Plantar Heel Pain
Andrew J. Rosenbaum, MD
*, John DiPreta, MD
David Misener, BSc(HK), CPO, MBA
Plantar heel pain is a very common complaint that can cause significant discomfort
and disability. Approximately 1 in 10 people are predicted to develop such heel pain
during their lifetime, with more than 2 million individuals undergoing treatment of it
annually in the United States.
Although 1% of all visits to orthopedic surgeons are
attributed to heel pain, it is also commonly treated by internists and family practi-
The annual cost of the evaluation and treatment of plantar heel pain by these
providers is estimated at approximately $284 million.
The cause, diagnosis, and effective management of plantar heel pain have chal-
lenged practitioners since the early 1800s, when Wood first described plantar fasciitis,
citing an infectious origin.
In the 1930s, gonorrhea, syphilis, tuberculosis, and strep-
tococcal infections were thought to be responsible.
The focus then shifted to plantar
fat pad impingement by heel spurs.
A plethora of conditions are now acknowledged
as causes of plantar heel pain.
A thorough history and physical examination are crucial to the diagnosis of plantar
heel disorders. Although plantar fasciitis is the most common culprit, accounting for
Division of Orthopaedic Surgery, Albany Medical College, 255 Patroon Creek Boulevard,
Apartment 1214, Albany, NY 12206, USA;
Clinical Prosthetics and Orthotics, 149 South Lake
Avenue, Albany, NY 12208, USA
* Corresponding author.
E-mail address: Andrewjrosenbaum@gmail.com
Plantar heel pain Plantar fascia Plantar fasciitis Windlass mechanism
Heel spur Baxter nerve First branch lateral plantar nerve
Extracorporeal shock-wave therapy
Approximately 1 in 10 people are predicted to develop such heel pain during their lifetime.
Plantar fasciitis is the most common cause of plantar heel pain and is responsible for
80% of the cases.
Plantar heel pain is usually responsive to conservative interventions, including home
stretches, nonsteroidal antiinflammatory drugs, orthoses, night splints, and, at times,
corticosteroid injections and extracorporeal shock-wave therapy.
If conservative measures do not provide pain relief, surgery can be considered.
Med Clin N Am -(2013) -–-
0025-7125/13/$ – see front matter Ó2013 Elsevier Inc. All rights reserved.
80% of patients with inferior heel pain, the clinician’s differential must always include
other causes. Mechanical, rheumatologic, and neurologic conditions can all manifest
as plantar heel pain. This article reviews the relevant anatomy and biomechanics of the
plantar hindfoot, the cause of plantar heel pain, pertinent components of the physical
examination, useful diagnostic adjuncts, as well as both conservative and operative
ANATOMY OF THE PLANTAR FASCIA AND HINDFOOT
The plantar fascia is a broad fibrous aponeurosis that spans the plantar surface of the
foot (Fig. 1). It originates from the medial and anterior aspects of the calcaneus and
helps to divide the intrinsic plantar musculature of the foot into 3 distinct compart-
ments: medial, central, and lateral. Distally, the plantar fascia forms 5 digital bands
at the metatarsophalangeal joints. Each digital band then divides to pass on either
side of the flexor tendons, inserting into the periosteum at the base of the proximal
The plantar fascia has a continuous connection with the Achilles tendon, leading to
tightening of the plantar fascia when tensile loads are applied to the tendon. For this
reason, Achilles tendon stretching and night splinting have become effective conser-
vative treatments for plantar fasciitis.
The heel’s fat pad, first described by Teitze in 1921, is also an integral component of
the plantar hindfoot.
It is anchored to both the calcaneus and skin, acting as a shock
absorber for the hindfoot. It helps to dissipate impact forces caused by heel strike dur-
ing ambulation, which generates forces up to 110% of one’s body weight when
walking and 250% of body weight when running.
However, after 40 years of age, it
begins to degenerate, losing some of its overall thickness and height. With this dete-
rioration, softening and thinning of the fat pad occur, which leads to diminished pro-
tection of the heel.
BIOMECHANICS OF THE PLANTAR FASCIA AND HINDFOOT
The foot and its ligaments can be thought of as a truss, with the calcaneus, midtarsal
joint, and metatarsals forming the truss’s medial longitudinal arch.
