The Foot 33 (2017) 57–67

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The Foot
journal homepage: www.elsevier.com/locate/foot

The effectiveness of conservative, non-pharmacological treatment, of MARK

plantar heel pain: A systematic review with meta-analysis
⁎
Stefano Salviolia, , Maddalena Guidib, Giulia Marcotullic
a
Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal-Infantile Sciences, University of Genoa, Italy
b
Bologna, Italy
c
Fermo, Italy

A R T I C L E I N F O A B S T R A C T

Keywords: Plantar heel pain is one of the most common causes of pain and musculoskeletal pathologies of the foot. The aim
Plantar heel pain of this systematic review was to identify the most effective, conservative and non-pharmacological treatments
Plantar fasciitis regarding pain in patients with plantar heel pain.
Conservative treatment The authors searched 5 databases and included only randomized control trials which investigated the efficacy
of a conservative non-pharmacological treatment compared to the placebo, for the outcome of pain.
Study selection, data collection and risk of bias assessment were conducted independently by two authors,
and consensus was reached with a third author. Results were quantitatively summarized in meta-analyses, by
separating homogeneous subgroups of trials by type of intervention.
A total of 20 studies that investigated the efficacy of 9 different types of interventions were included, with a
total of 4 meta-analyses carried out. The interventions: shock waves, laser therapy, orthoses, pulsed radio-
frequency, dry-needling, and calcaneal taping resulted in being effective treatments for the outcome pain in
patients with plantar heel pain when compared to the placebo. However, considering that the improvements
were very small, and the quality of evidence was mostly low or moderate for many of the interventions, it was
not possible to give definitive conclusions for clinical practice.

1. Introduction 2. Methods

Plantar heel pain is one of the most common causes of pain and
musculoskeletal pathologies of the foot [1,2]. The latest trials confirm
that it affects 2 million American people, and that 10% of the American
population has experienced plantar heel pain at least once in their
lifetime [2]. The most commonly reported presentation is plantar heel
pain, it can be intense and may radiate into and involve the entire
plantar fascia. Up to 80% (that is 4/5 cases) of plantar heel pain resolve
over the course of 12 months from the onset without any therapeutic
intervention. There is a reported 90% resolution of heel pain (that is 9/
10 cases) in those cases that undergo conservative treatments (non-
surgical) [3], which include: articular mobilization [4], stretching [5],
orthotic therapy [6], shock wave therapy [7], and laser therapy [8].
However there is a lack of overall evidence of the true effectiveness of
these interventions. This omission is addressed by this systematic re-
view and meta-analysis.
2.1. Registration
The review protocol was registered on the International
Register of Systematic Reviews (PROSPERO) on 09/03/2017 code
CRD42017058233, available here https://www.crd.york.ac.uk/
PROSPERO/display_record.asp?ID=CRD42017058233.
2.2. Inclusion criteria
Population: Studies of adults (> 18 years) with a clinical or in-
strumental (ultrasound or magnetic resonance) diagnosis of plantar
heel pain or plantar fasciitis, who were symptomatic at the time of
enrolment.
Treatments: Studies that considered conservative, non-pharmaco-
logical treatments, compared to a placebo, no treatment or sham
treatment.
Outcome: Studies that reported pain intensity, assessed by numer-
ical or visual analogue scales.

⁎
Corresponding author at: Via Rubicone 6, Finale Emilia, Modena, 41034, Italy.
E-mail addresses: stefano.salvioli@gmail.com (S. Salvioli), maddalena.guidi@student.unife.it (M. Guidi), giulia.marcotulli@student.unife.it (G. Marcotulli).

