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The Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline–Revision 2010

      Abstract

      Heel pain, whether plantar or posterior, is predominantly a mechanical pathology although an array of diverse pathologies including neurologic, arthritic, traumatic, neoplastic, infectious, or vascular etiologies must be considered. This clinical practice guideline (CPG) is a revision of the original 2001 document developed by the American College of Foot and Ankle Surgeons (ACFAS) heel pain committee.

      Keywords

      This clinical practice guideline (CPG) is based on consensus of current clinical practice and review of the clinical literature. The guideline was developed by the CPG Heel Pain Committee of the American College of Foot and Ankle Surgeons (ACFAS). This is the 2010 revision of the original 2001 CPG document published in the Journal of Foot & Ankle Surgery® (Vol. 40, No. 5, pages 329–340). The guideline and references annotate each node of the corresponding pathways.

      Plantar Heel Pain [Plantar Fasciitis, Plantar Fasciosis, Heel Spur Syndrome] (Pathway 2)

      Figure thumbnail fx2
      Figure thumbnail gr1
      Fig. 1(A) With plantar fasciitis, tenderness may be localized centrally along the plantar fascia (orange oval), along the plantar medial tuberosity (red circle), or directly plantar to the calcaneal tuberosity (yellow oval). (B) The anatomy of the plantar fascia as shown through MRI. (C) Depicted here are the lines of tension of the plantar fascia and its majority insertional attachment to the medial calcaneal tuberosity.
      The most common cause cited for plantar heel pain is biomechanical stress of the plantar fascia and its enthesis of the calcaneal tuberosity (Figure 2) (
      • Bergmann J.N.
      History and mechanical control of heel spur pain.
      ,
      • Contampasis J.P.
      Surgical treatment of calcaneal spurs.
      ,
      • McCarthy D.J.
      • Gorecki G.E.
      The anatomical basis of inferior calcaneal lesions.
      ,
      • Mitchell I.R.
      • Meyer C.
      • Krueger W.A.
      Deep fascia of the foot. Anatomical and clinical considerations.
      ,
      • Nack J.D.
      • Phillips R.D.
      Shock absorption.
      ,
      • Root M.
      • Weed J.
      • Orien W.
      Normal and Abnormal Function of the Foot, vol. II.
      ,
      • Fuller E.A.
      The windlass mechanism of the foot. A mechanical model to explain pathology.
      ,
      • Kogler G.F.
      • Solomonidis S.E.
      • Paul J.P.
      Biomechanics of longitudinal arch support mechanisms in foot orthoses and their effect on plantar aponeurosis strain.
      ). Mechanical overload, whether the result of biomechanical faults, obesity, or work habits, may contribute to the symptoms of heel pain. Discussion of a biomechanical etiology usually involves the windlass mechanism and tension of the plantar fascia in stance and gait (
      • Fuller E.A.
      The windlass mechanism of the foot. A mechanical model to explain pathology.
      ,
      • Messier S.P.
      Obesity and osteoarthritis: disease genesis and nonpharmacologic weight management.
      ,
      • Menz H.B.
      • Zammit G.V.
      • Landorf K.B.
      • Munteanu S.E.
      Plantar calcaneal spurs in older people: longitudinal traction or vertical compression?.
      ,
      • Hill J.J.
      • Cutting P.J.
      Heel pain and body weight.
      ,
      • Hills A.P.
      • Hennig E.M.
      • McDonald M.
      • Bar-Or O.
      Plantar pressure differences between obese and non-obese adults: a biomechanical analysis.
      ,
      • Gill L.H.
      Plantar fasciitis: diagnosis and conservative management.
      ,
      • Irving D.B.
      • Cook J.L.
      • Young M.A.
      • Menz H.B.
      Obesity and pronated foot type may increase the risk of chronic plantar heel pain: a matched case-control study.
      ,
      • Wearing S.C.
      • Hennig E.M.
      • Byrne N.M.
      • Steele J.R.
      • Hills A.P.
      Musculoskeletal disorders associated with obesity: a biomechanical perspective.
      ,
      • Riddle D.L.
      • Pulisic M.
      • Pidcoe P.
      • Johnson R.E.
      Risk factors for plantar fasciitis: a matched case-control study.
      ,
      • Irving D.B.
      • Cook J.L.
      • Menz H.B.
      Factors associated with chronic plantar heel pain: a systematic review.
      ,
      • Bolgla L.A.
      • Malone T.R.
      Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice.
      ).
      Figure thumbnail gr2
      Fig. 2Plantar heel pain often is related to (A) loading of the calcaneus and the tensile attachment of the plantar fascia, as shown in this MRI scan (B). (C) The weight-bearing lateral radiograph may or may not show an inferior os calcis spur. (D, E) The spur or enthesophyte begins small and may become very large, or on occasion, (F) may even fracture.
      Localized nerve entrapment of the medial calcaneal or muscular branch off the lateral plantar nerve may be a contributing factor (
      • Goecker R.M.
      • Banks A.S.
      Analysis of release of the first branch of the lateral plantar nerve.
      ,
      • Louisia S.
      • Masquelet A.C.
      The medial and inferior calcaneal nerves: an anatomic study.
      ,
      • Hendrix C.L.
      • Jolly G.P.
      • Garbalosa J.C.
      • Blume P.
      • DosRemedios E.
      Entrapment neuropathy: the etiology of intractable chronic heel pain syndrome.
      ,
      • Johnston M.R.
      Nerve entrapment causing heel pain.
      ,
      • Schon L.C.
      • Glennon T.P.
      • Baxter D.E.
      Heel pain syndrome: electrodiagnostic support for nerve entrapment.
      ,
      • Baxter D.E.
      • Pfeffer G.B.
      Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve.
      ,
      • Davidson M.R.
      • Copoloff J.A.
      Neuromas of the heel.
      ,
      • Didia B.C.
      • Horsefall A.U.
      Medial calcaneal nerve: an anatomical study.
      ,
      • Henricson A.S.
      • Westlin N.E.
      Chronic calcaneal pain in athletes: entrapment of the calcaneal nerve?.
      ,
      • Przylucki H.
      • Jones C.L.
      Entrapment neuropathy of muscle branch of lateral plantar nerve: a cause of heel pain.
      ,
      • Dellon A.L.
      Technique for determining when plantar heel pain can be neural in origin.
      ,
      • Diers D.J.
      Medial calcaneal nerve entrapment as a cause for chronic heel pain.
      ,
      • Saggini R.
      • Bellomo R.G.
      • Affaitati G.
      • Lapenna D.
      • Giamberardino M.A.
      Sensory and biomechanical characterization of two painful syndromes in the heel.
      ,
      • Jolly G.P.
      • Zgonis T.
      • Hendrix C.L.
      Neurogenic heel pain.
      ,
      • Oztuna V.
      • Ozge A.
      • Eskandari M.M.
      • Colak M.
      • Golpinar A.
      • Kuyurtar F.
      Nerve entrapment in painful heel syndrome.
      ,
      • Pfeffer G.B.
      Plantar heel pain.
      ,
      • Kenzora J.E.
      The painful heel syndrome: an entrapment neuropathy.
      ,
      • Toomey E.P.
      Plantar heel pain.
      ,
      • Plotkin D.
      • Patel D.
      • Roberto T.
      Heel neuroma: a case study.
      ,
      • Liden B.
      • Simmons M.
      • Landsman A.S.
      A retrospective analysis of 22 patients treated with percutaneous radiofrequency nerve ablation for prolonged moderate to severe heel pain associated with plantar fasciitis.
      ,
      • Cione J.A.
      • Cozzarelli J.
      • Mullin C.J.
      A retrospective study of radiofrequency thermal lesioning for the treatment of neuritis of the medial calcaneal nerve and its terminal branches in chronic heel pain.
      ,
      • Sinnaeve F.
      • Vandeputte G.
      Clinical outcome of surgical intervention for recalcitrant infero-medial heel pain.
      ).
      Patients usually present with plantar heel pain upon initiation of weight bearing, either in the morning upon arising or after periods of rest. The pain tends to decrease after a few minutes, and returns as the day proceeds and time on their feet increases. Associated significant findings may include high body mass index (BMI), tightness of the Achilles tendon, pain upon palpation of the inferior heel and plantar fascia, and inappropriate shoe wear (
      • Gill L.H.
      Plantar fasciitis: diagnosis and conservative management.
      ,
      • Wearing S.C.
      • Hennig E.M.
      • Byrne N.M.
      • Steele J.R.
      • Hills A.P.
      Musculoskeletal disorders associated with obesity: a biomechanical perspective.
      ,
      • Riddle D.L.
      • Pulisic M.
      • Pidcoe P.
      • Johnson R.E.
      Risk factors for plantar fasciitis: a matched case-control study.
      ,
      • Przylucki H.
      • Jones C.L.
