provided a 4 mm offset or less in the sole, increased the volumetric measurements of the abductor digiti minimi by 22% in 12 weeks, and increased the stiffness of the longitudinal arch by 60% (Miller et al., 2014). This was a very small study, however, and more research needs to be done. Also, a patient whose foot is already significantly pronated will not be likely to tolerate minimalist shoes, as each step will just increase the stresses on an already poorly functioning longitudinal arch. This could be considered as a recommendation for patients whose arch is intact. Keep in mind that this is part of a strengthening program. A patient who is accustomed to shoes that provide significant support may poorly tolerate long hours in shoes that provide minimal support. In patients for whom this recommendation is appropriate, it may be best to recommend using these types of shoes, or be barefoot, for only short periods at the beginning of the treatment. Patients can gradually increase time in these shoes, as tolerated. A systematic review of the literature published in 2019 compared several of the above mechanical treatment options. This study found that contoured full-length insoles are more effective in relieving symptoms related to plantar fasciitis than heel cups. Combining night splints or rocker shoes with insoles enhances improvement in pain relief and function compared with rocker shoes, night splints, or insoles alone. Taping is an effective short- term treatment (Schuitema et al., 2019). 30% satisfaction). There are also risks in the use of corticosteroid injections, most notably that of plantar fascia rupture. Given that there are increased risks with corticosteroid treatment, it is typically not used as a first-line treatment. Another newer option is the use of platelet-rich plasma injections. One study comparing its efficacy to steroid treatment in the treatment of plantar fasciitis that has failed conservative treatment found that it was as effective as steroid treatments up to 6 months, but it was significantly more effective than steroid treatments at one year (Jain et al., 2015). Therefore, this treatment shows promise in having more longevity than steroid treatments. Preliminary studies also suggest that Botox injections are very effective to manage chronic plantar fasciitis pain. A randomized controlled trial of 32 people published in 2020 found that ultrasound-guided injections of Botox in the gastrocnemius were very effective. Patients reported a decrease in pain from 8 to .33 on the VAS scale with this treatment compared to a drop of 7.4 to 4 in the placebo group (Abbasian et al., 2020). Another alternative treatment for plantar fasciitis pain is acupuncture. A review of the literature published in 2017 found that acupuncture is an effective treatment for pain for up to 8 weeks. There is currently no evidence of decreased pain with acupuncture past 8 weeks, so further studies will need to be done to determine if this helps with pain in the long run (Thiagarajah, 2016). In the meantime, this may be recommended for patients who want help decreasing pain during therapy but also want to avoid medications. study published in 2016 found patients had the highest patient satisfaction scores with the endoscopic method as compared to the open method. Patients reported less pain and had higher objective scores with the endoscopic method (Chou et al., 2016). Reviewing the research shows that the most effective treatments for plantar fasciitis are exercise, stretching, manual therapy, taping, orthotics, and night splints, with surgery being considered for long-term chronic pain. This makes it imperative for an effective physical therapy treatment program to focus on the most effective conservative treatments to prevent the need for surgery and the possible complications.
either. In a review of the evidence of the association between BMI and musculoskeletal disorders, there was a strong correlation between a high BMI and lower-extremity musculoskeletal disorders (Butterworth et al., 2012). There simply was not much evidence to prove that lowering BMI improved symptoms. More research is needed to prove this as an effective treatment. It may be best for physical therapists to counsel patients that a higher BMI is associated with increased rates of plantar fasciitis. Support and education regarding weight loss can be provided, as well as appropriate referrals, as needed; however, this would not be the focus of treatment. It is likely this could help to prevent recurrence of symptoms. Footwear A patient in significant pain is likely to ask the therapist what type of shoes are best for this condition. Unfortunately, there are few studies on this subject, so it may be best to focus the education on the type of orthotic that would be best suited to the patient. There is limited evidence (one study) that points to using rocker soles in conjunction with orthotics to provide a significant reduction in pain symptoms (Fong et al., 2012). One other study suggests rotating footwear as a solution for those who stand for long periods of time (Werner et al., 2010). These studies are very limited with poor evidence. Some evidence supports the use of minimalistic shoes to strengthen the intrinsic musculature of the foot. A 2014 study found that long-distance runners in shoes that Other treatments Other conservative treatments outside the scope of practice of physical therapy include extracorporeal shockwave treatment and corticosteroid treatment. Physical therapists typically do not perform these interventions, but if a patient is not responding to physical therapy treatment, they may be considered by the physician. A 2008 review of the literature on the effectiveness of extracorporeal shockwaves therapy (EWST) shows it to be no more effective than stretching and ultrasound (Landorf & Menz, 2008). As previously stated, however, ultrasound is no more effective than sham treatment, so the primary treatment in this case is stretching. A new randomized controlled trial published in 2016 did find a significant improvement in pain using extracorporeal shockwave treatment compared to placebo (Gollwitzer et al., 2015). Based on these findings, this may be an appropriate treatment in patients for whom traditional treatments are not providing relief. More research needs to be done to establish its effectiveness. Insurance companies generally consider this to be an unproven, ineffective treatment and will not cover it; therefore, it is not frequently used. A 2016 retrospective review of the efficacy of corticosteroid injections found they are ineffective for the treatment of plantar fasciitis for longer than 3 months (Grice et al., 2016). A 2016 single randomized study of 40 individuals who had not responded to a typical course of treatment for plantar fasciitis compared extracorporeal shockwave treatment with corticosteroid treatments (Eslamian et al., 2016). It found that both groups made significant improvement; however, the group with extracorporeal shockwave treatment had a greater improvement in the FFI and higher satisfaction rates among patients (55% satisfaction vs. Surgery Approximately 10 to 20% of patients with plantar fasciitis will still complain of symptoms at 12 months post-injury. If conservative treatments have failed, these patients may be candidates for a plantar fasciotomy. This release of the fascia can be performed by either an open method, or endoscopically. Recommending surgery for plantar fasciitis remains very controversial, as the plantar fascia has many functions, and releasing it can have negative consequences on other structures of the foot. Despite the possible complications, patients who still have significant pain for 12 months will often consider this option. A 2014 study found that 84% of patients were happy with the results of surgery even after 7 years of follow up (Wheeler et al., 2014). A small
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