http://dx.doi.org/10.1016/j.foot.2017.05.004
Received 10 April 2017; Received in revised form 9 May 2017; Accepted 12 May 2017
0958-2592/ © 2017 Elsevier Ltd. All rights reserved.
S. Salvioli et al.
Study characteristics: Published randomized controlled trials (RCT)
in English language, as the major journals available in medical data-
bases are published in English.
2.3. Exclusion criteria
Population: Studies that reported patients with fascial plantar fi-
bromatosis, tarsal tunnel syndrome, lesion of plantar nerve, Morton's
syndrome, fracture, tumor, osteoarthritis, diabetic pathologies e.g. ul-
cers, rheumatic pathologies, neurological pathologies, acute or chronic
infections.
Treatments: Studies that considered pharmacological treatments
and surgery.
Outcome: Studies that reported outcome data required for the meta-
analysis (i.e. mean difference and standard deviation) not available.
Study characteristics: Studies with abstract not available.
2.4. Search strategy and study selection
Two authors searched the following databases: Medline, PEDro,
Cochrane Central Register of Controlled Trials, Cinahl, and Embase.
The last search was made on 10th March, 2017. Search terms used
were: plantar fasciitis, heel spur, heel pain, physical therapy modalities,
acupuncture therapy, cryotherapy, laser therapy, placebos, diathermy,
orthotic devices, extracorporeal shock wave therapy, and dry needling
(Appendix A).
Further research was conducted by consulting the bibliographies of
the included trials, other systematic reviews, protocol databases of RCT,
and groups of interest. The study selection was carried out in-
dependently by the same two authors and consensus was reached with
the third author, in a two-phase screening process: firstly by reading the
title and abstract, and secondly by reading the full text by all parties.
2.5. Risk of bias of included studies
The risk of bias was assessed with the Cochrane’s Risk of Bias Tool
[9], specifically within the following domains: sequence generation,
allocation concealment, blinding of participants, personnel and out-
come assessors, incomplete outcome data, selective outcome reporting,
and other sources of bias.
The same two authors independently conducted the assessment, and
if consensus was not met, disagreements were resolved by the third
author so that every Risk of Bias judgement was given on the basis of a
minimum of a 2/3 consensus.
2.6. Data extraction, primary outcome and synthesis of results
Data extraction was conducted by using a pre-piloted form, in which
the following elements were collected: study design, country of the
study, condition, treatment type and characteristics, control, outcome
measure, follow-up considered in meta-analysis, sample size, number of
drop-outs, and study results.
Data extraction was conducted independently by the two authors,
and disagreements were resolved with the third author. The primary
outcome considered in this review was pain intensity, assessed with
numerical and visual-analogue scales, and considered the mean differ-
ence and standard deviation as a statistical index.
Results were reported quantitatively in the meta-analyses, using the
variance inverse method with the fixed effect in case of absence of
heterogeneity, and with the random effect in case of presence of het-
erogeneity, collecting the included studies in homogeneous subgroups
of the same intervention. For the estimate effect, the mean difference
was used when the meta-analysis included outcome measure scales that
were the same and the standardized mean difference was used when the
measure scales were different. Heterogeneity was assessed using the I2
and chi-squared test (X2, Chi2), where P-value lower than 0.05 indicates
58
The Foot 33 (2017) 57–67
significant heterogeneity. Meta-analyses were conducted using Review
Manager Software (RevMan, version 5.3.5 for Windows). The results
were interpreted with the help of some experienced physiotherapists,
with at least 10 years of clinical experience, and academics in field of
rehabilitation of musculoskeletal disorders. These were not considered
as co-authors as they did not participated actively and significantly at
the research, but only gave recommendations for results interpretation.
Quality of evidence was assessed using the GRADE approach, as
reported in the Cochrane Handbook for Systematic Reviews of
Interventions, by four grading levels from High to Very Low [9]. The
grading was given on the basis of the methodological quality of the
single studies, statistical heterogeneity, directness, precision of the es-
timate effect, and the presence of publication bias.
3. Results
3.1. Study selection
537 articles were screened for eligibility. After the removal of the
duplicate trials, only 244 remained. 133 were excluded after screening
by title and abstract, 13 because the abstract was not available, 1 did
not report the authors, 68 did not concern plantar heel pain, 9 were not
in English, and 6 were not RCT. Of the remaining 111 studies, 23 were
excluded as the full text was not available in the databases and the