      Entrapment neuropathy of muscle branch of lateral plantar nerve: a cause of heel pain.
      ,
      • Shikoff M.D.
      • Figura M.A.
      • Postar S.E.
      A retrospective study of 195 patients with heel pain.
      ,
      • Williams P.L.
      The painful heel.
      ,
      • Rano J.A.
      • Fallat L.M.
      • Savoy-Moore R.T.
      Correlation of heel pain with body mass index and other characteristics of heel pain.
      ).
      Many patients will have attempted self-remedies before seeking medical advice. A careful history is important and should include time(s) of day when pain occurs, current shoe wear, type of activity level both at work and leisure, and history of trauma. Presence of sensory disturbances including radiation of pain is generally indicative of neurologic pathology and is important to exclude. An appropriate physical examination of the lower extremity includes range of motion of the foot and ankle, with special attention to limitation of ankle dorsiflexion, palpation of the heel and plantar fascia, observation of swelling or atrophy of the heel pad, presence of hypesthesias or dysthesias, assessment of the architectural alignment of the foot, and angle and base of gait evaluation. The quality and height of the plantar fat pad also have been implicated as factors in plantar heel pain (Figure 3) (
      • Ozdemir H.
      • Soyuncu Y.
      • Ozgorgen M.
      • Dabak K.
      Effects of changes in heel fat pad thickness and elasticity on heel pain.
      ,
      • Osborne H.R.
      • Breidahl W.H.
      • Allison G.T.
      Critical differences in lateral X-rays with and without a diagnosis of plantar fasciitis.
      ,
      • Falsetti P.
      • Frediani B.
      • Acciai C.
      • Baldi F.
      • Filippou G.
      • Marcolongo R.
      Heel fat pad involvement in rheumatoid arthritis and in spondyloarthropathies: an ultrasonographic study.
      ,
      • Jahss M.H.
      • Kummer F.
      • Michelson J.D.
      Investigations into the fat pads of the sole of the foot: heel pressure studies.
      ,
      • Tsai W.C.
      • Wang C.L.
      • Hsu T.C.
      • Hsieh F.J.
      • Tang F.T.
      The mechanical properties of the heel pad in unilateral plantar heel pain syndrome.
      ).
      Figure thumbnail gr3
      Fig. 3(A) Plantar heel pain may be related to the height of the plantar fat pad, which may be determined from a weight-bearing lateral radiograph. In a slender or elderly individual this may be implicated as a causative factor. (B) This radiograph reveals a 6-mm height to the fat pad in a patient with a cavus architecture, whereas (C) this radiograph shows a patient who was measured at 8 mm in a more normal foot type. (D) Force plate or pressure analysis may demonstrate exaggerated loading of the heels, or (E) clinically the tuberosity may be easily palpable or callus may develop.
      Following physical evaluation, appropriate radiographs (weight-bearing views preferred) may be helpful. Biomechanical interpretation of weight-bearing radiographs may provide insight into architectural faults. An infracalcaneal spur frequently is associated with the symptomatology of plantar fasciitis, although its presence or absence may not necessarily correlate with the patient's symptoms (
      • Shama S.S.
      • Kominsky S.J.
      • Lemont H.
      Prevalence of non-painful heel spur and its relation to postural foot position.
      ). Radiographic identification of a plantar heel spur usually indicates that the condition has been present for at least 6 to 12 months, whether having been symptomatic or asymptomatic (Figure 2). As a rule, the longer the duration of heel pain symptoms, the longer will be the period to final resolution of the condition (
      • Kelly A.
      • Wainwright A.
      • Winson I.
      Spur formation and heel pain.
      ,
      • Lapidus P.W.
      • Guidotti F.P.
      Painful heel: report of 323 patients with 364 painful heels.
      ).
      Initial treatment options (see Plantar Heel Pain Treatment Ladder, Figure 4) may include padding and strapping of the foot (
      • Williams P.L.
      The painful heel.
      ,
      • Landorf K.B.
      • Radford J.A.
      • Keenan A.M.
      • Redmond A.C.
      Effectiveness of low-Dye taping for the short-term management of plantar fasciitis.
      ), therapeutic orthotic insoles (
      • Landorf K.B.
      • Keenan A.M.
      • Herbert R.D.
      Effectiveness of different types of foot orthoses for the treatment of plantar fasciitis.
      ,
      • Landorf K.B.
      • Keenan A.M.
      • Herbert R.D.
      Effectiveness of foot orthoses to treat plantar fasciitis: a randomized trial.
      ,
      • Pfeffer G.
      • Bacchetti P.
      • Deland J.
      • Lewis A.
      • Anderson R.
      • Davis W.
      • Alvarez R.
      • Brodsky J.
      • Cooper P.
      • Frey C.
      • Herrick R.
      • Myerson M.
      • Sammarco J.
      • Janecki C.
      • Ross S.
      • Bowman M.
      • Smith R.
      Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis.
      ,
      • Roos E.
      • Engstrom M.
      • Soderberg B.
      Foot orthoses for the treatment of plantar fasciitis.
      ,
      • Caselli M.A.
      • Clark N.
      • Lazarus S.
      • Velez Z.
      • Venegas L.
      Evaluation of magnetic foil and PPT insoles in the treatment of heel pain.
      ,
      • Stuber K.
      • Kristmanson K.
      Conservative therapy for plantar fasciitis: a narrative review of randomized controlled trials.
      ,
      • Filippou D.K.
      • Kalliakmanis A.
      • Triga A.
      • Rizos S.
      • Grigoriadis E.
      • Shipkov C.D.
      Sport related plantar fasciitis. Current diagnostic and therapeutic advances.
      ), oral anti-inflammatories (
      • Donley B.G.
      • Moore T.
      • Sferra J.
      • Gozdanovic J.
      • Smith R.
      The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: a randomized, prospective, placebo-controlled study.
      ), and a corticosteroid injection localized to the area of maximum tenderness (
      • Pribut S.M.
      Current approaches to the management of plantar heel pain syndrome, including the role of injectable corticosteroids.
      ,
      • Barrett S.J.
      • O'Malley R.
      Plantar fasciitis and other causes of heel pain.
      ,
      • Tatli Y.Z.
      • Kapasi S.
      The real risks of steroid injection for plantar fasciitis, with a review of conservative therapies.
      ,
      • Crawford F.
      • Atkins D.
      • Young P.
      • Edwards J.
      Steroid injection for heel pain: evidence of short-term effectiveness. A randomized controlled trial.
      ,
      • Kalaci A.
      • Cakici H.
      • Hapa O.
      • Yanat A.N.
      • Dogramaci Y.
      • Sevinç T.T.
      Treatment of plantar fasciitis using four different local injection modalities: a randomized prospective clinical trial.
      ). Patient-directed treatments appear to be as important as these approaches in resolving symptoms. Such treatments include regular Achilles and plantar fascia stretching (
      • DiGiovanni B.F.
      • Nawoczenski D.A.
      • Lintal M.E.
      • Moore E.A.
      • Murray J.C.
      • Wilding G.E.
      • Baumhauer J.F.
      Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study.
      ,
      • Digiovanni B.F.
      • Nawoczenski D.A.
      • Malay D.P.
      • Graci P.A.
      • Williams T.T.
      • Wilding G.E.
      • Baumhauer J.F.
      Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up.
      ), avoidance of flat shoes and barefoot walking, cryotherapy applied directly to the affected part, over-the-counter arch supports and heel cups, and limitation of extended (high-impact) physical activities (
      • Pribut S.M.
      Current approaches to the management of plantar heel pain syndrome, including the role of injectable corticosteroids.
      ,
      • Spears I.R.
      • Miller-Young J.E.
      • Waters M.
      • Rome K.
      The effect of loading conditions on stress in the barefooted heel pad.
      ,
      • Burnfield J.M.
      • Few C.D.
      • Mohamed O.S.
      • Perry J.
      The influence of walking speed and footwear on plantar pressures in older adults.
      ,
      • Bedinghaus J.M.
      • Niedfeldt M.W.
      Over-the-counter foot remedies.
      ). Patients usually have a clinical response within 6 weeks of initiation of treatment. If improvement is noted, the initial therapy program is continued until symptoms are resolved. If little or no improvement is noted, the patient should be referred to a foot and ankle surgeon if not already under this specialist's care.
      Figure thumbnail gr4
      Fig. 4The Plantar Heel Pain Treatment Ladder illustrates the stepwise approach to the ubiquitous condition of plantar heel pain. Initial treatment alternatives should be simple and cost-effective, whereas more resistant cases require more aggressive treatment. Few patients with plantar heel pain require surgical or invasive treatment therapies.
      Treatment options have been graded according to the levels of evidence and grades of recommendation shown in Table 1(
      • League A.C.
      Current concepts review: plantar fasciitis.
