching exercises to prevent and treat contracted
muscles and soft tissues; various heating and cooling
modalities; and taping techniques. There is good evidence
for the use of manual therapy, stretching, taping, and
foot orthosis for the management of such patients in the
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Menon and Jain: Plantar fasciitis

Figure 1: Normal plantar fascia on the right and affected plantar fascia on the left with increased thickness and areas of hypodensity

superior characteristics with significant pain relief lasting

Table 2: Summary of management strategies
up to 6 months in comparison with heel pads or cups.[28]
Treatment Use of night splints made in dorsiflexed position of the
Stage Noninvasive Invasive/systemic ankle to promote stretching of plantar fascia has been
Step 1 (0 to Stretching Acetaminophen reported to be effective.[29] Most orthotic devices whether
4–6 weeks) Footwear modification Nonsteroidal anti- custom-made or bought off the shelf have short-term
Heat or cold modalities inflammatory drugs
effect (up to 3 months), but are not proven to be effective
Off-the-shelf orthotics
in the long term as a stand-alone treatment option.[30]
Step 2 Osteopathic manipulation Steroid injections
(1–6 months) Strain–counterstrain release Botulinum toxin Judicious use of acetaminophen (paracetamol) or
Custom orthotics Prolotherapy nonsteroidal anti-inflammatory drugs may be useful in
Platelet-rich plasma the initial few weeks to support recovery and promote
injections exercises and other therapies.
Step 3 (more ESWT Surgery
than 6 months)
Step 2
If the aforementioned measures do not achieve desired
short term (1–6 weeks), but evidence for the effectiveness
results, more invasive treatments may be attempted. Such
of electrotherapy modalities, physical agents, laser,
interventions include dry needling, prolotherapy, injection
phonophoresis, and ultrasound is not as robust.[18] Review
of local corticosteroids, or the recent platelet-rich plasma
of various exercise modalities has shown that supervised
(PRP) preparations. Conventionally, depot steroid
exercises are better than home exercises, but nature of injections delivered close to plantar fascia insertion
documented pain relief is short because of inadequate at the calcaneum are considered as an effective early
follow-up of clinical trial designs.[19] Advanced forms of intervention. A  recent Cochrane review[31] however
physical therapy such as osteopathic manipulation and concluded that local steroid injections, in comparison to
strain–counterstrain technique have shown promising placebo or no treatment, may slightly reduce heel pain but
results in a few cases and may be attempted if initial only up to 1 month and not subsequently. Tendon rupture,
measures are unsuccessful.[20,21] collagen necrosis, plantar fascia rupture, plantar fat pad
Orthotics or foot support devices help in reducing pain and atrophy, plantar nerve injury, calcaneal osteomyelitis,
improving comfort by absorbing some of the shock due to and skin necrosis are some of the reported side effects
heel strike that is normally absorbed by plantar fascia. It of local steroid injections.[32] Palpation-guided injection
may also attempt to correct postural deviations that may and ultrasound-guided technique are not significantly
predispose one to plantar fasciitis.[22] Medial arch support, different with regard to pain relief.[33]
cushioned heel pads, or insoles are the most commonly In recent times, interventions that are considered more
prescribed off-the-shelf devices, and all are equally useful physiological have generated interest, especially as studies
without any one being significantly better.[23] Studies have have proven their effectiveness. A  study of 84 patients
shown that custom orthoses combined with stretching treated with dry needling over a 6-week period showed
exercise are more effective than either.[24,25] However, some significant improvement compared to sham needling with
studies have shown that there is no difference between pain relief lasting for up to 12 weeks.[34] Myofascial trigger
custom orthoses or prefabricated devices.[26,27] Semirigid points are identified over the leg and foot muscles, and
or rigid devices such as supramalleolar orthosis or standard dry needling techniques are used to release these
University of California and Biomechanics Laboratory triggers. Dry needling may not improve the range of motion
(UCBL) foot insert have been tried with varying degrees of foot and ankle joints but is reported to significantly
of success. The UCBL insert has been reported to have decrease pain and improve foot function.[35] Traditional

