Guideline sources The following summarized guidelines for the evaluation and management of plantar fasciitis are prepared by our editorial team based on guidelines from the American College of Radiology (ACR 2020), the American Association of Family Physicians (AAFP 2019), the American College of Foot and Ankle Surgeons (ACFAS 2018), and the American Physical Therapy Association (APTA 2014). 1 2 3 4 Guidelines 1. Screening and diagnosis Pathogenesis: recognize that infracalcaneal heel pain is a soft tissue-based disorder in most cases, and calcaneal spurring is most likely not a causative factor. E Differential diagnosis: assess for other diagnoses, including spondyloarthritis, fat-pad atrophy, and proximal plantar fibroma, when the reported activity limitations or impairments of body function and structure are not consistent with plantar fasciitis or when symptoms are not resolving with interventions aimed at normalization of the impairments of body function. B https://web.pathway.md/diseases/rec36CA2TVH0rnIJs 1/5 6/29/23, 11:13 PM Plantar fasciitis Pathway 2. Classification and risk stratification Risk factors: assess for limited ankle dorsiflexion ROM, high BMI in nonathletic individuals, running, and work-related weight-bearing activities (particularly under conditions with poor shock absorption) as risk factors for the development of heel pain/plantar fasciitis. B 3. Diagnostic investigations History and physical examination: As per ACFAS 2018 guidelines: Elicit history and perform a physical examination to establish the diagnosis of plantar fasciitis in most cases. E Assess the chronicity of symptoms to guide the treatment for plantar fasciitis. E As per APTA 2014 guidelines: Elicit history and perform a physical examination to assess for the following findings for the diagnosis of plantar fasciitis: plantar medial heel pain (most noticeable with initial steps after a period of inactivity but also worse following prolonged weight bearing) heel pain precipitated by a recent increase in weight-bearing activity pain with palpation of the proximal insertion of the plantar fascia positive windlass test negative testing for posterior tarsal tunnel syndrome limited active and passive talocrural joint dorsiflexion ROM abnormal Foot Posture Index score high BMI in nonathletic persons. B Use the FAAM, FHSQ, or the FFI and consider using the computer-adaptive version of the LEFS before and after interventions intended to alleviate the physical impairments, activity limitations, and participation restrictions associated with heel pain/plantar fasciitis. A Diagnostic imaging, X-ray: As per ACR 2020 guidelines, obtain foot X-ray for the initial imaging of chronic foot pain of unknown etiology. B As per ACFAS 2018 guidelines, do not obtain a routine foot X-ray for the diagnosis of nontraumatic plantar fasciitis since the presence of a calcaneal spur does not generally alter the treatment. D Diagnostic imaging, MRI/US: As per ACR 2020 guidelines, obtain foot MRI or ultrasound as the next imaging after negative or equivocal X-ray in patients with chronic plantar heel pain with suspected plantar fasciitis or plantar fascia tear. B As per AAFP 2019 guidelines, obtain ultrasound or MRI in patients with chronic heel pain despite conservative measures. B As per ACFAS 2018 guidelines, do not obtain MRI or ultrasound for diagnosis or guiding treatment in nontraumatic plantar fasciitis. D https://web.pathway.md/diseases/rec36CA2TVH0rnIJs 2/5 6/29/23, 11:13 PM Plantar fasciitis Pathway 4. Medical management Nonsteroidal anti-inflammatory drugs: insufficient evidence to support the use of NSAIDs for pain in patients with plantar fasciitis. I Intralesional corticosteroid injections: As per AAFP 2019 guidelines, consider administering intralesional corticosteroid injections for short-term relief in patients with acute or chronic plantar fasciitis. C As per ACFAS 2018 guidelines, consider administering corticosteroid injections for the management of plantar fasciitis. E Other intralesional injections: insufficient evidence to recommend other injection techniques, including amniotic tissue, platelet-rich plasma, botulinum toxin, needling, and prolotherapy, for the management of plantar fasciitis. I 5. Nonpharmacologic interventions Stretching: As per AAFP 2019 guidelines, offer plantar fascia stretches to reduce heel pain in patients with plantar fasciitis. B As per ACFAS 2018 guidelines, offer stretching for the management of plantar fasciitis. E As per APTA 2014 guidelines, offer plantar fascia-specific and gastrocnemius/soleus stretching for short-term (1 week to 4 months) pain relief in patients with heel pain/plantar fasciitis. Consider using heel pads to increase the benefits of stretching. A Taping and orthoses: As per AAFP 2019 guidelines, consider offering foot orthoses (prefabricated or custom) to reduce heel pain for up to 12 weeks but not for the long term. C As per ACFAS 2018 guidelines, offer biomechanical support for the management of plantar fasciitis. E As per APTA 2014 guidelines: Offer antipronation taping for immediate (up to 3 weeks) pain