      ). Evidence-based medicine (EBM) conclusions regarding tier 1 therapies are as follows:
      • Padding and strapping of the foot [Grade B recommendation] (
        • Williams P.L.
        The painful heel.
        ,
        • Landorf K.B.
        • Radford J.A.
        • Keenan A.M.
        • Redmond A.C.
        Effectiveness of low-Dye taping for the short-term management of plantar fasciitis.
        )
      • Therapeutic orthotic insoles [Grade B recommendation] (
        • Landorf K.B.
        • Keenan A.M.
        • Herbert R.D.
        Effectiveness of different types of foot orthoses for the treatment of plantar fasciitis.
        ,
        • Landorf K.B.
        • Keenan A.M.
        • Herbert R.D.
        Effectiveness of foot orthoses to treat plantar fasciitis: a randomized trial.
        ,
        • Pfeffer G.
        • Bacchetti P.
        • Deland J.
        • Lewis A.
        • Anderson R.
        • Davis W.
        • Alvarez R.
        • Brodsky J.
        • Cooper P.
        • Frey C.
        • Herrick R.
        • Myerson M.
        • Sammarco J.
        • Janecki C.
        • Ross S.
        • Bowman M.
        • Smith R.
        Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis.
        ,
        • Roos E.
        • Engstrom M.
        • Soderberg B.
        Foot orthoses for the treatment of plantar fasciitis.
        ,
        • Caselli M.A.
        • Clark N.
        • Lazarus S.
        • Velez Z.
        • Venegas L.
        Evaluation of magnetic foil and PPT insoles in the treatment of heel pain.
        ,
        • Stuber K.
        • Kristmanson K.
        Conservative therapy for plantar fasciitis: a narrative review of randomized controlled trials.
        ,
        • Filippou D.K.
        • Kalliakmanis A.
        • Triga A.
        • Rizos S.
        • Grigoriadis E.
        • Shipkov C.D.
        Sport related plantar fasciitis. Current diagnostic and therapeutic advances.
        )
      • Oral inflammatory medication [Grade I recommendation] (
        • Donley B.G.
        • Moore T.
        • Sferra J.
        • Gozdanovic J.
        • Smith R.
        The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: a randomized, prospective, placebo-controlled study.
        )
      • Cortisone injections [Grade B recommendation] (
        • Pribut S.M.
        Current approaches to the management of plantar heel pain syndrome, including the role of injectable corticosteroids.
        ,
        • Barrett S.J.
        • O'Malley R.
        Plantar fasciitis and other causes of heel pain.
        ,
        • Tatli Y.Z.
        • Kapasi S.
        The real risks of steroid injection for plantar fasciitis, with a review of conservative therapies.
        ,
        • Crawford F.
        • Atkins D.
        • Young P.
        • Edwards J.
        Steroid injection for heel pain: evidence of short-term effectiveness. A randomized controlled trial.
        ,
        • Kalaci A.
        • Cakici H.
        • Hapa O.
        • Yanat A.N.
        • Dogramaci Y.
        • Sevinç T.T.
        Treatment of plantar fasciitis using four different local injection modalities: a randomized prospective clinical trial.
        )
      • Achilles and plantar fascia stretching [Grade B recommendation] (
        • DiGiovanni B.F.
        • Nawoczenski D.A.
        • Lintal M.E.
        • Moore E.A.
        • Murray J.C.
        • Wilding G.E.
        • Baumhauer J.F.
        Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study.
        ,
        • Digiovanni B.F.
        • Nawoczenski D.A.
        • Malay D.P.
        • Graci P.A.
        • Williams T.T.
        • Wilding G.E.
        • Baumhauer J.F.
        Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up.
        )
      Table 1Level of evidence and grades of recommendation
      Adapted from League AC. Current concepts review: plantar fasciitis. Foot Ankle Int 29:358–366, 2008.
      Level of Evidence
       – Level I: High quality prospective randomized clinical trail
       – Level II: Prospective comparative study
       – Level III: Retrospective case control study
       – Level IV: Expert opinion
      Grades of Recommendation
      (given to various treatment options based on Level of Evidence supporting that treatment)
       – Grade A: Treatment options are supported by strong evidence

      (consistent with Level I or II studies)
       – Grade B: Treatment options are supported by fair evidence

      (consistent with Level III or IV studies)
       – Grade C: Treatment options are supported by either conflicting or

      (Level IV studies)
       – Grade I: When insufficient evidence to make a recommendation
      The second tier of the treatment ladder includes continuation of the initial (tier 1) treatment options with considerations for additional therapies: orthotic devices (
      • Rome K.
      • Gray J.
      • Stewart F.
      • Hannant S.C.
      • Callaghan D.
      • Hubble J.
      Evaluating the clinical effectiveness and cost-effectiveness of foot orthoses in the treatment of plantar heel pain: a feasibility study.
      ,
      • Lee S.Y.
      • McKeon P.
      • Hertel J.
      Does the use of orthoses improve self-reported pain and function measures in patients with plantar fasciitis? A meta-analysis.
      ,
      • Martin J.E.
      • Hosch J.C.
      • Goforth W.P.
      • Murff R.T.
      • Lynch D.M.
      • Odom R.D.
      Mechanical treatment of plantar fasciitis. A prospective study.
      ,
      • Campbell J.W.
      • Inman V.T.
      Treatment of plantar fasciitis and calcaneal spurs with the UC-BL shoe insert.
      ), night splints to maintain an extended length of the plantar fascia and gastroc-soleus complex during sleep (
      • Roos E.
      • Engstrom M.
      • Soderberg B.
      Foot orthoses for the treatment of plantar fasciitis.
      ,
      • Stuber K.
      • Kristmanson K.
      Conservative therapy for plantar fasciitis: a narrative review of randomized controlled trials.
      ,
      • Martin J.E.
      • Hosch J.C.
      • Goforth W.P.
      • Murff R.T.
      • Lynch D.M.
      • Odom R.D.
      Mechanical treatment of plantar fasciitis. A prospective study.
      ,
      • Crawford F.
      • Atkins D.
      • Edwards J.
      Interventions for treating plantar heel pain (Cochrane review).
      ,
      • Huang H.H.
      • Qureshi A.A.
      • Biundo J.J.
      Sports and other soft tissue injuries, tendinitis, bursitis, and occupation-related syndromes.
      ,
      • Powell M.
      • Post W.R.
      • Keener J.
      • Wearden S.
      Effective treatment of chronic plantar fasciitis with dorsiflexion night splints: a crossover prospective randomized outcome study.
      ,
      • Weise J.
      Plantar fasciitis, posterior night splints and activity during recovery.
      ,
      • Ryan J.
      Use of posterior night splints in the treatment of plantar fasciitis.
      ,
      • Wapner K.L.
      • Sharkey P.F.
      The use of night splints for treatment of recalcitrant plantar fasciitis.
      ,
      • Neufeld S.K.
      • Cerrato R.
      Plantar fasciitis: evaluation and treatment.
      ,
      • Cole C.
      • Seto C.
      • Gazewood J.
      Plantar fasciitis: evidence-based review of diagnosis and therapy.
      ,
      • Crawford F.
      • Thomson C.
      Interventions for treating plantar heel pain.
      ,
      • Barry L.D.
      • Barry A.N.
      • Chen Y.
      A retrospective study of standing gastrocnemius-soleus stretching versus night splinting in the treatment of plantar fasciitis.
      ,
      • Young C.C.
      • Rutherford D.S.
      • Niedfeldt M.W.
      Treatment of plantar fasciitis.
      ,
      • Zamorski M.
      Plantar fasciitis, posterior night splints and activity during recovery.
      ,
      • Little R.B.
      Plantar fasciitis, posterior night splints and activity during recovery.
      ,
      • Probe R.A.
      • Baca M.
      • Adams R.
      • Preece C.
      Night splint treatment for plantar fasciitis. A prospective randomized study.
      ,
      • Batt M.E.
      • Tanji J.L.
      • Skattum N.
      Plantar fasciitis: a prospective randomized clinical trial of the tension night splint.
      ), repeat corticosteroid injection (
      • Lemont H.
      • Ammirati K.M.
      • Usen N.
      Plantar fasciitis: a degenerative process (fasciosis) without inflammation.
      ,
      • Gill L.H.
      Plantar fasciitis: diagnosis and conservative management.
      ,
      • Williams P.L.
      The painful heel.
      ,
      • Pribut S.M.
      Current approaches to the management of plantar heel pain syndrome, including the role of injectable corticosteroids.
      ,
      • Barrett S.J.
      • O'Malley R.
      Plantar fasciitis and other causes of heel pain.
      ,
      • Lee S.Y.
      • McKeon P.
      • Hertel J.
      Does the use of orthoses improve self-reported pain and function measures in patients with plantar fasciitis? A meta-analysis.
      ,
      • Crawford F.
      • Atkins D.
      • Edwards J.
      Interventions for treating plantar heel pain (Cochrane review).