paper’s authors did not give any answer when asked for the full texts, 4
were not randomized, 16 used pharmacological treatments, 4 did not
meet inclusion criteria, 3 did not include outcomes of interest, and 41
did not report the necessary data for meta-analysis. Ultimately, 20 ar-
ticles were determined to have met all inclusion criteria and were eli-
gible to be included in the review; 16 of these could be included in the
meta-analysis. 4 studies were not suitable to be included in the meta-
analysis as each one of them considered a different type of intervention
(Fig. 1).
3.2. Study characteristics
The sample size in each study ranged from a minimum of 10 par-
ticipants to a maximum of 285 [10,11], giving an aggregate total of
6656 participants, which included the totality of treated and not-
treated subjects. Every study compared an active intervention with a
sham or no-intervention. The eligibility criteria used in the majority of
the studies are summarized in Table 1. The interventions analyzed in
the included studies were: shock waves [11–20], laser therapy [8,21],
orthoses [6,22], stretching [10,23], ultrasound-guided pulsed radio-
frequency (USGPRF) [24], pulsed radiofrequency electromagnetic fields
(PRFE) [25], dry-needling [26], low-dye taping [27], and calcaneal
taping [10]. All of these interventions were compared to the placebo.
Data collected from the studies are reported in Tables 2 and 3, orga-
nized firstly by the type of intervention and secondly by author in al-
phabetical order (Tables 2 & 3).
3.3. Risk of bias among studies
All of the included studies confirmed randomization, despite one
not reporting the mode used [14]. 10 studies did not report information
regarding concealed allocation [8,10–12,14,16,18–20,22,24], leading
to a moderate risk of selection bias. There is a high risk of performance
bias because 7 of these studies did not have blinding of personnel and 3
did not report it [6,10,14,18–20,22,23,26,27], and 1 did not report
blinding of participants [17]. Since the outcome of interest of the re-
view (pain intensity) was assessed by a subjective scale, blinding of
patients corresponded to blinding of outcome assessment, with only one
study not reporting information about assessor blinding [17]. There is a
high risk of attrition bias between the studies, as 7 studies reported a
high number of drop-outs, and 3 did not declare them
[8,12–15,17–19,21,24]. Finally, there is high presence of other bias, as
S. Salvioli et al.
Table 1
Eligibility criteria in included studies.
Most common eligibility criteria in included studies
•Age (> 18ofyears);
• Diagnosis plantar fasciitis;
• Plantar or calcaneal pain.
five studies used small block randomization [6,11–13,19], three re-
ported treatment interruption due to severe adverse events [18,23,27],
one had a performance bias only at 3 months [15] and one had a sig-
nificative differences between groups at baseline [16] (Fig. 2 and
Appendix B).
3.4. Synthesis of results
3.4.1. Extracorporeal shock wave therapy (ESWT)
Ten studies used shock waves as intervention for a total of 1114
participants [11–20]. The global results of the meta-analysis was sta-
tistically significant in favour of the intervention group (SMD −0.26
[−0.38; −0.14]). I2 showed no heterogeneity (I2 = 15%) (Fig. 3).
Quality of evidence for this intervention was low, since there was a
moderate risk of selection bias, performance bias and publication bias.
One study used radial shock waves [13], one study used focal waves
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Fig. 1. Identification and selection of studies.
[14], one study used radial and focal waves [20], and the other 7 stu-
dies did not define the type of wave used [11,12,15–19]. The number of
impulses supplied in every session ranged from a minimum of 1500 to a
maximum of 4000 and the energy ranged from 0.08 mJ/mm2 to
0.64 mJ/mm2 every impulse. Studies involved 1 to 3 sessions, with
3 days to 2 weeks rest after every session. Information about adverse
effects were reported in 7 studies [11–13,15,17–19], with an absence in
the remaining 3 studies [14,16,20]. Adverse effects included: pain
during treatment, edema, skin redness, temporary paresthesia, and one
case of syncope for pain.
3.4.2. Laser therapy
Two studies analyzed laser therapy as an intervention with a total of
94 participants [8,21]. The meta-analysis showed a significant differ-
ence in favour of the intervention group in the VAS scale for pain in-
tensity (MD −23.52 [−33.60; −13.43]). I2 showed no heterogeneity
(I2 = 0%) (Fig. 4). This intervention resulted in moderate quality evi-
dence, as there is a moderate risk of selection and attrition bias.
One study used laser therapy with gallium-arsenide technology
which was carried out over a 6 week period, within 18 sessions, for a
duration of 147 s sessions [21]. Another study used a diode laser
technology which was carried out over 3 weeks, within 6 sessions, for a
duration of 10 min sessions [8]. Both were defined as low level laser
therapy. Neither of them showed adverse effects.
 S. Salvioli et al.