The plantar fascia
acts as a tie-rod, preventing arch collapse via its great tensile strength, particularly
during weight bearing. Preservation of the medial longitudinal arch is crucial for ambu-
lation in a systematic and efficient manner. With arch collapse, the appropriate timing
of pronation and supination during the gait cycle is altered, leading to inefficient foot
The windlass mechanism is a term used to describe the role of the plantar fascia in
dynamic function during gait; a windlass is the tightening of a rope or cable.
toes are dorsiflexed, the plantar fascia tightens, shortening the distance between the
calcaneus and metatarsals and elevating the medial longitudinal arch (Fig. 2).
high-arched position, less tension on the truss is required for arch support, as
opposed to a low-arched position. In other words, in a high-arched position, there
is less tension on the plantar fascia.
CAUSE OF PLANTAR HEEL PAIN
A multitude of mechanical, neurologic, and rheumatologic conditions can manifest as
plantar heel pain (Box 1). The mechanical causes include derangements of the plantar
fascia, calcaneal stress fractures, and heel pad disorders. Although heel spurs are
intimately associated with these conditions, they do not directly cause plantar heel
Rosenbaum et al
pain. Neurologic disorders are typically caused by nerve compression, whereas rheu-
matoid conditions may present with systemic manifestations. Infection, which was
once thought to be the primary cause of heel pain, is not as common as previously
Fascial derangements include rupture and fasciitis. Rupture most often occurs
acutely following trauma or athletic competition, whereas plantar fasciitis is a sub-
acute and degenerative process resulting from repetitive and excessive loading of
Fig. 1. The plantar fascia is a thick band of connective tissue that supports the foot’s plantar
arch. It originates at the calcaneal tuberosity of the hindfoot, ultimately inserting into
the periosteum at the base of the toes’ proximal phalanges. (Netter illustration from
www.netterimages.com. ÓElsevier Inc. All rights reserved.)
Plantar Heel Pain 3
After the metatarsals, the calcaneus is the most common location in the foot for a
These injuries most frequently occur in those with osteopenia of
the calcaneus and athletes involved in running and jumping sports. Both benign and
malignant neoplasms can also cause plantar heel pain. Benign lesions include simple
bone cysts, which can weaken bone and cause pathologic fracture. Malignant lesions
include primary tumors, of which Ewing sarcoma is the most common, and metastatic
disease, including endometrial adenocarcinoma, bronchogenic carcinoma, bladder
cancer, and gastric cancer.
The deterioration of the fat pad’s structural integrity, with advancing age and weight
gain, is also thought to contribute to heel pain. Although some think that the progres-
sive thinning of the fat pad is primarily responsible, others have shown an increased
thickness to correlate most closely with pain. Further, some think that a reduced elas-
ticity, not fat pad thickness, is the most significant factor.
pad elasticity was reduced in those with pain and that elasticity decreases with
increasing age and body weight.
Heel spurs are often associated with heel pain; up to 75% of patients with pain have
been shown to have spurs (Fig. 3).
However, spurs are also common in those
Fig. 2. The windlass mechanism occurs with dorsiflexion of the toes, which leads to tight-
ening of the plantar fascia. (From Greisberg J. Foot and ankle anatomy and biomechanics.
In: DiGiovanni CW, Greisberg J, editors. Core knowledge in orthopedics: foot and ankle.
Philadelphia: Elsevier; 2007; with permission.)
The differential diagnosis of plantar heel pain
Fat pad atrophy
Partial or complete plantar fascial rupture
Calcaneal stress fracture
Plantar nerve impingement
Hindfoot deformity (cavus or calcaneus)
Rosenbaum et al
without heel pain, suggesting that they are not necessarily the cause of pain.
randomly chosen sample of 1000 patients, Shmokler and colleagues
13.2% incidence of heel spurs but only a 5.2% incidence of heel pain. This finding sug-
gests that both spurs and pain may develop from a common underlying pathologic
condition. The work of Kumai and Benjamin
supports this notion because their
cadaveric study identified degenerative changes within the plantar fascia as the cause
of spur formation.
HISTORY AND PHYSICAL EXAMINATION
A comprehensive history is imperative when evaluating patients with plantar heel pain.
The patients’ general health and past medical history must be reviewed first, identi-
fying any prior treatments for plantar heel pain (ie, medications, injections, therapy,
orthoses, surgeries) and the presence of comorbidities. Obesity is an independent
risk factor for the development of plantar fasciitis and is present in up to 70% of pa-
tients with this disorder.
