Plantar fasciitis: which treatments work according to the evidence
Sharp heel pain with the first steps of the morning is one of the most frequent reasons people come to the clinic. Before buying the next pharmacy insole or waiting for it to settle on its own, it is worth knowing what has clinical and scientific evidence behind it and what does not.
Why it hurts
The plantar fascia is a band of connective tissue running along the sole of the foot from the heel bone to the toes. When it is overloaded (sudden changes in activity, unsuitable footwear, excess weight, altered biomechanics), it develops a degenerative rather than inflammatory process, which is why current clinical terminology includes "fasciosis" or "fasciopathy", not just "fasciitis".
The first step, and it happens at home
Managing plantar heel pain: a best practice guide
Synthesis of 51 randomised trials (4,351 patients): two simple interventions improve first-step pain in the short term, specific plantar fascia stretching (SMD 1.21; 95% CI 0.78–1.63) and offloading taping (SMD 0.47; 95% CI 0.05–0.88).
This international clinical practice guideline, led from Queen Mary University of London, combined systematic review, expert clinical reasoning and patient values. Specific plantar fascia stretching has the largest effect size recorded in the guide. Together with education on load management and a footwear review, these make up the first step of treatment.
Morrissey D, Cotchett M, Said J'Bari A, Prior T, Griffiths IB, Rathleff MS, et al. Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values. Br J Sports Med. 2021;55(19):1106-18. doi:10.1136/bjsports-2019-101970
Therapeutic exercise is not optional
Strength training speeds up recovery
RCT with 48 patients with ultrasound-verified plantar fasciitis. At 3 months, the group doing high-load strength training scored 29 points better on a functional scale (95% CI 6 to 52, p=0.016) than the stretching-only group.
Single-leg heel raises over a towel placed under the toes to keep them extended, every other day. At 12 months both groups converge, so strengthening does not necessarily beat stretching in the long run, but it speeds up recovery in the first months, when pain limits the patient's life the most.
Rathleff MS, Mølgaard CM, Fredberg U, Kaalund S, Andersen KB, Jensen TT, et al. High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scand J Med Sci Sports. 2015;25(3):e292-300. doi:10.1111/sms.12313
The foot has its own "core"
The foot core system paradigm proposes that the intrinsic foot muscles play a role comparable to the lumbopelvic core. Treating plantar fasciitis only by "externally supporting" the foot without training those muscles goes against that paradigm.
That is why a well-built treatment plan includes progressive strengthening, not just orthoses. An orthosis should support the biomechanics, not immobilise them.
McKeon PO, Hertel J, Bramble D, Davis I. The foot core system: a new paradigm for understanding intrinsic foot muscle function. Br J Sports Med. 2015;49(5):290. doi:10.1136/bjsports-2013-092690
If it does not respond within 4-6 weeks: biomechanical gait assessment
Custom orthoses do reduce pain, in the medium term
Systematic review and meta-analysis of 19 RCTs with 1,660 patients. Orthoses reduce pain at 7-12 weeks compared with sham orthoses: SMD −0.27 (95% CI −0.48 to −0.06).
Here lies the difference between buying a generic insole and an orthosis designed from an individual biomechanical gait assessment: the first treats "heels in general"; the second treats your gait, your foot loading and your footwear. And one clinically relevant detail: an orthosis should support the biomechanics, not immobilise them.
Whittaker GA, Munteanu SE, Menz HB, Tan JM, Rabusin CL, Landorf KB. Foot orthoses for plantar heel pain: a systematic review and meta-analysis. Br J Sports Med. 2018;52(5):322-8. doi:10.1136/bjsports-2016-097355
When it becomes persistent
Refractory plantar fasciitis: each technique has its niche
Network meta-analysis of 63 RCTs and 4,170 patients: ultrasound-guided corticosteroids deliver the greatest short-term functional improvement, PRP stands out in the long term for function and fascia thickness, and shockwave therapy shows broad efficacy across all time frames.
The message is not "this one is best", but that the decision should be tailored to symptom duration and the therapeutic goal, not to the fashion of the moment.
Tien CH, Chiu MC, Shen YL, Ko YC, Lee JJ. Comparative effectiveness of minimally invasive therapies for plantar fasciitis: a systematic review and network meta-analysis. Sci Rep. 2026;16(1):9074. doi:10.1038/s41598-026-40038-z
Ultrasound-guided EPI vs corticosteroid in plantar fasciosis
Comparative study of 64 patients: both percutaneous needle electrolysis (EPI) and ultrasound-guided corticosteroid injection improved clinical and ultrasound outcomes at 12 months (p<0.001), with distinct mechanisms of action.
Their therapeutic roles are complementary, not mutually exclusive. The choice depends on the patient, how long-standing the problem is and the ultrasound findings.
Iborra-Marcos Á, Ramos-Álvarez JJ, Rodriguez-Fabián G, Del Castillo-González F, López-Román A, Polo-Portes C, et al. Intratissue Percutaneous Electrolysis vs Corticosteroid Infiltration for the Treatment of Plantar Fasciosis. Foot Ankle Int. 2018;39(6):704-11. doi:10.1177/1071100718754421
Diathermy: a well-placed adjunct
Biophysical basis of capacitive-resistive diathermy
Study on cadaveric anatomical specimens: capacitive-resistive electric transfer produces measurable temperature increases in the Achilles tendon and adjacent muscle, with the magnitude varying by mode (capacitive/resistive) and power.
On this mechanistic basis, and with the caution that specific clinical evidence in the plantar fascia is still limited, diathermy is used as an adjunct, never a substitute, to strengthening and biomechanical correction.
López-de-Celis C, Hidalgo-García C, Pérez-Bellmunt A, Fanlo-Mazas P, González-Rueda V, Tricás-Moreno JM, et al. Thermal and non-thermal effects of capacitive-resistive electric transfer application on the Achilles tendon and musculotendinous junction of the gastrocnemius muscle: a cadaveric study. BMC Musculoskelet Disord. 2020;21(1):46. doi:10.1186/s12891-020-3072-4
Take-home
- Start with plantar fascia stretching, taping and a footwear review. The simplest measures have the most evidence.
- Add progressive exercise from the first month; strengthening the intrinsic foot muscles speeds up recovery.
- If you are not improving after 4-6 weeks, ask for a biomechanical gait assessment, targeted ultrasound and an integrated plan with orthoses, exercise and diathermy.
- Advanced techniques (ultrasound-guided EPI, PRP or hyaluronic acid injections) are chosen case by case, guided by imaging, not by fashion.
At Avanza Salud we can help
We treat plantar fasciitis in a stepped way and with the imaging in hand: biomechanical gait assessment, musculoskeletal ultrasound, Podonexus custom orthoses, ultrasound-guided EPI/EPTE, ultrasound-guided injections and Indiβa diathermy, integrated with a progressive exercise programme.