Which treatment actually works for stubborn plantar fasciitis?

Three papers landed on stubborn heel pain from three different angles, and read together they change how you should be talking about it in the room.

The first is a network meta-analysis of minimally invasive therapies for plantar fasciitis, pooling 63 randomised controlled trials and 4,170 participants. A network meta-analysis lets you compare treatments that were never tested head to head, by linking them through the comparisons that were made. The treatments in the network were extracorporeal shockwave therapy, prolotherapy, platelet-rich plasma, botulinum toxin A, corticosteroids, autologous blood and local anaesthetics. It was published open access in Scientific Reports.

The second is a systematic review and meta-analysis of radial shockwave against other electrophysical modalities, meaning the other machines in the room such as low-level laser and therapeutic ultrasound. It included 14 randomised controlled trials and 797 people, with 12 trials contributing to the meta-analysis, and was published in Foot & Ankle Specialist.

The third is an MRI study of 108 people with plantar fasciitis against 100 age-matched controls, measuring plantar fascia thickness alongside Achilles tendon diameters and paratenon dimensions, and recording retrocalcaneal bursitis and Achilles tendinopathy.

No single treatment won. In the network meta-analysis, the ranking changed depending on what you were chasing and when you were measuring it. Botulinum toxin A gave the greatest short-term improvements in pain and in plantar fascia thickness. Corticosteroid injection produced the largest short-term function gains. Prolotherapy was the most effective for sustained pain relief. Platelet-rich plasma supported long-term improvements in both function and fascia thickness. Shockwave was the all-rounder, showing broad efficacy across every domain and every timepoint.

The authors' own conclusion is the useful one: treatment should be tailored to symptom duration and to the goal you are actually chasing, rather than defaulting to one intervention for everybody.

Radial shockwave did not beat the other machines. In the second review, radial shockwave, alone or combined with conventional physiotherapy, was not superior to other electrophysical modalities for pain (standardised mean difference -0.03, 95% CI -0.39 to 0.33) or for function (-0.11, 95% CI -0.47 to 0.25). Low-level laser therapy actually showed a small but statistically significant advantage over radial shockwave for functional outcomes. Risk of bias was high across most of the included trials, which limits how much certainty you can put on it.

The heel was not the only thing that was different. On MRI, people with plantar fasciitis had a thicker plantar fascia, as you would expect, but they also had significantly larger Achilles tendon anteroposterior and mediolateral diameters than controls. Retrocalcaneal bursitis and Achilles tendinopathy were both significantly more common in the plantar fasciitis group. The only direct correlation the authors report between fascia thickness and Achilles diameter was a weak one, and it was in the control group, so this is a group-level pattern rather than a tight relationship you can read off an individual scan. The design is retrospective, so it tells you these things travel together, not that one causes the other.

Stop treating "injection" as one thing. When a patient asks about injections for their heel, they are usually asking a single question and expecting a single answer. This network gives you a better one. If they need to be functional quickly, for a wedding or a season or a work trip, corticosteroid gives the biggest short-term function gain, and you can be upfront that it fades. If they are playing the long game and want the fascia itself to change, PRP is the option that held up at the far end. If sustained pain relief is the priority, prolotherapy ranked best. The agent should follow the timeframe and the goal, and now you can say that with a number behind it.

PRP is not one evidence bucket. A separate review this month pulled PRP out of the general injection pile and looked at it condition by condition across the foot and ankle. Its conclusion lines up with the network above: the most consistent support is for plantar fasciitis and osteochondral lesions of the talus, where it improved pain and function, while the evidence for Achilles tendinopathy and ankle osteoarthritis is mixed and muddied by how differently PRP is prepared from one study to the next. One caveat on that review: it carries a commercial grant tied to the regenerative-medicine space, so read the enthusiasm accordingly.

The Achilles contrast is the one to hold onto, because it is where patients most often assume the evidence carries over. A fresh meta-analysis of four placebo-controlled trials, 337 people, found no clinical or radiological benefit from PRP over placebo for Achilles tendinopathy, on pain, on the VISA-A function score or on tendon imaging. So the same injection that has a real case in the plantar fascia does not have one in the Achilles. That is a genuinely useful thing to be able to say to the patient who has read one headline and assumed it applies to every tendon in their leg.

Position shockwave honestly, and it survives. These two papers pull in slightly different directions. Against the injections, shockwave was the most consistent performer across pain, function and timepoints. Against the other machines, radial shockwave did not separate from laser or ultrasound, and laser edged it on function. So shockwave is a solid, broadly useful option, and it is not a magic bullet, and if you are running a shockwave clinic that is a distinction worth being straight about.

The bigger caveat is the one neither paper tests. Loading was not in either comparison. The network compared injections and shockwave to each other, and the second review compared machines to machines. Neither one asked whether any of it beats a well-run loading program, which remains the treatment with the strongest base. Read these papers as a guide to choosing your adjunct, not as permission to skip the exercise.

Look up the leg before you commit. The MRI paper is the one I would let change a habit this fortnight. Your plantar fasciitis patients are more likely than controls to also have Achilles tendinopathy and retrocalcaneal bursitis sitting there, and to have measurably bigger Achilles tendons. Whether the calf is driving the heel or simply travelling with it, the practical answer is the same. Palpate the Achilles, check the retrocalcaneal space, test calf capacity and dorsiflexion range properly, and if you find something, treat it. A patient whose heel keeps relapsing through a good fascia program may have a posterior chain problem you have not addressed.

The change to make this fortnight. For your next recalcitrant heel, ask two questions before reaching for the shockwave head or the referral pad. What is this patient's actual goal, function now or fascia change later, and what is the calf doing? Then choose the adjunct that matches the first answer, and treat what you find in the second.

There is no single best treatment for stubborn plantar fasciitis, and the choice should follow the patient's timeframe and goal: corticosteroid for fast function, botulinum toxin for fast pain, prolotherapy for durable pain relief, PRP for the long game, shockwave as the consistent all-rounder. Radial shockwave is not superior to laser or ultrasound, so sell it accordingly. And a meaningful share of these patients have an Achilles problem sitting alongside the heel, so assess the calf before you decide the fascia is the whole story.