Chronic plantar fasciitis is a common condition but can be difficult to successfully treat. Platelet rich plasma (PRP), a concentrated bioactive component of autologous blood rich in cytokines and other growth factors, was compared with cortisone injection in the treatment of severe cases of plantar fasciitis resistant to traditional non-operative paradigms. Thirty-six patients (16 males 20 females) were prospectively randomized into two study groups. All patients had pre-treatment MRI and ultrasound studies consistent with plantar fasciitis. The first group was treated with a single ultrasound guided injection of 40 mg Depo-Medrol at the injury site and the second group was treated with a single ultrasound guided injection of un-buffered autologous PRP at the injury site. The cortisone group had an average age of 59 (24–74) and had failed 4 months (3–24) of standard non-operative management (rest, heel lifts, PT, NSAIDS, cam walker immobilization, night splinting, local modalities) and had pre-treatment AOFAS scores of 52 (24–60). The PRP group had an average age of 51 (21–67) and had failed 5 months (3–26) of standard non-operative management (rest, heel lifts, PT, NSAIDS, cam walker immobilization, night splinting, local modalities) and had pre-treatment AOFAS scores of 37 (30–56). All patients were then immobilized fully weight bearing in a cam walker for 2 weeks, started on eccentric home exercises and allowed to return to normal activities as tolerated and without brace support. Post-treatment AOFAS scores were PRP 95 (84–100) and cortisone 81(60–90) at 3 months (CI 95% p< .0001), PRP 95 (86–100) and cortisone 81 (60–90) at 6 months (CI 95% p< .0001), and PRP 94 (86–100) and cortisone 58 (45–77) at 12 months (CI 95% p< .0001). Platelet rich plasma injection is more effective and durable than cortisone injection for the treatment of severe chronic plantar fasciitis refractory to traditional non-operative management

Platelet rich plasma has been advocated for the treatment of plantar fasciitis but there are few good quality clinical trials to support its use. We report a pilot double blind randomised controlled trial of platelet rich plasma versus normal saline. Methods. Patients with more than 6 months of MRI proven plantar fasciitis who had failed conservative management were invited to participate in this study. Patients were block randomised to either platelet rich plasma injection (intervention) or equivalent volume of normal saline (control). The techniques used for the injection and rehabilitation were standardised for both groups. The patient and independent assessor were blinded. Visual analogue scale for pain (VAS) and painDETECT were recorded pre-op and at 6 months. Results. Twenty-eight patients (19 females, mean age 50 years) were recruited, with 14 randomised to each arm. At 6 month follow-up, 8 patients (28.6%) were lost to follow-up. There was a significant change in VAS score from baseline to follow-up in both intervention (mean change 37.2, p = 0.008) and control (mean change 42.2, p = 0.003) groups. However there was no difference between the arms in terms of the change in VAS score from baseline to follow-up (p = 0.183). There was no correlation between pre-op PainDETECT score and change in VAS. Conclusion. This pilot study has failed to show a significant benefit of platelet rich plasma compared to saline injection, although both treatments have shown a significant improvement in symptoms. This may be due to the needling effect of injections. A larger study is required to demonstrate a meaningful change. Loss to follow in this patient group should be considered

We report five patients with nutritional osteomalacia who presented with the symptoms and signs of plantar fasciitis. All the patients were Asian vegetarian women. All improved with treatment of the osteomalacia, albeit slowly in two cases

The October 2023 Sports Roundup. 360. looks at: Extensor mechanism disruption in the treatment of dislocated and multiligament knee injuries; Treatment of knee osteoarthritis with injection of stem cells; Corticosteroid injection plus exercise or exercise alone as adjuvants for patients with plantar fasciitis?; Generalized joint hypermobility and a second ACL injury?; The VISA-A ((sedentary) questionnaire for Achilles tendinopathy?

The February 2023 Research Roundup. 360. looks at: Clinical and epidemiological features of scaphoid fracture nonunion; Routine sterile glove and instrument change at the time of abdominal wound closure to prevent surgical site infection (ChEETAh); Characterization of genetic risk of end-stage knee osteoarthritis treated with total knee arthroplasty; Platelet-rich plasma or autologous blood injection for plantar fasciitis; Volume and outcomes of joint arthroplasty; The hazards of absolute belief in the p-value laid bare