It is also important to ask about constitutional symptoms,
such as weight loss, fevers, chills, and night sweats, which are findings that suggest a
neoplastic or infectious process.
The clinician should inquire into patients’ recreational and occupational activities
because work-related weight bearing, like obesity, is an independent risk factor for
When discussing athletics, the specific sport being played can
help differentiate the diagnosis because those who perform running and jumping ac-
tivities are particularly vulnerable to plantar heel pain. It is also helpful to determine if
the pain occurs during heel strike as opposed to push off; if it occurs at the onset of,
during, or after activity; and the type of shoe and its insole being used when the pain is
A description of the pain and its alleviating and exacerbating factors will assist the
clinician in establishing a diagnosis. With the exception of an acute hindfoot fracture or
plantar fascia rupture, patients will typically describe the pain as gradual in onset. Of
note, those patients with a plantar fascia rupture often have histories of corticosteroid
Pain that is worse with the first steps in the morning or when standing
after prolonged sitting is consistent with plantar fasciitis. These patients may also
Fig. 3. Lateral radiograph of the hindfoot. A heel spur is evident on the inferior aspect of
the calcaneus. (From Berkson EM, Greisberg J, Theodore GH. Heel pain. In: DiGiovanni CW,
Greisberg J, editors. Core knowledge in orthopedics: foot and ankle. Philadelphia: Elsevier;
2007; with permission.)
Plantar Heel Pain 5
experience decreased pain with progressive activity, only to have it return later in the
day. Constitutional symptoms in the setting of night and/or rest pain suggest either a
neoplastic or infectious process. Bilateral plantar heel pain, particularly in conjunction
with joint pain and pain at multiple sites of tendon/ligament insertion, suggests that the
pain may be related to a rheumatologic process, such as ankylosing spondylitis or
Reiter syndrome. With nerve entrapment, patients may describe burning, tingling, or
The physical examination is another critical component of the workup because
determination of the location of the pain will facilitate the proper diagnosis. The ex-
amination includes a visual assessment of the foot, which may identify swelling,
skin breakdown, bruising, or deformity. Palpation of the foot’s bony prominences
and tendinous insertions near the heel and midfoot must also be done, noting
any defects or tenderness; Achilles tendon tightness can contribute to the pain.
Observation of ankle and hindfoot range of motion as well as of the foot’s posture
and arch during weight bearing should also be performed. The physician should
also evaluate the patients’ spine because an L5-S1 radiculopathy can cause plantar
With proximal plantar fasciitis, tenderness over the medial aspect of the calcaneal
tuberosity is present. Conversely, distal plantar fasciitis produces pain in the distal
aspect of the plantar fascia. Passive dorsiflexion of the toes exacerbates the pain in
both the proximal and distal types because this stretches the entire plantar fascia.
When a rupture of the plantar fascia occurs, a palpable defect may be evident at
the calcaneal tuberosity, along with localized swelling and ecchymosis.
suggestive of plantar fibromatosis include pain along the plantar fascia in conjunction
with palpable nodules.
A calcaneal stress fracture is diagnosed on physical examination by the squeeze
test in which diffuse heel pain is elicited with medial and lateral heel compression.
Swelling and warmth may also be present. Neoplastic processes must be considered
in the setting of persistent heel pain that is refractory to conservative treatment.
Tarsal tunnel syndrome is a compression neuropathy involving the posterior tibial
nerve as it traverses the tunnel. Percussion of the nerve within the tarsal tunnel, as
well as simultaneous dorsiflexion and eversion, may reproduce symptoms, which
include pain and numbness that radiate to the plantar heel. The findings seen with
plantar fasciitis are often similar. However, unlike tarsal tunnel syndrome, patients
with plantar fasciitis will have pain with passive toe dorsiflexion. Patients may also pre-
sent with entrapment of the first branch of the lateral plantar nerve (Baxter nerve,
FBLPN). Because of its close proximity to the medial calcaneal tubercle, it is usually
present with plantar fasciitis and difficult to distinguish.
Pain that is attributed to the fat pad is centered more proximally than the plantar fas-
cia’s origin. It is often associated with erythema and inflammation at the plantar heel.
On palpation, it is often softened and flattened.
The history and physical examination will often reliably diagnose the cause of plantar
heel pain. However, when the diagnosis remains unclear, imaging modalities and lab-
oratory studies can be obtained. Plain radiographs provide information about the
foot’s bony structures and alignment. Weight-bearing anteroposterior and lateral
views are standard, with axial and 45medial oblique views included at times. Heel
spurs are commonly seen on the lateral radiographs of patients with plantar heel
pain (see Fig. 3). A calcaneal lucency, referred to as the saddle sign often
Rosenbaum et al
accompanies the spur, visible just proximal to it on the radiograph.