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Menon and Jain: Plantar fasciitis
Table 3: Summary of evidence for treatment of plantar
fasciitis (Oxford Centre for Evidence-Based Medicine
method)
Grade of Level of Treatment
recommendation evidence
A 1,2 Exercises[18,19]
A 1 ESWT[46]
B 2 Orthoses[27,28]
D 5 Nonsteroidal
anti-inflammatory drugs[17]
B 2 Dry needling[34,35]
C 4 Prolotherapy[43]
A 1 Steroid injections[31]
B 2 Botulinum toxin[37,38]
A 1,2 Platelet-rich plasma[40,41]
C 4 Surgery[48]
A = level 1 studies, B = level 2 or 3, C = level 4, D = level 5, 1 = RCT,
2  =  reviews, 3  =  case control, 4  =  case reports or series, 5  =  expert
­opinion/insufficient evidence
Figure 2: Plantar heel pain treatment ladder (modified from Thomas
et al.[17])
Chinese acupuncture is also reported to be useful in few
cases.[36] Botulinum toxin A injected into the painful areas,
quadratus plantae and short toe flexors (total 100 units), is
reportedly useful in producing relief from pain.[37] A group
of 22 patients with heel pain injected with botulinum toxin
showed improvement lasting for up to 8 weeks.[38]
Injection of PRP obtained by spinning patient’s own
blood is helpful in a number of chronic painful conditions
including plantar fasciitis.[39] Platelets contain growth factors
in their alpha granules, which stimulate fibroblasts, help
with the recruitment of other healing cells, stimulate new
blood vessels, and promote growth of extracellular matrix.
A  meta-analysis showed that in 12 studies consisting of
445 patients injected with various preparations of PRP, all
showed superior response compared to steroid injections
even in single doses, especially when given with peppering
technique (multiple punctures).[40] Other studies have also
reported similar outcomes.[41,42] Prolotherapy with injection
of hyperosmolar dextrose solution (1 mL of 25% dextrose
with 1 mL of 2% lignocaine, 3–4 injections 1 week apart) in
a group of 40 patients with chronic plantar fasciitis showed
improvement lasting for up to 12 months in a small case
series.[43] A  review of all conservative therapies showed
Indian Journal of Pain  ¦  Volume 32  ¦  Issue 1  ¦  January‑April 2018
highly variable results for singular therapies, and urged the
usage of combined therapies to achieve better results.[44]
Step 3
Extracorporeal shock wave therapy (ESWT) is an option
for patients not responding to initial line of treatment
and with persistent symptoms beyond 3–6 months. Shock
waves, generated by a device and delivered to the patient
by means of a probe, are believed to stimulate tissue
hyperemia leading to vascularization and healing.[45]
ESWT is reported to be effective in reducing intensity
of pain and improving function lasting up to 6  months,
particularly low-intensity type.[46] Shock waves are of two
types: focused (concentrating on one particular area) and
radial (dissipating to surrounding tissues). In a study of
68 patients in whom radial ESWT (4–8 sessions) was used
for the treatment of plantar fasciitis, there was a mean
reduction of 86% in visual analog scale scores at 1  year
and only 8% recurrence at the end of that period.[47]
Extremely difficult to treat cases may be considered for
surgery. Patients who do not obtain relief from multiple
previous interventions and conservative trials and who are
significantly disabled as a result are suitable candidates.
Options include plantar fasciotomy, plantar fascia
release, and decompression of nerve bundles. Results
are considered “good,” but risks of biomechanical
deterioration are present with such surgery [Table 2].[48]
Conclusion
Plantar fasciitis is a common cause of foot pain with a
number of treatment options available to the clinician.
However, a lack of good quality, randomized control trials
makes writing treatment recommendations a challenge.
A few principles though may be kept in mind:
a. Initial management should consist of ruling out other
causes of foot pain with good history, appropriate
examination, and imaging studies.
b. Physical therapy measures such as stretching, hot
or cold modalities, footwear modification, and
off-the-shelf orthosis should be prescribed at the
outset as they are cheap, fairly effective, and without
side effects (grade A, grade B recommendation).
c. Interventions such as steroid injection (grade A), PRP
(grade A), dry needling (grade B), botulinum toxin
(grade B), and prolotherapy (grade C) may be attempted,
if the above measures lead to suboptimal pain relief.
d. ESWT (grade A) and surgery (grade C) may be reserved
for hard to manage cases persisting beyond 6  months,
where all other treatment modalities have been attempted
[Table 3].
Future Research
We encourage well-designed trials comparing each
treatment option against standard treatments or placebo
to help more precise decision-making.
27
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Menon and Jain: Plantar fasciitis
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Menon and Jain: Plantar fasciitis

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