The August 2024 Foot & Ankle Roundup. 360. looks at: ESWT versus surgery for fifth metatarsal stress fractures; Minimally invasive surgery versus open fusion for hallux rigidus; Diabetes and infection risk in total ankle arthroplasty; Is proximal medial gastrocnemius recession useful for managing chronic plantar fasciitis?; Fuse the great toe in the young!; Conservative surgery for diabetic foot osteomyelitis; Mental health and outcome following foot and ankle surgery

The April 2023 Foot & Ankle Roundup. 360. looks at: Outcomes following a two-stage revision total ankle arthroplasty for periprosthetic joint infection; Temporary bridge plate fixation and joint motion after an unstable Lisfranc injury; Outcomes of fusion in type II os naviculare; Total ankle arthroplasty versus arthrodesis for end-stage ankle osteoarthritis; Normal saline for plantar fasciitis: placebo or therapeutic?; Distraction arthroplasty for ankle osteoarthritis: does it work?; Let there be movement: ankle arthroplasty after previous fusion; Morbidity and mortality after diabetic Charcot foot arthropathy

Surgical treatment is considered for treatment of plantar fasciitis in the 10% of patients who do not improve with large range of non-operative measures. The aim of this study is to describe a surgical technique that maintains normal foot mechanics by preserving the integrity of plantar fascia and to demonstrate its effectiveness in the treatment of severe plantar fasciitis unresponsive to no-operative treatment. The study is a retrospective-prospective analysis of patients who underwent surgery for plantar fasciitis unresponsive to at least 6 month of non-operative measures. The surgical technique involves excision of the heel spur if present, drilling of the calcaneus and a split of the plantar fascia in line with its fibres taking great care not to detach it from its calcaneal attachment. The clinical outcome was assessed prospectively using the Foot and Ankle Ability Measure which is a self-reported questionnaire used to assess the effectiveness of treatment in ankle and foot disorders. Between 1993 and 2007, 52 patients (56 feet) had surgery for plantar fasciitis. There were 35 females and 17 males and the average age at surgery was 51. Retrospective data was available on all patients. No patients had prior surgery for their symptoms. Of 52 patients treated, 34 were able to be contacted at an average of 46 months after surgery. The average FAAM score was 93 (maximum of 100, 95%CI, 89, 97) and 80% of patients reported a normal or nearly normal overall level of function with no reports of a severely abnormal level of function. Two patients reported no change in symptoms after the surgery. All other patients reported they were satisfied with the outcome of surgery. No patient reported recurrence of symptoms or further surgery for plantar fasciitis. The early postoperative complications were superficial cellulitis (2 patients), wound breakdown (3 patients) and deep vein thrombosis (1 patient). The only long term complication was hypoaesthesia around the surgical scar (8 patients) with no adverse impact on the final outcome. Plantar fascia release or division has been associated with altered foot biomechanics which may be responsible for forefoot fractures and medial and lateral column foot pain sometimes described after this procedure. Our surgical technique avoids these problems by preserving the integrity of plantar fascia and at the same time is very effective in relieving the symptoms of chronic and severe plantar fasciitis

Background: Non-operative treatment for plantar fasciitis varies widely and includes the use of night ankle-foot orthoses (AFO’s). Some studies have shown that this is more effective in the initial management of plantar fasciitis than anti-inflammatory therapy. During sleep the foot and ankle tend to assume a plantarflexed position, which results in tightness of the calf muscle group, accounting for the stiffness and pain experienced by patients as they take their first weight bearing steps in the morning. However, when the foot and ankle are kept in a dorsiflexed stretched position at night, stress relaxation occurs and the plantar fascia relaxes. Aim: Compliance with night AFO’s that dorsiflex the foot/ankle has always been a problem. This study compares the effectiveness of a posterior AFO, which dorsiflexes the foot, with an anterior AFO, which maintains the foot in plantigrade, asking whether it is absolutely necessary to dorsiflex the foot and ankle during the night to avoid early morning pain and stiffness, or whether it is it sufficient just to maintain the foot in plantigrade. Methods: 18 participants were recruited on a voluntary basis and at random from among those patients referred to the Orthotics department with plantar fasciitis to be provided with a night orthosis. The inclusion criterion was that the diagnosis was purely plantar fasciitis with no secondary diagnosis, symptoms or complications. Each participant was given a questionnaire to fill in; this evaluated how satisfied the participants were with the orthosis with regards to comfort, ease of use and appearance, and whether the pain in the foot was reduced and at what stage was it reduced. The two types of AFO’s used in this study were:. A posterior AFO that holds the foot in dorsiflexion. The amount of dorsiflexion could be adjusted. An anterior AFO that keeps the ankle and foot in plantigrade, with no adjustment to the amount of dorsiflexion. Results: 67% of the participants confirmed that morning pain and stiffness was less after wearing the AFO; this included 78% of those that wore the anterior AFO and 56% of those that used the posterior orthosis. 56% of all participants reported that the orthoses were uncomfortable and disrupted sleep. The most uncomfortable was the posterior AFO (89%), as opposed to the anterior one (22%). Both types of orthoses were reported to be relatively easy to don and doff (89% anterior AFO and 78% posterior AFO). On a scale of 1 to 10, the participants were asked to grade the pain before starting the orthosis treatment regime, after 6 weeks of wearing the AFO and again 6 weeks later. On average, the anterior AFO reduced the pain from 7 to 2.1, while the posterior orthosis only reduced the pain from 8.1 to 6.7. Conclusion: In general, plantar fasciitis night AFO’s are poorly tolerated orthoses, however, their use can be justified in that the pain levels are reduced. The anterior AFO seems to be more effective in achieving this, without dorsiflexing the foot/ankle beyond plantigrade. Thus, one could argue that there is no need to dorsiflex to achieve the goal. However, further investigation is necessary with a larger patient cohort