Although soft tis-
sues are poorly visualized on plain radiographs, tumors, osteomyelitis, stress frac-
tures, and fat pad atrophy are sometimes visible.
When a calcaneal stress fracture is suspected, a triple-phase bone scan will have
increased uptake. With plantar fasciitis, this too will occur.
increased uptake in this setting will be localized to the inferomedial aspect of the
heel, enabling this test to distinguish the two processes.
Magnetic resonance imaging (MRI) has become a frequently used adjunct in the
evaluation of plantar heel pain because it provides great detail of soft tissue structures
through its multiplanar capability. Fascial thickening and increased signal intensity
within the plantar fascia are typical MRI findings seen with plantar fasciitis. Admittedly,
these findings are nonspecific, making MRI most useful for excluding other causes
of heel pain. It has been shown that plantar fibromatosis, tumors, infection, and nerve
entrapment are all reliably diagnosed with MRI.
Ultrasound can identify fascial thickenings and soft tissue edema in the plantar heel
and is becoming a commonly used diagnostic tool. In the setting of plantar fasciitis,
ultrasound will reveal thickened, hypoechoic fascia. Although the quality of images
obtained is operator dependent, some studies suggest that it is superior to MRI,
with fat pad edema and degeneration being detected earlier via this modality. Ultra-
sound is also inexpensive and fast, further distinguishing it from MRI.
When bilateral or recalcitrant heel pain is present, clinicians should order a complete
blood count, erythrocyte sedimentation rate, rheumatoid factor, antinuclear anti-
bodies, uric acid, and human leukocyte antigen-B27 studies. These tests may help
identify a rheumatologic or autoimmune disorder, such as a seronegative spondy-
loarthropathy, Behc¸ et syndrome, or inflammatory bowel arthritis.
Nerve conduction velocity and electromyography testing can objectively delineate
the severity of a compression neuropathy around the foot and ankle as well as diag-
nose a spinal radiculopathy or peripheral neuropathy. However, these studies are of
more benefit in the diagnosis of tarsal tunnel syndrome than plantar nerve entrapment
because the FBLPN is difficult to examine with these tests.
TREATMENT OF PLANTAR HEEL PAIN
Mechanical, rheumatologic, and neurologic sources of plantar heel pain require, and
are usually responsive to, a trial of conservative measures. Interventions include
home stretching programs and physical therapy, nonsteroidal antiinflammatory drugs
(NSAIDs), injections, heel pads, orthoses, night splints, and extracorporeal shock-
wave therapy (ESWT). In a work by Wolgin and colleagues,
82 of 100 patients’
plantar heel pain improved with conservative therapy, and an additional 15 patients
were able to work and perform activities despite having mild symptoms. Callison
found that 73% of patients treated with nonoperative modalities had significant
improvement within 6 months of treatment, whereas only 20% failed to improve.
A study by Davies and colleagues
also supports nonoperative interventions because
they showed that less than 50% of patients who had a surgical procedure for heel pain
were completely satisfied with the results.
A home stretching program is the first-line treatment of plantar heel pain. Both
plantar fascia–specific and Achilles tendon–based protocols are available. Plantar fas-
cia–specific stretching attempts to recreate the windlass mechanism, whereas Achilles
tendon programs attempt to optimize the length of the gastrocnemius-soleus complex.
DiGiovanni and colleagues
compared these protocols and showed that heel pain
Plantar Heel Pain 7
was resolved or improved at 8 weeks in 52% of patients treated with a plantar fascia–
specific program versus 22% of those performing Achilles tendon exercises. However,
at the 2-year follow-up, no difference was evident between the two groups.
NSAIDs are an appropriate treatment of plantar heel pain but are typically
prescribed in conjunction with another intervention, such as stretching. The true effec-
tiveness of NSAIDs is, thus, unclear because they are infrequently the sole treatment
modality. Although up to 76% of patients report successful outcomes with their use,
no study to date has examined their efficacy alone.
Corticosteroid injections are a commonly used treatment of plantar fasciitis, with
one study identifying 170 of 233 orthopedic surgeons polled as using steroid injections
for heel pain.