      ,
      • Crawford F.
      • Thomson C.
      Interventions for treating plantar heel pain.
      ,
      • Beals T.C.
      • Pomeroy G.C.
      • Manoli A.
      Posterior tendon insufficiency: diagnosis and treatment.
      ,
      • Acevedo J.I.
      • Beskin J.L.
      Complications of plantar fascia rupture associated with corticosteroid injection.
      ,
      • Plantar fasciitis
      Repeated corticosteroid injections are safe.
      ,
      • Van Wyngarden T.M.
      The painful foot. Part II: Common rearfoot deformities.
      ,
      • Cunnane G.
      • Brophy D.P.
      • Gibney R.G.
      • FitzGerald O.
      Diagnosis and treatment of heel pain in chronic inflammatory arthritis using ultrasound.
      ,
      • Sellman J.R.
      Plantar fascia rupture associated with corticosteroid injection.
      ,
      • Sorrentino F.
      • Iovane A.
      • Vetro A.
      • Vaccari A.
      • Mantia R.
      • Midiri M.
      Role of high-resolution ultrasound in guiding treatment of idiopathic plantar fasciitis with minimally invasive techniques.
      ,
      • Lee T.G.
      • Ahmad T.S.
      Intralesional autologous blood injection compared to corticosteroid injection for treatment of chronic plantar fasciitis. A prospective, randomized, controlled trial.
      ,
      • Kiter E.
      • Celikbas E.
      • Akkaya S.
      • Demirkan F.
      • Kilic B.A.
      Comparison of injection modalities in the treatment of plantar heel pain: a randomized controlled trial.
      ,
      • Buccilli Jr., T.A.
      • Hall H.R.
      • Solmen J.D.
      Sterile abscess formation following a corticosteroid injection for the treatment of plantar fasciitis.
      ,
      • Porter M.D.
      • Shadbolt B.
      Intralesional corticosteroid injection versus extracorporeal shock wave therapy for plantar fasciopathy.
      ,
      • Tallia A.F.
      • Cardone D.A.
      Diagnostic and therapeutic injection of the ankle and foot.
      ,
      • Kane D.
      • Greaney T.
      • Shanahan M.
      • Duffy G.
      • Bresnihan B.
      • Gibney R.
      • FitzGerald O.
      The role of ultrasonography in the diagnosis and management of idiopathic plantar fasciitis.
      ,
      • Evans A.
      Podiatric medical applications of posterior night stretch splinting.
      ,
      • Quinn M.
      • Gough A.
      Ultrasound guided injection of plantar fasciitis.
      ,
      • Miller R.A.
      • Torres J.
      • McGuire M.
      Efficacy of first-time steroid injection for painful heel syndrome.
      ) or injection of botulinum toxin (
      • Seyler T.M.
      • Smith B.P.
      • Marker D.R.
      • Ma J.
      • Shen J.
      • Smith T.L.
      • Mont M.A.
      • Kolaski K.
      • Koman L.A.
      Botulinum neurotoxin as a therapeutic modality in orthopaedic surgery: more than twenty years of experience.
      ,
      • Jeynes L.C.
      • Gauci C.A.
      Evidence for the use of botulinum toxin in the chronic pain setting—a review of the literature.
      ,
      • Placzek R.
      • Holscher A.
      • Deuretzbacher G.
      • Meiss L.
      • Perka C.
      [Treatment of chronic plantar fasciitis with botulinum toxin A—an open pilot study on 25 patients with a 14-week-follow-up.].
      ,
      • Logan L.R.
      • Klamar K.
      • Leon J.
      • Fedoriw W.
      Autologous blood injection and botulinum toxin for resistant plantar fasciitis accompanied by spasticity.
      ,
      • Placzek R.
      • Deuretzbacher G.
      • Meiss A.L.
      Treatment of chronic plantar fasciitis with Botulinum toxin A: preliminary clinical results.
      ,
      • Placzek R.
      • Deuretzbacher G.
      • Buttgereit F.
      • Meiss A.L.
      Treatment of chronic plantar fasciitis with botulinum toxin A: an open case series with a 1 year follow up.
      ,
      • Babcock M.S.
      • Foster L.
      • Pasquina P.
      • Jabbari B.
      Treatment of pain attributed to plantar fasciitis with botulinum toxin a: a short-term, randomized, placebo-controlled, double-blind study.
      ,
      [Botulinum toxin A–therapy option in cases of chronic plantar fasciitis?—an open treatment attempt with 9 patients and a one year observation period.].
      ), a course of physical therapy (
      • Cleland J.A.
      • Abbott J.H.
      • Kidd M.O.
      • Stockwell S.
      • Cheney S.
      • Gerrard D.F.
      • Flynn T.W.
      Manual physical therapy and exercise versus electrophysical agents and exercise in the management of plantar heel pain: a multicenter randomized clinical trial.
      ), and cast immobilization for 4 to 6 weeks or use of a short-leg walking boot to immobilize or offload the foot during activity (
      • Pribut S.M.
      Current approaches to the management of plantar heel pain syndrome, including the role of injectable corticosteroids.
      ,
      • Cole C.
      • Seto C.
      • Gazewood J.
      Plantar fasciitis: evidence-based review of diagnosis and therapy.
      ,
      • Tisdel C.L.
      • Harper M.C.
      Chronic plantar heel pain: treatment with a short leg walking cast.
      ,
      • Gill L.H.
      • Kiebzak G.M.
      Outcome of nonsurgical treatment for plantar fasciitis.
      ,
      • Kavros S.J.
      The efficacy of a pneumatic compression device in the treatment of plantar fasciitis.
      ). In patients with a high BMI, a consultation and referral for an appropriate weight-loss program may be considered. Clinical response to this second tier of treatment will usually occur within 2 to 3 months in 85% to 90% of patients (
      • Irving D.B.
      • Cook J.L.
      • Young M.A.
      • Menz H.B.
      Obesity and pronated foot type may increase the risk of chronic plantar heel pain: a matched case-control study.
      ,
      • Shikoff M.D.
      • Figura M.A.
      • Postar S.E.
      A retrospective study of 195 patients with heel pain.
      ,
      • Rano J.A.
      • Fallat L.M.
      • Savoy-Moore R.T.
      Correlation of heel pain with body mass index and other characteristics of heel pain.
      ,
      • Ozdemir H.
      • Soyuncu Y.
      • Ozgorgen M.
      • Dabak K.
      Effects of changes in heel fat pad thickness and elasticity on heel pain.
      ,
      • Sadat-Ali M.
      Plantar fasciitis/calcaneal spur among security forces personnel.
      ,
      • Frey C.
      • Zamora J.
      The effects of obesity on orthopaedic foot and ankle pathology.
      ,
      • Karr S.D.
      Subcalcaneal heel pain.
      ,
      • Lynch D.M.
      • Goforth W.P.
      • Martin J.E.
      • Odom R.D.
      • Preece C.K.
      • Kotter M.W.
      Conservative treatment of plantar fasciitis. A prospective study.
      ,
      • McBryde A.M.
      Plantar fasciitis.
      ,
      • Meltzer E.F.
      A rational approach to the management of heel pain. A protocol proposal.
      ,
      • Quaschnick M.S.
      The diagnosis and management of plantar fasciitis.
      ). For those who have shown improvement, continuation of tier 1 and tier 2 therapies should be continued until resolution of symptoms. Following a therapeutic regimen as outlined in Pathway 2, 90% to 95% of patients experience resolution of symptoms within 1 year (
      • Quaschnick M.S.
      The diagnosis and management of plantar fasciitis.
      ,
      • Kinley S.
      • Frascone S.
      • Calderone D.
      • Wertheimer S.J.
      • Squire M.A.
      • Wiseman F.A.
      Endoscopic plantar fasciotomy versus traditional heel spur surgery: a prospective study.
      ). When little or no improvement is noted, other etiologic entities should be considered (
      • Olivieri I.
      • Barozzi L.
      • Padula A.
      Enthesiopathy: clinical manifestations, imaging and treatment.
      ,
      • Ott H.
      • Van Linthoudt D.
      Heel pain in sarcoidosis—is sarcoid a cause of spondarthropathy?.
      ,
      • Pavlica L.
      • Mitrovic D.
      • Mladenovic V.
      • Popovic M.
      • Krstic S.
      • Andelkovic Z.
      [Reiter's syndrome—analysis of 187 patients.].
      ,
      • Perrot S.
      • Mortier E.
      • Renoux M.
      • Job-Deslandre C.
      • Menkes C.J.
      Monostotic Paget's disease involving the calcaneus. Diagnostic and therapeutic problems. Two case-reports.
      ,
      • Resnick D.
      • Feingold M.L.
      • Curd J.
      • Niwayama G.
      • Goergen T.G.
      Calcaneal abnormalities in articular disorders. Rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis and Reiter's syndrome.