Abstract: Plantar fasciitis is the most common cause of heel pain for which medical care is sought. It is associated with significant morbidity placing activity limitations on the patients. The response of plantar fasciitis to any treatment is unpredictable. Many different modalities of treatment are used in its management. Injection of plantar fascia with local anaesthetic and steroids under general anaesthesia was carried out in 50 patients who had a clinical diagnosis of plantar fasciitis of greater than 3 month duration. Following induction of general anesthesia, a 20-gauge needle was guided toward and into the plantar fascia. 5mls of local anaesthetic and steroid was injected into the proximal plantar fascia. The patients were followed up over a mean of 6 months. Pain intensity was graded on an 11-point visual analog scale (VAS). Questionnaires with the VAS were filled out after treatment to determine the effectiveness of the procedure. The mean pain score decreased by 5.4 points. There were no complications during or after the procedure. Patients were questioned in relation to their occupational, athletic and recreational activities pre and post the injection. Injection of the plantar fascia under general anaesthesia is a safe and effective method for the relief of conservatively unmanageable heel pain due to plantar fasciitis. A larger patient population and a greater than 1 year follow up would be helpful to determine the long term benefits & outcomes of this treatment

Introduction. Whilst most cases of plantar fasciitis can be resolved with existing conservative established treatment options, a few intractable cases can be difficult to resolve. New biologic treatments have been proposed for a variety of soft tissue tendon problems. We evaluated the results of PRP in the treatment of recalcitrant chronic cases of plantar fasciitis. Methods. Patients with plantar fasciitis that had not responded to a minimum of 8 months standard conservative management (eccentric stretching, physiotherapy, cortisone injection, night splints) were offered PRP therapy. The injection into the tender spot at the proximal plantar fascial insertion was performed in theatre as a day case. Roles Maudsley (RM) scores, Visual analogue scores (VAS) for pain, AOFAS scores and ‘would have injection again’ were collated pre-operatively, at three and six months. Results. Prospective data was collected on 39 patients (44 heels – 15 males, 24 females; mean age 51 years, range 25–79 years). No complications were noted. At six months review RM score improved from 3.8 to 2.5 (p<0.001), VAS improved from 7.7 to 4.2 (p<0.001) and AOFAS improved from 61 to 82 (p<0.001). 21 patients had complete relief of symptoms on 3 months review. 25 patients were very satisfied with the clinical improvement and would have the injection again. Whilst there was a slight improvement in scores from 3 to 6 months, this was not significant. 3 patients with bilateral injections on the same sitting did not improve, though 2 patients with bilateral injections on separate sittings did improve. Conclusion. In this series of chronic intractable cases, PRP injection produced a 64% satisfaction rate from patients. The procedure was safe with no reported complications. The authors feel PRP for plantar fasciitis may have some role in treatment and merits further study with a prospective randomised trial