However, there is limited evidence to suggest that this intervention is
effective at providing sustained pain relief. Crawford and colleagues
symptoms at 1 month but not at 6 months as compared with a control group. Compli-
cations of steroid injection include rupture of the plantar fascia and fat pad atrophy.
One’s injection technique can reduce the incidence of these complications; the needle
should be placed superior to the fascia, from the medial side. This placement spreads
the solution across the fascial layer, avoiding the fat pad and plantar nerves.
The injection of botulinum toxin A (BTX-A) is also being used to treat plantar foot
pain. Its analgesic and antiinflammatory properties make it an intriguing intervention.
In a placebo-controlled, double-blinded study, Babcock and colleagues
BTX-A injections with significant improvements in pain relief and foot function at both
3 and 8 weeks following treatment. Elizondo-Rodriguez and colleagues
found BTX-A to be an effective treatment of plantar fasciitis. In their prospective, ran-
domized, double-blinded, and controlled clinical trial, the effectiveness of BTX-A
injected into the gastrocnemius-soleus complex was compared with steroid injection
into the medial plantar fascia. Over the 6 months that the patients were followed after
receiving one of the two aforementioned injections, the group who received the BTX-A
was found to have faster and more sustained symptom relief.
Heel pads, foot orthoses, and shoe modifications are adjunctive modalities often
used in the treatment of plantar heel pain. From a biomechanical perspective, foot or-
thoses are designed to place the foot and lower extremity in a more advantageous po-
sition by minimizing the existing stresses to the static and dynamic soft tissues of the
foot and lower limb; orthoses off-load the plantar fascia, recreate the shape of the heel
pad, and decrease excessive pronation.
Commonly used orthoses include prefabricated silicone or rubber heel cups and
arch supports, felt pads, custom arch supports, the University of California Biome-
chanics Laboratory orthosis (UCBL), and the supramalleolar ankle foot orthosis
(SMO). The UCBL shoe insert is a maximum control foot orthotic that was named after
the location in which it was developed, the University of California Berkeley Laboratory
in 1967 (Fig. 4). It has since been defined as a deep-seated foot orthosis. The UCBL
differs from other foot orthoses in that it fully encompasses the heel, which in turn
holds the heel, or hindfoot, in a neutral, vertical position. While correcting and holding
the heel in a neutral position, the UCBL also controls the inside arch of the foot and the
outside border of the forefoot. These 3 corrective forces keep the foot held in a neutral
The SMO, as with other orthoses, gets its name for the part of the body for which it
encompasses (Fig. 5). This orthosis supports the leg just above the medial and lateral
malleoli. The SMO is designed to maintain a vertical or neutral heel while also support-
ing the 3 arches of the foot, which can help improve standing balance and walking.
This design also allows for more control of the ankle and foot. It is more supportive
than a UCBL but less supportive than a standard ankle foot orthosis (AFO).
Rosenbaum et al
Shoes are integral to the success of an orthosis because they help to stabilize the
orthosis within the shoe and around the foot. A proper shoe provides stability and
shock absorption. How a shoe is built also makes a difference in its fit and function.
Neutral-arched feet should be placed in shoes with firm midsoles, straight to semi-
curved lasts, and moderate hindfoot stability. Low-arched or flat feet should be placed
in shoes with a straight last and with motion control to help stabilize the feet. High-
arched feet require cushioning and moderate hindfoot stability to compensate for
the lack of natural shock absorption.
Ample evidence exists based on subjective pain relief, symptom resolution, and pa-
tient satisfaction for the success of orthosis.
In a randomized study by Pfeffer and
236 patients were randomized into 5 treatment groups: 1 control and 4
with different shoe inserts. Those treated with prefabricated inserts had the largest
improvement in heel pain.
Roos and colleagues
also found foot orthoses to be
effective in both the short- and long-term treatment of plantar fasciitis. In this prospec-
tive randomized trial, those who used orthoses experienced a 62% decrease in pain at
1 year as compared with patients treated with night splints. Admittedly, other studies
have questioned the effectiveness of foot orthoses, identifying only small benefits.
Despite this, heel pads and orthoses are powerful tools in the clinician’s armamen-
tarium for the treatment of plantar heel pain.
Night splints are designed to prevent shortening of the plantar fascia during long pe-
riods of rest, with the goal of alleviating morning start-up pain. The night splint AFO
Fig. 4. The UCBL orthosis. (Courtesy of David Misener, BSc, CPO, MBA, Albany, NY.)