      ,
      • Resnick D.
      • Niwayama G.
      Rheumatoid arthritis and the seronegative spondyloarthropathies: radiographic and pathologic changes.
      ,
      • Shaw R.A.
      • Holt P.A.
      • Stevens M.B.
      Heel pain in sarcoidosis.
      ,
      • Geppert M.J.
      • Mizel M.S.
      Management of heel pain in the inflammatory arthritides.
      ,
      • Campbell P.
      • Lawton J.O.
      Heel pain: diagnosis and management.
      ,
      • Dailey J.M.
      Differential diagnosis and treatment of heel pain.
      ,
      • Alvarez-Nemegyei J.
      • Canoso J.J.
      Heel pain: diagnosis and treatment, step by step.
      ,
      • Aldridge T.
      Diagnosing heel pain in adults.
      ,
      • Gerster J.C.
      • Vischer T.L.
      • Bennani A.
      • Fallet G.H.
      The painful heel. Comparative study in rheumatoid arthritis, ankylosing spondylitis, Reiter's syndrome, and generalized osteoarthrosis.
      ).
      EBM conclusions regarding tier 2 therapies are as follows:
      • Prefabricated and custom orthotic devices [Grade B recommendation] (
        • Rome K.
        • Gray J.
        • Stewart F.
        • Hannant S.C.
        • Callaghan D.
        • Hubble J.
        Evaluating the clinical effectiveness and cost-effectiveness of foot orthoses in the treatment of plantar heel pain: a feasibility study.
        ,
        • Lee S.Y.
        • McKeon P.
        • Hertel J.
        Does the use of orthoses improve self-reported pain and function measures in patients with plantar fasciitis? A meta-analysis.
        ,
        • Martin J.E.
        • Hosch J.C.
        • Goforth W.P.
        • Murff R.T.
        • Lynch D.M.
        • Odom R.D.
        Mechanical treatment of plantar fasciitis. A prospective study.
        ,
        • Campbell J.W.
        • Inman V.T.
        Treatment of plantar fasciitis and calcaneal spurs with the UC-BL shoe insert.
        )
      • Night splint [Grade B recommendation] (
        • Roos E.
        • Engstrom M.
        • Soderberg B.
        Foot orthoses for the treatment of plantar fasciitis.
        ,
        • Stuber K.
        • Kristmanson K.
        Conservative therapy for plantar fasciitis: a narrative review of randomized controlled trials.
        ,
        • Lee S.Y.
        • McKeon P.
        • Hertel J.
        Does the use of orthoses improve self-reported pain and function measures in patients with plantar fasciitis? A meta-analysis.
        ,
        • Martin J.E.
        • Hosch J.C.
        • Goforth W.P.
        • Murff R.T.
        • Lynch D.M.
        • Odom R.D.
        Mechanical treatment of plantar fasciitis. A prospective study.
        ,
        • Crawford F.
        • Atkins D.
        • Edwards J.
        Interventions for treating plantar heel pain (Cochrane review).
        ,
        • Huang H.H.
        • Qureshi A.A.
        • Biundo J.J.
        Sports and other soft tissue injuries, tendinitis, bursitis, and occupation-related syndromes.
        ,
        • Powell M.
        • Post W.R.
        • Keener J.
        • Wearden S.
        Effective treatment of chronic plantar fasciitis with dorsiflexion night splints: a crossover prospective randomized outcome study.
        ,
        • Weise J.
        Plantar fasciitis, posterior night splints and activity during recovery.
        ,
        • Ryan J.
        Use of posterior night splints in the treatment of plantar fasciitis.
        ,
        • Wapner K.L.
        • Sharkey P.F.
        The use of night splints for treatment of recalcitrant plantar fasciitis.
        ,
        • Neufeld S.K.
        • Cerrato R.
        Plantar fasciitis: evaluation and treatment.
        ,
        • Cole C.
        • Seto C.
        • Gazewood J.
        Plantar fasciitis: evidence-based review of diagnosis and therapy.
        ,
        • Crawford F.
        • Thomson C.
        Interventions for treating plantar heel pain.
        ,
        • Barry L.D.
        • Barry A.N.
        • Chen Y.
        A retrospective study of standing gastrocnemius-soleus stretching versus night splinting in the treatment of plantar fasciitis.
        ,
        • Young C.C.
        • Rutherford D.S.
        • Niedfeldt M.W.
        Treatment of plantar fasciitis.
        ,
        • Zamorski M.
        Plantar fasciitis, posterior night splints and activity during recovery.
        ,
        • Little R.B.
        Plantar fasciitis, posterior night splints and activity during recovery.
        ,
        • Probe R.A.
        • Baca M.
        • Adams R.
        • Preece C.
        Night splint treatment for plantar fasciitis. A prospective randomized study.
        ,
        • Batt M.E.
        • Tanji J.L.
        • Skattum N.
        Plantar fasciitis: a prospective randomized clinical trial of the tension night splint.
        )
      • Repeat cortisone injections [Grade B recommendation] (
        • Lemont H.
        • Ammirati K.M.
        • Usen N.
        Plantar fasciitis: a degenerative process (fasciosis) without inflammation.
        ,
        • Gill L.H.
        Plantar fasciitis: diagnosis and conservative management.
        ,
        • Williams P.L.
        The painful heel.
        ,
        • Pribut S.M.
        Current approaches to the management of plantar heel pain syndrome, including the role of injectable corticosteroids.
        ,
        • Barrett S.J.
        • O'Malley R.
        Plantar fasciitis and other causes of heel pain.
        ,
        • Lee S.Y.
        • McKeon P.
        • Hertel J.
        Does the use of orthoses improve self-reported pain and function measures in patients with plantar fasciitis? A meta-analysis.
        ,
        • Crawford F.
        • Atkins D.
        • Edwards J.
        Interventions for treating plantar heel pain (Cochrane review).
        ,
        • Crawford F.
        • Thomson C.
        Interventions for treating plantar heel pain.
        ,
        • Beals T.C.
        • Pomeroy G.C.
        • Manoli A.
        Posterior tendon insufficiency: diagnosis and treatment.
        ,
        • Acevedo J.I.
        • Beskin J.L.
        Complications of plantar fascia rupture associated with corticosteroid injection.
        ,
        • Plantar fasciitis
        Repeated corticosteroid injections are safe.
        ,
        • Van Wyngarden T.M.
        The painful foot. Part II: Common rearfoot deformities.
        ,
        • Cunnane G.
        • Brophy D.P.
        • Gibney R.G.
        • FitzGerald O.
        Diagnosis and treatment of heel pain in chronic inflammatory arthritis using ultrasound.
        ,
        • Sellman J.R.
        Plantar fascia rupture associated with corticosteroid injection.
        ,
        • Sorrentino F.
        • Iovane A.
        • Vetro A.
        • Vaccari A.
        • Mantia R.
        • Midiri M.
        Role of high-resolution ultrasound in guiding treatment of idiopathic plantar fasciitis with minimally invasive techniques.
        ,
        • Lee T.G.
        • Ahmad T.S.
        Intralesional autologous blood injection compared to corticosteroid injection for treatment of chronic plantar fasciitis. A prospective, randomized, controlled trial.
        ,
        • Kiter E.
        • Celikbas E.
        • Akkaya S.
        • Demirkan F.
        • Kilic B.A.
        Comparison of injection modalities in the treatment of plantar heel pain: a randomized controlled trial.
        ,
        • Buccilli Jr., T.A.
        • Hall H.R.
        • Solmen J.D.
        Sterile abscess formation following a corticosteroid injection for the treatment of plantar fasciitis.
        ,
        • Porter M.D.
        • Shadbolt B.
        Intralesional corticosteroid injection versus extracorporeal shock wave therapy for plantar fasciopathy.
        ,
        • Tallia A.F.
        • Cardone D.A.
        Diagnostic and therapeutic injection of the ankle and foot.
        ,
        • Kane D.
        • Greaney T.
        • Shanahan M.
        • Duffy G.
        • Bresnihan B.
        • Gibney R.
        • FitzGerald O.
        The role of ultrasonography in the diagnosis and management of idiopathic plantar fasciitis.
        ,
        • Evans A.
        Podiatric medical applications of posterior night stretch splinting.
        ,
        • Quinn M.
        • Gough A.
        Ultrasound guided injection of plantar fasciitis.
        ,
        • Miller R.A.
        • Torres J.
        • McGuire M.
        Efficacy of first-time steroid injection for painful heel syndrome.
        )
      • Botulinum toxin [Grade I recommendation] (
        • Seyler T.M.
        • Smith B.P.
        • Marker D.R.
        • Ma J.
        • Shen J.
        • Smith T.L.
        • Mont M.A.
        • Kolaski K.
        • Koman L.A.
        Botulinum neurotoxin as a therapeutic modality in orthopaedic surgery: more than twenty years of experience.