Introduction and Aims: The purpose of this study was to determine if celecoxib would improve the conservative treatment of plantar fasciitis. Method: Twenty-nine patients with plantar fasciitis were given a night splint, viscoelastic heel cups and a home heel cord stretching program. Thirteen of the patients were given celecoxib 200mg a day for one month and 16 were given a placebo for one month. After their initial visit, patients were followed at one, two and six months. Results: Twenty-eight patients improved, and one patient’s symptoms were subjectively worse at the end of the six months. Pain scores improved 5.79 points for the celecoxib group and 4.59 for the placebo group. Disability scores improved 5.03 points and 3.44 respectively. The celecoxib group had greater reductions in both pain and disability than the placebo group. Conclusion: Although, our study was limited by the small sample size, our results indicate that plantar fasciitis can be treated effectively by non-surgical methods and that the use of an anti-inflammatory early in the course of plantar fasciitis may have some beneficial effects in improvement of symptoms

Chronic plantar fasciitis is a common but sometimes difficult condition to successfully treat. Platelet rich plasma (PRP), a concentrated bioactive component of autologous blood that is rich in cytokines and other growth factors, was compared with cortisone injection in the treatment of severe cases of plantar fasciitis resistant to traditional non-operative paradigms. Thirty-six patients (16 males 20 females) were prospectively block-randomized into two study groups. All patients had pre-treatment MRI and ultrasound studies consistent with plantar fasciitis. The first group was treated with a single ultrasound guided injection of 40 mg Depo-Medrol at the injury site and the second group was treated with a single ultrasound guided injection of un-buffered autologous PRP at the injury site. The cortisone group had an average age of 59 (24–74) and had failed 4 months (3–24) of standard non-operative management (rest, heel lifts, PT, NSAIDS, cam walker immobilization, night splinting, local modalities) and had pre-treatment AOFAS scores of 52 (24–60). The PRP group had an average age of 51 (21–67) and had failed 5 months (3–26) of standard non-operative management (rest, heel lifts, PT, NSAIDS, cam walker immobilization, night splinting, local modalities) and had pre-treatment AOFAS scores of 37 (30–56). All patients were then immobilized fully weight bearing in a cam walker for 2 weeks, started on eccentric home exercises and then allowed to return to normal activities as tolerated and without support. Post-treatment AOFAS scores in the cortisone initially improved to 81(60–90) at 3 months but decreased to 74 (56–85) at 6 months. Post-treatment AOFAS scores in the PRP group improved to 95 (84–90) at 3 months and remained excellent at 94 (87–100) at 6 months follow-up. This study suggests that platelet rich plasma injection is more effective and durable than cortisone injection for the treatment of severe chronic plantar fasciitis refractory to traditional non-operative management

Background. Previous studies have individually shown extracorporeal shockwave therapy (ESWT) to be beneficial for mid-substance Achilles tendinopathy, insertional Achilles tendinopathy or plantar fasciitis. The purpose of this pragmatic study was to determine the efficacy of ESWT in managing the three main causes of refractory heel pain in our routine clinical practice. Methods. 236 patients (261 feet) aged between 25 – 81 years (mean age 50.4) were treated in our NHS institute with ESWT between April 2014 and May 2016. They all underwent a clinical and radiological assessment (ultrasonography +/− magnetic resonance imaging) to determine the primary cause of heel pain. Patients were subsequently categorized into three groups, mid-substance Achilles tendinopathy (55 cases), insertional Achilles tendinopathy (55 cases) or plantar fasciitis (151 cases). If their symptoms were recalcitrant to compliant first line management for 6 months, they were prescribed three consecutive ESWT sessions at weekly intervals. All outcome measures (foot & ankle pain score, EQ-5D) were recorded at baseline and 3-month follow-up (mean 18.3 weeks, range 11.4 to 41). Results. Complete data sets were obtained for 41% of the ESWT treatments (107/261). EQ-5D scores showed a statistically significant improvement between baseline and follow-up in all three-treatment groups; mid-substance Achilles tendinopathy 0.681 to 0.734, insertional Achilles tendinopathy 0.687 to 0.742 and plantar fasciitis 0.684 to 0.731 (p< 0.05). The foot & ankle pain scores grouped for all causes of heel pain also showed a statistically significant reduction from 6.78 at baseline to 5.36 at follow-up (p< 0.05). Conclusion. Overall our results showed that ESWT is an effective tool for the management of all refractory heel pain in an NHS foot & ankle clinical practice