Fig. 5. The SMO. (Courtesy of David Misener, BSc, CPO, MBA.)
Plantar Heel Pain 9
should be placed in 5of dorsiflexion. Wapner and Sharkey
reported that 11 of their
14 patients improved when splinted in this position. Conversely, Probe and col-
found no significant benefit in adding night splinting to a standard NSAID
and stretching protocol. Casting has also been used to unload the heel and immobilize
the plantar fascia, hoping to reduce the repetitive microtrauma associated with plantar
ESWT is indicated for patients who have had at least 6 months of plantar fasciitis
heel pain recalcitrant to at least 3 nonsurgical interventions (Fig. 6). The powerful
shock waves break up scar tissue, stimulate angiogenesis, promote new bone forma-
tion, disrupt calcific deposits, and increase cytokine diffusion. Good or excellent re-
sults in the setting of chronic heel pain have been reported in 57% to 80% of
ESWT is often performed under conscious sedation with regional anes-
thesia. It is well tolerated by patients. The contraindications include patients with
hemophilia, coagulopathies, malignancy, and skeletal immaturity.
Surgery is indicated in the treatment of plantar heel pain that has failed a minimum
of 6 months of conservative modalities (Box 2). An open partial release of the plantar
fascia is the standard intervention. Although both open and endoscopic techniques
have been described, there is no consensus as to the best choice; no studies have
been conducted that directly compare these two techniques. Because entrapment
neuropathy of the FBLPN presents similarly to plantar fasciitis, decompression of
this nerve is frequently performed concurrently. Watson and colleagues
that 93% of their patients had satisfactory outcomes with partial medial plantar fas-
ciectomy and nerve decompression. When nerve decompression is to be performed,
an open approach is advocated because the risk of nerve injury may be higher with
Resection of heel spurs is also performed at times, most commonly in conjunc-
tion with the aforementioned procedures. However, Manoli and colleagues
ported calcaneal fractures secondary to extensive resection, an unwelcome
complication of this procedure. Additionally, the notion that the subcalcaneal
spur is the cause of plantar pain has lost popularity in recent years; therefore,
this supplementary procedure is being performed less frequently. Fallat and col-
retrospectively compared percutaneous plantar fasciotomy with open
fasciotomy and heel spur resection, determining that the percutaneous procedure
Fig. 6. ESWT. (From Berkson EM, Greisberg J, Theodore GH. Heel pain. In: DiGiovanni CW,
Greisberg J, editors. Core knowledge in orthopedics: foot and ankle. Philadelphia: Elsevier;
2007; with permission.)
Rosenbaum et al
was as effective at relieving the plantar fasciitis pain and that those patients had a
faster return to full activity.
Gastrocnemius recession is another procedure that may be indicated for the treat-
ment of plantar fasciitis recalcitrant to conservative interventions. Because limited
ankle dorsiflexion, specifically isolated gastrocnemius contracture, is frequently asso-
ciated with plantar fasciitis, the release of the gastrocnemius can be an effective treat-
Abbassian and colleagues
found proximal medial gastrocnemius release to
provide complete or significant pain relief in 81% of their patients treated with this.
Additionally, none of their patients reported worsening of their symptoms.
Plantar heel pain is a frequently encountered phenomenon that transcends multiple
medical specialties, including orthopedic surgery and primary care. Plantar fasciitis
is the most common cause. However, other mechanical, rheumatologic, neurologic,
and infectious causes exist; a comprehensive history and physical examination is
pivotal to making the correct diagnosis. When the cause remains unclear after the
evaluation, diagnostic adjuncts are available and include triple-phase bone scan,
MRI, ultrasound, and laboratory studies. Regardless of diagnosis, nonoperative inter-
ventions are the mainstay of treatment and include but are not limited to stretching,
NSAIDs, orthoses, and steroid injections. Operative intervention is only indicated after
6 months of failed conservative modalities.
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Algorithm for the treatment of plantar fasciitis
If history and physical examination consistent with plantar fasciitis, begin
Home stretching program multiple times daily (either plantar fascia specific or Achilles
Wear shoes with good support and a premade or custom-made orthotic
Trial of NSAIDs
If no improvement
Reexamine patient and consider alternative diagnoses
If still consistent with plantar fasciitis, add alternative treatment, such as night splints and
If symptoms persist more than 6 months
Consider shock-wave therapy
Plantar Heel Pain 11
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