        ,
        • Jeynes L.C.
        • Gauci C.A.
        Evidence for the use of botulinum toxin in the chronic pain setting—a review of the literature.
        ,
        • Placzek R.
        • Holscher A.
        • Deuretzbacher G.
        • Meiss L.
        • Perka C.
        [Treatment of chronic plantar fasciitis with botulinum toxin A—an open pilot study on 25 patients with a 14-week-follow-up.].
        ,
        • Logan L.R.
        • Klamar K.
        • Leon J.
        • Fedoriw W.
        Autologous blood injection and botulinum toxin for resistant plantar fasciitis accompanied by spasticity.
        ,
        • Placzek R.
        • Deuretzbacher G.
        • Meiss A.L.
        Treatment of chronic plantar fasciitis with Botulinum toxin A: preliminary clinical results.
        ,
        • Placzek R.
        • Deuretzbacher G.
        • Buttgereit F.
        • Meiss A.L.
        Treatment of chronic plantar fasciitis with botulinum toxin A: an open case series with a 1 year follow up.
        ,
        • Babcock M.S.
        • Foster L.
        • Pasquina P.
        • Jabbari B.
        Treatment of pain attributed to plantar fasciitis with botulinum toxin a: a short-term, randomized, placebo-controlled, double-blind study.
        ,
        [Botulinum toxin A–therapy option in cases of chronic plantar fasciitis?—an open treatment attempt with 9 patients and a one year observation period.].
        )
      • Physical therapy [Grade I recommendation] (
        • Cleland J.A.
        • Abbott J.H.
        • Kidd M.O.
        • Stockwell S.
        • Cheney S.
        • Gerrard D.F.
        • Flynn T.W.
        Manual physical therapy and exercise versus electrophysical agents and exercise in the management of plantar heel pain: a multicenter randomized clinical trial.
        )
      • Cast or boot immobilization [Grade C recommendation] (
        • Pribut S.M.
        Current approaches to the management of plantar heel pain syndrome, including the role of injectable corticosteroids.
        ,
        • Cole C.
        • Seto C.
        • Gazewood J.
        Plantar fasciitis: evidence-based review of diagnosis and therapy.
        ,
        • Tisdel C.L.
        • Harper M.C.
        Chronic plantar heel pain: treatment with a short leg walking cast.
        ,
        • Gill L.H.
        • Kiebzak G.M.
        Outcome of nonsurgical treatment for plantar fasciitis.
        ,
        • Kavros S.J.
        The efficacy of a pneumatic compression device in the treatment of plantar fasciitis.
        )
      The third tier of treatment continues tier 1 and/or 2 programs with consideration of surgical management. Options at this time may include surgical plantar fasciotomy using a recognized technique. This may entail endoscopic plantar fasciotomy, in-step fasciotomy, or minimally invasive surgical technique (
      • Kinley S.
      • Frascone S.
      • Calderone D.
      • Wertheimer S.J.
      • Squire M.A.
      • Wiseman F.A.
      Endoscopic plantar fasciotomy versus traditional heel spur surgery: a prospective study.
      ,
      • O'Malley M.J.
      • Page A.
      • Cook R.
      Endoscopic plantar fasciotomy for chronic heel pain.
      ,
      • Zimmerman B.J.
      • Cardinal M.D.
      • Cragel M.D.
      • Goel A.R.
      • Lane J.W.
      • Schramm K.A.
      Comparison of three types of postoperative management for endoscopic plantar fasciotomy. A retrospective study.
      ,
      • Fishco W.D.
      • Goecker R.M.
      • Schwartz R.I.
      The instep plantar fasciotomy for chronic plantar fasciitis. A retrospective review.
      ,
      • Benton-Weil W.
      • Borrelli A.H.
      • Weil L.S.
      Percutaneous plantar fasciotomy: a minimally invasive procedure for recalcitrant plantar fasciitis.
      ,
      • Stone P.A.
      • Davies J.L.
      Retrospective review of endoscopic plantar fasciotomy—1992 through 1994.
      ,
      • Amarnek D.L.
      The medial instep plantar fasciotomy.
      ,
      • Perelman G.K.
      • Figura M.A.
      • Sandberg N.S.
      The medial instep plantar fasciotomy.
      ,
      • Barrett S.L.
      • Day S.V.
      • Pignetti T.T.
      • Robinson L.B.
      Endoscopic plantar fasciotomy: a multi-surgeon prospective analysis of 652 cases.
      ,
      • Tomczak R.L.
      • Haverstock B.D.
      A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome.
      ,
      • Barrett S.L.
      Endoscopic plantar fasciotomy.
      ,
      • Wander D.S.
      Endoscopic plantar fasciotomy versus traditional heel spur surgery.
      ,
      • Barrett S.L.
      • Day S.V.
      Endoscopic plantar fasciotomy vs. traditional heel spur surgery.
      ,
      • Ko J.Y.
      • Wang J.W.
      • Wan Y.L.
      • Chen W.J.
      Multiple schwannomas of the foot: report of a case.
      ,
      • Daly P.J.
      • Kitaoka H.B.
      • Chao E.Y.
      Plantar fasciotomy for intractable plantar fasciitis: clinical results and biomechanical evaluation.
      ,
      • Barrett S.L.
      • Day S.V.
      Endoscopic plantar fasciotomy for chronic plantar fasciitis/heel spur syndrome: surgical technique—early clinical results.
      ,
      • Lafforgue P.
      • Siles S.
      • Daumen-Legre V.
      • Acquaviva P.C.
      An unexpected, benign cause of increased muscular uptake at bone scintigraphy.
      ,
      • Lester D.K.
      • Buchanan J.R.
      Surgical treatment of plantar fasciitis.
      ,
      • Lewis G.
      • Gatti A.
      • Barry L.D.
      • Greenberg P.M.
      • Levenson M.
      The plantar approach to heel surgery: a retrospective study.
      ,
      • Ogilvie-Harris D.J.
      • Lobo J.
      Endoscopic plantar fascia release.
      ,
      • Snider M.P.
      • Clancy W.G.
      • McBeath A.A.
      Plantar fascia release for chronic plantar fasciitis in runners.
      ,
      • Stone P.A.
      • McClure L.P.
      Retrospective review of endoscopic plantar fasciotomy. 1994 through 1997.
      ,
      • Tountas A.A.
      • Fornasier V.L.
      Operative treatment of subcalcaneal pain.
      ,
      • Vohra P.K.
      • Giorgini R.J.
      • Sobel E.
      • Japour C.J.
      • Villalba M.A.
      • Rostkowski T.
      Long-term follow-up of heel spur surgery. A 10-year retrospective study.
      ,
      • Ward W.G.
      • Clippinger F.W.
      Proximal medial longitudinal arch incision for plantar fascia release.
      ,
      • White D.L.
      Plantar fascial release.
      ,
      • Barrett S.L.
      • Day S.V.
      Endoscopic plantar fasciotomy: two portal endoscopic surgical techniques—clinical results of 65 procedures.
      ,
      • Woelffer K.E.
      • Figura M.A.
      • Sandberg N.S.
      • Snyder N.S.
      Five-year follow-up results of instep plantar fasciotomy for chronic heel pain.
      ,
      • Urovitz E.P.
      • Birk-Urovitz A.
      • Birk-Urovitz E.
      Endoscopic plantar fasciotomy in the treatment of chronic heel pain.
      ,
      • Chuckpaiwong B.
      • Berkson E.M.
      • Theodore G.H.
      Extracorporeal shock wave for chronic proximal plantar fasciitis: 225 patients with results and outcome predictors.
      ,
      • Bazaz R.
      • Ferkel R.D.
      Results of endoscopic plantar fascia release.
      ,
      • Theodore G.H.
      • Buch M.
      • Amendola A.
      • Bachmann C.
      • Fleming L.L.
      • Zingas C.
      Extracorporeal shock wave therapy for the treatment of plantar fasciitis.
      ,
      • Saxena A.
      Uniportal endoscopic plantar fasciotomy: a prospective study on athletic patients.
      ,
      • Lane G.D.
      • London B.
      Heel spur syndrome: a retrospective report on the percutaneous plantar transverse incisional approach.
      ,
      • Jerosch J.
      • Schunck J.
      • Liebsch D.
      • Filler T.
      Indication, surgical technique and results of endoscopic fascial release in plantar fasciitis (E FRPF).
      ,
      • Hogan K.A.
      • Webb D.
      • Shereff M.
      Endoscopic plantar fascia release.
      ,
      • Boyle R.A.
      • Slater G.L.
      Endoscopic plantar fascia release: a case series.
      ) or extracorporeal shock wave therapy (ESWT) as an alternative to traditional surgical approaches (
      • Pribut S.M.
      Current approaches to the management of plantar heel pain syndrome, including the role of injectable corticosteroids.
      ,
      • Chuckpaiwong B.