Background. Plantar fasciitis is a frequently chronic and disabling cause of foot pain in adults. This prospective study aims to evaluate the analgesic effect of ultrasound guided dry needling in patients with chronic plantar fasciitis, refractory to conservative treatment. Method and Materials. Patients undergoing dry needling for plantar fasciitis, followed by perifascial injection between Jan ′09 and Feb ′10 were identified. Pain scores were recorded on a visual analogue scale from 0 (no pain) to 10 (worst pain possible) before the procedure, 2 weeks and 6 weeks post procedure. Patients were also contacted in April to assess their current pain level. Responses were graded as excellent (> 75% pain score improvement), good (50-74%), fair (25-49%) and poor (<25% relief). Any complications or need for any further intervention were recorded. Results. 55 feet (46 patients) were identified. All patients had had no relief with previous treatment. 24 feet who had calf tightness had undergone a gastrocnemius muscle lengthening. All patients had radiological confirmation of diagnosis prior to undergoing the procedure. At 2 weeks: 1 foot lost to follow-up. 43/54 feet had excellent or good pain relief. At 6 weeks: 5 feet (4 patients) were lost to follow up. 37 feet (28 patients) reported excellent or good pain relief. 11/13 feet patients with fair to poor response underwent a repeat procedure. Redo-Procedure. Using the same outcome measures, 8/11 and 9/11 feet had excellent or good response at 2 and 6 weeks respectively. Long-term follow-up:. 42 feet (34 patients) were contacted. 13 feet (12 patients) lost to follow-up. Follow-up duration from 2 to 13 months. Mean F/U = 7 months. 23 feet (5 redos) had excellent or good outcome 19 feet (6 redos) had fair or poor outcome. If symptoms reoccurred, average duration of total analgesic effect was 3 months. Conclusion. 80% and 74% of patients had excellent or good outcome at 2 and 6 weeks respectively. After an average of 7 months follow-up, 55% patients had excellent or good results. In those patients in whom symptoms recurred, the average duration of total analgesic effect was 3 months. We believe that ultrasound guided dry needling is an effective treatment method for plantar fasciitis

Background. We compared platelet rich plasma (PRP) injection to cortisone (40mg triamcinolone) injection in the treatment of chronic plantar fasciitis resistant to traditional nonoperative management. The aims were to compare early and long term efficacy of PRP to that of Steroid (3, 6 and 12 months after injection). Methods. 60 heels with intractable plantar fasciitis with failed conservative treatment were randomized to either PRP or Steroid injection. All patients were assessed with Roles-Maudsley (RM) Score, Visual Analogue Score (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Data was collected prospectively on the cohort, pre-treatment, at 3, 6 and 12 months post injection. The mean scores of the two groups were compared using Student t test. Results. Pre-injection, the two groups were well matched with no statistically significant difference in the values. At 3 months, all three outcome scores in both groups had significantly improved from their pretreatment level with no significant difference between the groups (PRP: RM 3.7 to 2.0, VAS 8.3 to 3.5, AOFAS 58 to 84; Steroid: RM 3.6 to 1.9, VAS 8.3 to 2.8, AOFAS 57 to 86). At 6 months, improvement was maintained in both groups with no significant difference between groups (PRP: RM 2.1, VAS 3.7, AOFAS 89; Steroid: RM 2.2, VAS 3.3, and AOFAS 84). At 12 months, all outcome measures were significantly better for the PRP group as response in the steroid group had deteriorated (PRP: RM 1.9, VAS 3.3 and AOFAS 89; Steroid: RM 2.6, VAS 5.1 and AOFAS 77: p = 0.008, 0.02 and 0.002 respectively). Conclusions. PRP is better for the treatment of chronic plantar fasciitis as compared to steroid. It shows no statistical difference in effectiveness early on, but unlike steroid, its effectiveness does not wear off with time, making it more durable

Introduction Plantar fasciitis is a common presenting problem and there are multiple treatments available. There is little scientific data to assist in the selection of the most efficacious or cost-effective treatment. This study compared the efficacy of corticosteroid injection and low-dose ESWT for the treatment of chronic proximal plantar fasciitis. Methods One hundred and thirty-two cases of plantar fasciitis were enrolled into this prospective study over five years. Eligible patients performed a stretching program for the gastrocsoleus. In addition, patients randomized to group A received an intralesional corticosteroid injection, while group B received low dose ESWT (3 x 1000 pulses, energy flux density 0.08/mm2). Nineteen patients were not randomized and comprised a control group C. Patients were assessed before, and then three and 12 months post treatment using a VAS, and algometer (tenderness threshold, TT). The groups were compared using generalized linear models for repeated measures of VAS and TT scores, with orthogonal contrasts. Results The three groups were significantly different in their VAS scores post treatment. Over the 12 months, pain levels reduced for all groups, but the trends between them differed significantly. The corticosteroid (CSI) group, had significantly lower levels of pain than the ESWT or controls. At 12 months, the CSI and ESWT had similar levels of pain, both significantly lower than that in the controls. Similar trends were found for TT. Threshold levels increased for all three groups post treatment but the trends between the groups were significantly different. At three months, the CSI group had significantly higher TTs than both the ESWT and control groups. By 12 months, all groups had higher TTs but they were similar. The TT of the CSI group had plateaued by three months. Of the 64 heels that received CSI, there were no infections and no cases of rupture of the plantar fascia. There were eight cases of post-injection pain. All patients found the injection unpleasant. Of the 61 heels treated with ESWT, six reported throbbing pain and erythema. Four reported a severe headache. All patients found the procedure unpleasant. Conclusions Intralesional corticosteroid injection is more efficacious, and much more cost-effective, than ESWT, in the treatment of plantar fasciitis present for at least six weeks. The injection achieves a significant and lasting reduction in pain and tenderness within three months. Correctly used, this treatment has a low incidence of complications