reduction and improved function in patients with heel pain/plantar fasciitis. Consider offering elastic therapeutic taping applied to the gastrocnemius and plantar fascia additionally for short-term (1 week) pain reduction. A Offer foot orthoses (prefabricated or custom fabricated/fitted) to support the medial longitudinal arch and cushion the heel for pain reduction and function improvement for short- (2 weeks) to long-term (1 year) periods in patients with heel pain/plantar fasciitis, especially if responding positively to antipronation taping techniques. A Night splints: As per AAFP 2019 guidelines, insufficient evidence to support the use of night splints for reducing pain in patients with plantar fasciitis. I As per APTA 2014 guidelines, offer night splints for 1-3 months in patients with heel pain/plantar fasciitis consistently having pain with the first step in the morning. A https://web.pathway.md/diseases/rec36CA2TVH0rnIJs 3/5 6/29/23, 11:13 PM Plantar fasciitis Pathway Specific footwear: consider offering rocker-bottom shoe construction in conjunction with a foot orthosis to reduce pain in patients with heel pain/plantar fasciitis. Consider offering shoe rotation during the work week in patients standing for long periods. C Manual therapy: offer manual therapy, consisting of joint and soft tissue mobilization, for the management of relevant lower extremity joint mobility and calf flexibility deficits and to decrease pain and improve function in patients with heel pain/plantar fasciitis. A Dry needling: insufficient evidence to recommend trigger point dry needling in patients with heel pain/plantar fasciitis. I 6. Therapeutic procedures Extracorporeal shock wave therapy: As per AAFP 2019 guidelines, consider offering extracorporeal shock wave therapy in patients with chronic plantar fasciitis not responding to conservative therapies. C As per ACFAS 2018 guidelines, consider offering extracorporeal shockwave therapy for the management of plantar fasciitis. E Low-level laser therapy: consider offering low-level laser therapy to reduce pain and activity limitations in patients with heel pain/plantar fasciitis. C Iontophoresis and phonophoresis: Consider offering iontophoresis with dexamethasone or acetic acid for short-term (2-4 weeks) pain relief and improved function in selected patients with plantar fasciitis. C Consider offering phonophoresis with ketoprofen gel to reduce pain in patients with heel pain/plantar fasciitis. C Therapeutic ultrasound: do not use therapeutic ultrasound in patients with heel pain/plantar fasciitis. D 7. Surgical interventions Indications for surgery: Consider offering plantar fasciotomy (open or endoscopic) as an option in patients with chronic, refractory plantar fasciitis. E Consider offering gastrocnemius release as an option in patients with chronic, refractory plantar fasciitis in the presence of clinically significant equinus. E 8. Patient education General counseling: consider counseling patients with heel pain/plantar fasciitis on exercise strategies to gain or maintain optimal lean body mass. Consider referring patients to an appropriate healthcare practitioner to address nutrition issues. C 9. Follow-up and surveillance https://web.pathway.md/diseases/rec36CA2TVH0rnIJs 4/5 6/29/23, 11:13 PM Plantar fasciitis Pathway Assessment of treatment response: use the FAAM, FHSQ, or the FFI and consider using the computer-adaptive version of the LEFS after interventions intended to alleviate the physical impairments, activity limitations, and participation restrictions associated with heel pain/plantar fasciitis. A Show 2 more Clinical findings Symptoms Triggers Difficulty walking Pain aggravated by weight- bearing Gait disturbance Pain relieved by rest Heel pain Pain worse in the morning Past medical history Pain worse with standing Achilles tendinopathy Social history Obesity Prolonged periods of standing Musculoskeletal exam Sports participation Calf tightness Imaging findings Heel tenderness Calcaneal spur Limping Perifascial edema Pes cavus plantar fascia thickness Pes planus ankle dorsiflexion windlass test References 1. Robroy L Martin, Todd E Davenport, Stephen F Reischl et al. Heel pain-plantar fasciitis: revision 2014. J Orthop Sports Phys Ther. 2014 Nov;44 11 A1 33. Open 2. Harry P Schneider, John M Baca, Brian B Carpenter et al. American College of Foot and Ankle Surgeons Clinical Consensus Statement: Diagnosis and Treatment of Adult Acquired Infracalcaneal Heel Pain. J Foot Ankle Surg. 2018 Mar-Apr;57 2 370 381. Open 3. Thomas Trojian, Alicia K Tucker. Plantar Fasciitis. Am Fam Physician. 2019 Jun 15;99 12 744 750. Open 4. Expert Panel on Musculoskeletal Imaging, Monica Tafur, Jenny T Bencardino et al. ACR Appropriateness Criteria Chronic Foot Pain. J Am Coll Radiol. 2020 Nov;17 11S S391 S402. Open 5. James D Goff, Robert Crawford. Diagnosis and treatment of plantar fasciitis. Am Fam Physician. 2011 Sep 15;84 6 676 82. Open 6. S Cutts, N Obi, C Pasapula et al. Plantar fasciitis. Ann R Coll Surg Engl. 2012 Nov;94 8 539 42. Open https://web.pathway.md/diseases/rec36CA2TVH0rnIJs 5/5