Although recently published studies have started to clarify the effectiveness of some of the numerous options available for the treatment of plantar fasciitis, the conclusions of a systemic review performed in 2003 remain relevant. Crawford and Thomson9 reviewed all randomized trials assessing the treatment of plantar heel pain in adults published between 1966 and 2002. Only 19 trials involving 1626 participants met their inclusion criteria. The authors found the quality of the trials to be generally poor and inadequate to yield poolable data. As a result, they attempted to provide a limited summary of nonoperative interventions. They were only able to conclude that limited evidence existed to support the short-term effectiveness of local steroid injections. All other treatments could not be adequately judged for their effectiveness due to the lack of randomized, controlled studies. The authors encouraged the development of well-designed trials to assist in clinical decision-making and to optimize patient care. Despite these limitations, this review of the current literature has identified several concepts that may guide our collective approach to the treatment of plantar fasciitis: 1. Plantar fasciitis is a common cause of inferior heel pain. In most cases, its clinical course reflects a self-limited process with the resolution of symptoms occurring within one year. 2. The diagnosis of plantar fasciitis in made clinically in most cases. A history of "start-up pain" and tenderness at the plantar medial aspect of the calcaneus supports the diagnosis. Additional findings after a thorough interview and physical examination of the patient may warrant the use of plain radiographs or advanced imaging to rule out other possible diagnoses. 3. Due to the natural history of this condition and the lack of high-quality evidence to support one particular intervention, the initial treatment of plantar fasciitis should be limited to nonoperative methods. This may include the use of night splints, over-the-counter foot orthoses and routine stretching of the plantar fascia and/or the Achilles tendon. The use of anti-inflammatory agents administered orally, topically or by injection may be included in the initial management regimen. However, the risk of fascial rupture or fat pad atrophy weighs against repeated or the immediate use of injections. Further, the capacity of these agents to relieve pain has not been demonstrated to extend beyond the first month of use. 4. The evidence currently available to assess the efficacy of extracorporeal shock wave therapy lacks the quality and consistency to support its unconditional use in the management of plantar fasciitis. For those patients who have complied with a monitored course of nonoperative treatment and have failed to respond within six months, the use of extracorporeal shock wave therapy may be considered. No study directly comparing the efficacy of the ESWT devices currently available has been published. Therefore, no high-quality evidence exists to guide the choice of whether to employ a low or high energy device to administer shock wave therapy. 5. High quality evidence to support the surgical release of the plantar fascia alone or in combination with a neurolysis of the posterior tibial nerve and its branches is lacking. The absence of randomized, controlled trials in a well-defined cohort prevents the clear determination of the role, timing and effectiveness of these operations in the treatment of plantar fasciitis.