      • Berkson E.M.
      • Theodore G.H.
      Extracorporeal shock wave for chronic proximal plantar fasciitis: 225 patients with results and outcome predictors.
      ,
      • Krischek O.
      • Rompe J.D.
      • Herbsthofer B.
      • Nafe B.
      [Symptomatic low-energy shockwave therapy in heel pain and radiologically detected plantar heel spur.].
      ,
      • Maier M.
      • Steinborn M.
      • Schmitz C.
      • Stabler A.
      • Kohler S.
      • Pfahler M.
      • Durr H.R.
      • Refior H.J.
      Extracorporeal shock wave application for chronic plantar fasciitis associated with heel spurs: prediction of outcome by magnetic resonance imaging.
      ,
      • Perlick L.
      • Boxberg W.
      • Giebel G.
      [High energy shock wave treatment of the painful heel spur].
      ,
      • Sistermann R.
      • Katthagen B.D.
      [5-years lithotripsy of plantar of plantar heel spur: experiences and results—a follow-up study after 36.9 months].
      ,
      • Wang C.J.
      • Chen H.S.
      • Chen W.S.
      • Chen L.M.
      Treatment of painful heels using extracorporeal shock wave.
      ,
      • Greve J.M.
      • Grecco M.V.
      • Santos-Silva P.R.
      Comparison of radial shockwaves and conventional physiotherapy for treating plantar fasciitis.
      ,
      • Gollwitzer H.
      • Diehl P.
      • von Korff A.
      • Rahlfs V.W.
      • Gerdesmeyer L.
      Extracorporeal shock wave therapy for chronic painful heel syndrome: a prospective, double blind, randomized trial assessing the efficacy of a new electromagnetic shock wave device.
      ,
      • Wang C.J.
      • Wang F.S.
      • Yang K.D.
      • Weng L.H.
      • Ko J.Y.
      Long-term results of extracorporeal shockwave treatment for plantar fasciitis.
      ,
      • Malay D.S.
      • Pressman M.M.
      • Assili A.
      • Kline J.T.
      • York S.
      • Buren B.
      • Heyman E.R.
      • Borowsky P.
      • LeMay C.
      Extracorporeal shockwave therapy versus placebo for the treatment of chronic proximal plantar fasciitis: results of a randomized, placebo-controlled, double-blinded, multicenter intervention trial.
      ,
      • Landorf K.B.
      • Menz H.B.
      • Radford J.A.
      Effectiveness of extracorporeal shockwave treatment in 353 patients with chronic plantar fasciitis.
      ,
      • Kudo P.
      • Dainty K.
      • Clarfield M.
      • Coughlin L.
      • Lavoie P.
      • Lebrun C.
      Randomized, placebo-controlled, double-blind clinical trial evaluating the treatment of plantar fasciitis with an extracoporeal shockwave therapy (ESWT) device: a North American confirmatory study.
      ,
      • DiResta J.
      Effectiveness of extracorporeal shockwave treatment in 353 patients with chronic plantar fasciitis.
      ,
      • Norris D.M.
      • Eickmeier K.M.
      • Werber B.R.
      Effectiveness of extracorporeal shockwave treatment in 353 patients with chronic plantar fasciitis.
      ,
      • Hyer C.F.
      • Vancourt R.
      • Block A.
      Evaluation of ultrasound-guided extracorporeal shock wave therapy (ESWT) in the treatment of chronic plantar fasciitis.
      ,
      • Wilner J.M.
      • Strash W.W.
      Extracorporeal shockwave therapy for plantar fasciitis and other musculoskeletal conditions utilizing the Ossatron—an update.
      ,
      • Wang C.J.
      • Chen H.S.
      • Huang T.W.
      Shockwave therapy for patients with plantar fasciitis: a one-year follow-up study.
      ,
      • Strash W.W.
      • Perez R.R.
      Extracorporeal shockwave therapy for chronic proximal plantar fasciitis.
      ,
      • Ogden J.A.
      • Alvarez R.G.
      • Marlow M.
      Shockwave therapy for chronic proximal plantar fasciitis: a meta-analysis.
      ,
      • Hammer D.S.
      • Rupp S.
      • Kreutz A.
      • Pape D.
      • Kohn D.
      • Seil R.
      Extracorporeal shockwave therapy (ESWT) in patients with chronic proximal plantar fasciitis.
      ,
      • Chung B.
      • Wiley J.P.
      Extracorporeal shockwave therapy: a review.
      ,
      • Buch M.
      • Knorr U.
      • Fleming L.
      • Theodore G.
      • Amendola A.
      • Bachmann C.
      • Zingas C.
      • Siebert W.E.
      [Extracorporeal shockwave therapy in symptomatic heel spurs.
      ,
      • Boddeker R.
      • Schafer H.
      • Haake M.
      Extracorporeal shockwave therapy (ESWT) in the treatment of plantar fasciitis—a biometrical review.
      ,
      • Heller K.D.
      [Extracorporeal shockwave therapy in heel spur—analysis of the literature.].
      ,
      • Tornese D.
      • Mattei E.
      • Lucchesi G.
      • Bandi M.
      • Ricci G.
      • Melegati G.
      Comparison of two extracorporeal shock wave therapy techniques for the treatment of painful subcalcaneal spur. A randomized controlled study.
      ,
      • Weil Jr., L.S.
      • Roukis T.S.
      • Weil L.S.
      • Borrelli A.H.
      Extracorporeal shock wave therapy for the treatment of chronic plantar fasciitis: indications, protocol, intermediate results, and a comparison of results to fasciotomy.
      ,
      • Rompe J.D.
      • Schoellner C.
      • Nafe B.
      Evaluation of low-energy extracorporeal shock-wave application for treatment of chronic plantar fasciitis.
      ,
      • Gerdesmeyer L.
      • Frey C.
      • Vester J.
      • Maier M.
      • Weil Jr., L.
      • Weil Sr., L.
      • Russlies M.
      • Stienstra J.
      • Scurran B.
      • Fedder K.
      • Diehl P.
      • Lohrer H.
      • Henne M.
      • Gollwitzer H.
      Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis: results of a confirmatory randomized placebo-controlled multicenter study.
      ,
      • Marks W.
      • Jackiewicz A.
      • Witkowski Z.
      • Kot J.
      • Deja W.
      • Lasek J.
      Extracorporeal shock-wave therapy (ESWT) with a new-generation pneumatic device in the treatment of heel pain. A double blind randomised controlled trial.
      ) (Figure 5). Current practice favors a minimally invasive approach to plantar fasciotomy versus extensive open surgical exposures (
      • Pribut S.M.
      Current approaches to the management of plantar heel pain syndrome, including the role of injectable corticosteroids.
      ,
      • Kinley S.
      • Frascone S.
      • Calderone D.
      • Wertheimer S.J.
      • Squire M.A.
      • Wiseman F.A.
      Endoscopic plantar fasciotomy versus traditional heel spur surgery: a prospective study.
      ,
      • O'Malley M.J.
      • Page A.
      • Cook R.
      Endoscopic plantar fasciotomy for chronic heel pain.
      ,
      • Zimmerman B.J.
      • Cardinal M.D.
      • Cragel M.D.
      • Goel A.R.
      • Lane J.W.
      • Schramm K.A.
      Comparison of three types of postoperative management for endoscopic plantar fasciotomy. A retrospective study.
      ,
      • Fishco W.D.
      • Goecker R.M.
      • Schwartz R.I.
      The instep plantar fasciotomy for chronic plantar fasciitis. A retrospective review.
      ,
      • Benton-Weil W.
      • Borrelli A.H.
      • Weil L.S.
      Percutaneous plantar fasciotomy: a minimally invasive procedure for recalcitrant plantar fasciitis.
      ,
      • Stone P.A.
      • Davies J.L.
      Retrospective review of endoscopic plantar fasciotomy—1992 through 1994.
      ,
      • Amarnek D.L.
      The medial instep plantar fasciotomy.
      ,
      • Perelman G.K.
      • Figura M.A.
      • Sandberg N.S.
      The medial instep plantar fasciotomy.
      ,
      • Barrett S.L.
      • Day S.V.
      • Pignetti T.T.
      • Robinson L.B.
      Endoscopic plantar fasciotomy: a multi-surgeon prospective analysis of 652 cases.
      ,
      • Tomczak R.L.
      • Haverstock B.D.
      A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome.
      ,
      • Barrett S.L.
      Endoscopic plantar fasciotomy.
      ,
      • Wander D.S.
      Endoscopic plantar fasciotomy versus traditional heel spur surgery.
      ,
      • Barrett S.L.
      • Day S.V.
      Endoscopic plantar fasciotomy vs. traditional heel spur surgery.
      ,
      • Daly P.J.
      • Kitaoka H.B.
      • Chao E.Y.
      Plantar fasciotomy for intractable plantar fasciitis: clinical results and biomechanical evaluation.
