Do Advances In Plantar Fasciitis Treatment Hold Up To Scientific Scrutiny?

Allen Jacobs DPM FACFAS

I am constantly amazed at the variety of treatment modalities that are effective for plantar fasciitis. In fact, I am amazed when a modality exists that is not effective for plantar fasciitis. Just think about all that you learn at conferences, see in exhibit halls and read in non-peer reviewed journals. You would have to be an idiot not to be able to cure plantar fasciitis.

Of course, being older, I had been under the mistaken impression that stretching, supports or orthotics, perhaps a brief course of analgesics or anti-inflammatory, and an injection or two were working. Sometimes weight loss or activity modification was necessary. This was odd. I thought my patients had generally done quite well. In fact, I seldom need to use invasive therapy for the treatment of plantar fasciitis in my patient population.

Boy, was I wrong. Turns out everything works well. We have low-energy extracorporeal shockwave therapy (ESWT), high-energy ESWT, endoscopic plantar fasciotomy, in-step plantar fasciotomy, radiofrequency Coblation (Topaz, Arthrocare), tarsal tunnel surgery, Baxter's nerve release, cryosurgical nerve ablation, drilling holes in the calcaneus, thermal nerve ablation and now platelet rich plasma injections. Do not forget botulinum (Botox, Allergan) injections, plantar fascia needling, open plantar fasciotomy, percutaneous plantar fasciotomy, subtalar joint arthroereisis, night splints and controlled ankle motion (CAM) walkers. Interesting.

Supposedly, only 10 to 15 percent of plantar fasciitis patients fail conservative care and require advanced or invasive therapy. Yet we see large numbers of patients who reportedly have responded to these advanced modalities, all with 80 to 95 percent success. Some alleged institutes or individual researchers “publish” large numbers for multiple advanced modalities. I guess they see thousands of patients with heel pain in order for them to have hundreds of patients in the 10 to 15 percent failure of conservative care group.

I have personally evaluated and reviewed many medical records of individuals who have sustained complications -- most commonly nerve injury, complex regional pain syndrome (CRPS), chronic pain and swelling, and so-called “lateral column syndrome” -- following plantar fascia surgery.

I do not believe that such injuries are rare. I similarly believe that many of the touted newer technologies lack any legitimate randomized controlled trials or level I or II evidence to justify the cost or the risk to the patient.


Allen....A well needed overview about this epidemic malady. It took me nearly 35 years in practice to realize that the differences in treatment outcomes of patients is likely a function of how well their physiology manages inflammation. Based on my experience,our diabetics, fibromyalgics, the morbidly obese, patients afflicted with any of the "itis's" don't seem to do as well as the shrinking "healthy" population. Rx drugs generally encourage inflammation due to their acidity. The sugar and white flour in processed foods do the same. Plantar fasciitis is nothing more than one of a myriad of symptoms the body is unable to heal by itself due to chronic malnutrition and toxic overload. I think the placebo effect has a lot to do with the treatment outcomes.

Must be my experience, I agree with you. Mort Wittenberg Evans,Ga.

Reassurring to know there are others like you Mort who see the big picture. Steve Schwartz,DPM -- Chambersburg, PA.

Many years ago my father went to a physician with heel pain. He was told that he needed surgery. Six months later following surgery he went to a podiatrist who made him orthotics. He did well. Had the physician at least tried a conservative course initially my father would have never had surgery. Had the conservation course failed, surgery would have been an option. I had a patient in my office this after who had been in Arizona for the winter. Two cortisone injections that provided temporary relief prompted the podiatrist to recommend surgery. The patient came home for the summer and saw me. I told him my father's story. Conservative care works well in most patients. I enjoy Dr. Jacobs reference to being older. I consider myself an old fart but experience is a good teacher. Thanks to such a great teacher in Allen Jacobs years ago, I think putting the patient first makes a lot of sense. Craig Holman

Sometimes I think that since we are limited by anatomy in what we treat we try to be as creative as possible in what we do to treat that anatomy. Dr. Jacobs points out something we see often in our profession: conservative care is given short shrift in order to get to the "real definitive" and usually invasive and expensive care. Then after the expensive treatment is done the postoperative care consists of the conservative care that should have been done in the first place. Of course, the success is always attributed to the new, invasive and expensive treatment! Gary Prant, DPM

Interesting ... conservative treatments, why do we need Physicans at all?

The platonic collision of the World of the Ideals with the World of the Real is probably more the heart of this matter than the financially driven motives (I would hope. There is this notion that the perfect treatment exists and perhaps it does. With the perfect treatment one should consider that it can only follow after the perfect evaluation and assessment.

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