Microtenotomy coblation using a radiofrequency (RF) probe is a minimally invasive procedure for treating chronic tendinopathy. It has been described for conditions including tennis elbow and rotator cuff tendinitis. There have been no studies to show the effectiveness of such a procedure for plantar fasciitis. Fourteen patients with plantar fasciitis with failed conservative treatment underwent. TOPAZ RF treatment for their symptoms between 2007 and 2008. The RF-based microdebridement was performed using the TOPAZ Microdebrider device (ArthroCare, Sunnyvale, CA). They were followed-up for up to six months thereafter. Pre-operative, three and six months post-operative VAS, AOFAS ankle-hindfoot and SF-36 scores were analysed. There were six men and eight women, with an average age of 44.0 years (23–57). There were 15 feet, with six right and nine left feet. They were followed up for six months post-operatively. There was a significant improvement in mean pre-op and six-month VAS scores from 8.13 to 3.27(p=0.00), and AOFAS hindfoot scores from 34.37 to 71.33 (p=0.00). There was a significant decrease in SF-36 for bodily pain, and significant increases in physical and social function scores. Twelve out of 14 (85.7%) patients reported ‘good’ to ‘excellent’ satisfaction results at six months, and 11 out of 14 (78.6%) patients had their expectations met from the procedure at six months follow-up. TOPAZ RF coblation is a good and effective method for the treatment of plantar fasciitis. Early results are encouraging, and we believe that the pain experienced by the patients in the follow-ups will subsequently improve

The October 2013 Foot & Ankle Roundup. 360 . looks at: Operative treatment of calcaneal fractures advantageous in the long term?; Varus ankles and arthroplasty; Reducing autograft complications in foot and ankle surgery; The biomechanics of ECP in plantar fasciitis; Minimally invasive first ray surgery; Alcohol: better drunk than injected?; Is it different in the foot?; It’s all about the temperature

Heel pain is very prevalent. Pain, especially after a period of rest, is the main symptom. Reduced ability to walk long distances and inability to participate in exercise and sport are other complaints. Plantar heel pain is most commonly caused by plantar fasciitis. Whilst only the recalcitrant cases reach secondary care, this can still be a significant workload. In the Royal Surrey County Hospital, Guildford, we see approximately 200 cases of recalcitrant heel pain each year. The vast majority of cases never come to hospital and are managed in primary care (1500/yr in podiatry alone). Effective primary treatments should reduce the number of long-term sufferers. Recalcitrant cases of plantar fasciitis often have atypical symptoms. Radiological imaging is extremely useful in clarifying the diagnosis. Ultrasound is our preferred modality. There is a spectrum of pathology that affects the plantar fascia, and this is less well classified than for the achilles tendon, where the distinction between insertional tendinopathy and tendinopathy of the main body of the tendon is helpful in guiding treatment. The evidence for many forms of treatment for plantar fasciitis is weak. Currently, the use of formal calf stretching programs is widely considered to be the best first-line treatment. There are additional benefits with stretches to the fascia itself. The mechanism by which these stretches help is not well established. Calf contracture is, however, associated with a variety of clinical problems in the foot and ankle. This is especially true for isolated gastrocnemius contracture. There is also laboratory evidence that increased plantar fascia strain is seen with increased calf muscle tension. Surgery to release a gastrocnemius contracture improves biomechanics and has been used in refractory cases of heel pain with good effect. Radial extracorporeal shock wave lithotripsy is the latest version of this non-invasive treatment. Results in our centre are encouraging. For selected cases of atypical plantar fasciopathy injection treatments are effective