      ,
      • Barrett S.L.
      • Day S.V.
      Endoscopic plantar fasciotomy for chronic plantar fasciitis/heel spur syndrome: surgical technique—early clinical results.
      ,
      • Stone P.A.
      • McClure L.P.
      Retrospective review of endoscopic plantar fasciotomy. 1994 through 1997.
      ,
      • Barrett S.L.
      • Day S.V.
      Endoscopic plantar fasciotomy: two portal endoscopic surgical techniques—clinical results of 65 procedures.
      ,
      • Woelffer K.E.
      • Figura M.A.
      • Sandberg N.S.
      • Snyder N.S.
      Five-year follow-up results of instep plantar fasciotomy for chronic heel pain.
      ,
      • Urovitz E.P.
      • Birk-Urovitz A.
      • Birk-Urovitz E.
      Endoscopic plantar fasciotomy in the treatment of chronic heel pain.
      ,
      • Saxena A.
      Uniportal endoscopic plantar fasciotomy: a prospective study on athletic patients.
      ,
      • Yu J.S.
      • Smith G.
      • Ashman C.
      • Kaeding C.
      The plantar fasciotomy: MR imaging findings in asymptomatic volunteers.
      ,
      • Wander D.S.
      A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome.
      ,
      • Barrett S.L.
      • Day S.V.
      • Pignetti T.T.
      • Egly B.R.
      Endoscopic heel anatomy: analysis of 200 fresh frozen specimens.
      ,
      • Graves R.H.
      • Levin D.R.
      • Giacopelli J.
      • White P.R.
      • Russell R.D.
      Fluoroscopy-assisted plantar fasciotomy and calcaneal exostectomy: a retrospective study and comparison of surgical techniques.
      ,
      • Barrett S.L.
      • Day S.V.
      • Brown M.G.
      Endoscopic plantar fasciotomy: preliminary study with cadaveric specimens.
      ,
      • Marafko C.
      Endoscopic partial plantar fasciotomy as a treatment alternative in plantar fasciitis.
      ,
      • Cheung J.T.
      • An K.N.
      • Zhang M.
      Consequences of partial and total plantar fascia release: a finite element study.
      ,
      • Lundeen R.O.
      • Aziz S.
      • Burks J.B.
      • Rose J.M.
      Endoscopic plantar fasciotomy: a retrospective analysis of results in 53 patients.
      ). In most cases, removal of the plantar heel spur does not seem to add to the success of the outcome in the surgical treatment of plantar heel pain (
      • Tomczak R.L.
      • Haverstock B.D.
      A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome.
      ,
      • Wander D.S.
      Endoscopic plantar fasciotomy versus traditional heel spur surgery.
      ,
      • Vohra P.K.
      • Giorgini R.J.
      • Sobel E.
      • Japour C.J.
      • Villalba M.A.
      • Rostkowski T.
      Long-term follow-up of heel spur surgery. A 10-year retrospective study.
      ,
      • Wander D.S.
      A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome.
      ).
      Figure thumbnail gr5
      Fig. 5Operative treatment of plantar fasciitis may include (A) open plantar fasciotomy, (B) minimally invasive plantar fasciotomy, or (C) instep plantar fasciotomy. (D) Extracorporal shockwave therapy has become a popular alternative to traditional surgical approaches.
      In some cases, multiple etiologic factors including nerve entrapment may be implicated, necessitating the combination of nerve release and plantar fasciotomy (see Neurologic section, Pathway 4). Radiofrequency coblation of the plantar fascia as well as radiofrequency nerve ablation and cryoprobe have been advocated more recently as an alternative surgical approach to chronic heel pain (
      • Liden B.
      • Simmons M.
      • Landsman A.S.
      A retrospective analysis of 22 patients treated with percutaneous radiofrequency nerve ablation for prolonged moderate to severe heel pain associated with plantar fasciitis.
      ,
      • Cione J.A.
      • Cozzarelli J.
      • Mullin C.J.
      A retrospective study of radiofrequency thermal lesioning for the treatment of neuritis of the medial calcaneal nerve and its terminal branches in chronic heel pain.
      ,
      • Sollitto R.J.
      • Plotkin E.L.
      • Klein P.G.
      • Mullin P.
      Early clinical results of the use of radiofrequency lesioning in the treatment of plantar fasciitis.
      ,
      • Allen B.H.
      • Fallat L.M.
      • Schwartz S.M.
      Cryosurgery: an innovative technique for the treatment of plantar fasciitis.
      ,
      • Weil Jr., L.
      • Glover J.P.
      • Weil Sr., L.S.
      A new minimally invasive technique for treating plantar fasciosis using bipolar radiofrequency: a prospective analysis.
      ,
      • Cavazos G.J.
      • Khan K.H.
      • D'Antoni A.V.
      • Harkless L.B.
      • Lopez D.
      Cryosurgery for the treatment of heel pain.
      ).
      EBM conclusions regarding tier 3 therapies are as follows:
      • Endoscopic plantar fasciotomy, in-step fasciotomy, or minimally invasive surgical technique [Grade B recommendation] (
        • Pribut S.M.
        Current approaches to the management of plantar heel pain syndrome, including the role of injectable corticosteroids.
        ,
        • Kinley S.
        • Frascone S.
        • Calderone D.
        • Wertheimer S.J.
        • Squire M.A.
        • Wiseman F.A.
        Endoscopic plantar fasciotomy versus traditional heel spur surgery: a prospective study.
        ,
        • O'Malley M.J.
        • Page A.
        • Cook R.
        Endoscopic plantar fasciotomy for chronic heel pain.
        ,
        • Zimmerman B.J.
        • Cardinal M.D.
        • Cragel M.D.
        • Goel A.R.
        • Lane J.W.
        • Schramm K.A.
        Comparison of three types of postoperative management for endoscopic plantar fasciotomy. A retrospective study.
        ,
        • Fishco W.D.
        • Goecker R.M.
        • Schwartz R.I.
        The instep plantar fasciotomy for chronic plantar fasciitis. A retrospective review.
        ,
        • Benton-Weil W.
        • Borrelli A.H.
        • Weil L.S.
        Percutaneous plantar fasciotomy: a minimally invasive procedure for recalcitrant plantar fasciitis.
        ,
        • Stone P.A.
        • Davies J.L.
        Retrospective review of endoscopic plantar fasciotomy—1992 through 1994.
        ,
        • Amarnek D.L.
        The medial instep plantar fasciotomy.
        ,
        • Perelman G.K.
        • Figura M.A.
        • Sandberg N.S.
        The medial instep plantar fasciotomy.
        ,
        • Barrett S.L.
        • Day S.V.
        • Pignetti T.T.
        • Robinson L.B.
        Endoscopic plantar fasciotomy: a multi-surgeon prospective analysis of 652 cases.
        ,
        • Tomczak R.L.
        • Haverstock B.D.
        A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome.
        ,
        • Barrett S.L.
        Endoscopic plantar fasciotomy.
        ,
        • Wander D.S.
        Endoscopic plantar fasciotomy versus traditional heel spur surgery.
        ,
        • Barrett S.L.
        • Day S.V.
        Endoscopic plantar fasciotomy vs. traditional heel spur surgery.
        ,
        • Daly P.J.
        • Kitaoka H.B.
        • Chao E.Y.
        Plantar fasciotomy for intractable plantar fasciitis: clinical results and biomechanical evaluation.
        ,
        • Barrett S.L.
        • Day S.V.
        Endoscopic plantar fasciotomy for chronic plantar fasciitis/heel spur syndrome: surgical technique—early clinical results.
        ,
        • Stone P.A.
        • McClure L.P.
        Retrospective review of endoscopic plantar fasciotomy. 1994 through 1997.
        ,
        • Barrett S.L.
        • Day S.V.
        Endoscopic plantar fasciotomy: two portal endoscopic surgical techniques—clinical results of 65 procedures.
        ,
        • Woelffer K.E.
        • Figura M.A.
        • Sandberg N.S.
        • Snyder N.S.
        Five-year follow-up results of instep plantar fasciotomy for chronic heel pain.
        ,
        • Urovitz E.P.
        • Birk-Urovitz A.
        • Birk-Urovitz E.
        Endoscopic plantar fasciotomy in the treatment of chronic heel pain.
        ,
        • Saxena A.
        Uniportal endoscopic plantar fasciotomy: a prospective study on athletic patients.
        ,
        • Yu J.S.
        • Smith G.
        • Ashman C.
        • Kaeding C.
        The plantar fasciotomy: MR imaging findings in asymptomatic volunteers.
        ,
        • Wander D.S.
        A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome.
        ,
        • Barrett S.L.
        • Day S.V.
        • Pignetti T.T.
        • Egly B.R.
        Endoscopic heel anatomy: analysis of 200 fresh frozen specimens.