Table 2
Study characteristics of shock waves and laser therapy studies. ESWT: extracorporeal shock wave therapy. VAS: visual analogic scale. NRS: numerical rating scale. SD: standard deviation. I: intervention group. C: control group.

Author, year Study Country Condition Intervention group Control Outcome measure (considered Sample size (drop- Results Mean ± SD (P value)
design group follow-up) outs)

Buchbinder et al. [12] RCT Australia Subacute plantar ESWT 2000-2500 impulses, 0,33mJ/mm2. 3 sessions in 3 Placebo VAS 0–100 mm (3 months) 166 (6) I: −26.3 ± 34.8
heel pain weeks C: −25 ± 34.9 (0.8138)
Gerdesmeyer et al. [13] RCT Germany Chronic plantar heel ESWT 2000 radial impulses, 0,16 mJ/mm2. 3 sessions in 6 Placebo NRS 0–10 (3 months) 252 (9) I: −5.6 ± 3.93
pain weeks C: −4.41 ± 4.18 (0.022)
Haake et al. [11] RCT Germany Chronic plantar heel ESWT, 4000 impulses, 0,08 mJ/mm2. With anaesthesia. 3 Placebo NRS 0–10 (3 months) 272 (16) I: −3.8 ± 4
pain sessions in 6 weeks C: −3.2 ± 4.1 (0.2371)
Hawamdeh and Nassar RCT Jordan Chronic plantar heel ESWT 2000 focused impulses, 0,25 mJ/mm2. Ice pre e Placebo NRS 0–10 (3 weeks) 34 (10) I: −1.53 ± 3.1
[14] pain post ESWT. 3 sessions in 3 weeks C: −0.48 ± 3.26 (0.4274)
Kudo et al. [15] RCT Canada Chronic plantar heel ESWT 3500 impulses, 0,64 mJ/mm2. With anaesthesia. 1 Placebo NRS 0–10 (3 months) 114 (9) I: −3.6 ± 3.53

60
pain session C: −2.6 ± 3.09 (0.1258)
Marks et al. [16] RCT Poland Chronic plantar heel ESWT 2000 impulses, 0,16 mJ/mm2. 3 sessions in 9 days Placebo VAS 0–100 mm (6 months) 25 (0) I: −28.25 ± 26.06
pain C: −1.78 ± 44.42 (0.0714)
Rompe et al. [17] RCT Germany Chronic plantar heel ESWT 2100 impulses, 0,16 mJ/mm2. 3 sessions Placebo NRS 0–1 (6 months) 45 (6) I: −4.8 ± 2.39
pain C: −2.3 ± 2.3 (0.0020)
2
Speed et al. [18] RCT UK Chronic plantar heel ESWT, 1500 impulses, 0,12 mJ/mm . 3 sessions in 3 Placebo VAS 0–100 mm (3 months) 88 (12) I: −32.2 ± 34.06
pain months C: −22.9 ± 37.37 (0.2540)
Theodore et al. [19] RCT USA Chronic plantar heel ESWT, 3800 impulses, 0,36 mJ/mm2. With anaesthesia. 1 Placebo NRS 0–10 (baseline,3 months 150 (4) I: −4.4 ± 2.8
pain session C: −3.6 ± 3.1 (0.149)
Vahdatpour et al. [20] RCT Iran Chronic plantar heel ESWT, 2000 focused impulses and 2000 radial impulses, 0, Placebo NRS 0–10 (3 months 40 (0) I: −4.2 ± 2.9
pain 2 mJ/mm2. 3 sessions in 3 weeks C: −2.7 ± 1.8 (0.0567)
Kiritsi et al. [21] RCT Greece Subacute plantar Low level laser therapy (gallium-arsenide). A total of 680, Placebo VAS 0–100 mm (6 weeks) 30 (5) I: −39 ± 25.68
heel pain 4 J in 157 s. 18 sessions in 6 weeks C: −17 ± 18.42 (0.0288)
Macias et al. [8] RCT USA Plantar heel pain Low level laser therapy (diode laser). 10 min. 6 sessions in Placebo VAS 0–100 mm(3 weeks) 69 (0) I: −29.6 ± 30.65
3 weeks C: −5.3 ± 21.69 (0.0004)
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Table 3
Study characteristics of orthoses, stretching, pulsed radiofrequency, pulsed radiofrequency electromagnetic field, dry-needling, low-dye taping, and calcaneal taping studies. USGPRF:
ultrasound-guided pulsed radiofrequency. PRFE: pulsed radiofrequency electromagnetic fields. FHSQ: foot health status questionnaire. VAS: visual analogic scale. NRS: numerical rating
scale. SD: standard deviation. I: intervention group. C: control group.

Author, year Study Country Condition Intervention group Control Outcome measure Sample size Results Mean ± SD (P value)
design group (considered follow- (drop-outs)
up)

Landorf RCT Australia Subacute Prefabricated orthosis Placebo FHSQ (3 months) 136 (5) I: 29.3 ± 27.7
et al. plantar heel C: 18.3 ± 22.5 (0.044)
[22] pain Customized orthosis I: 23.4 ± 26.9
C: 18.3 ± 22.5 (0.3352)
Oliveira RCT Brazil Plantar heel Ethylene vinyl acetate – total contact Placebo FHSQ (3 months) 74 (4) I: 27.63 ± 34.77
et al. [6] pain insoles C: 25.69 ± 36.12 (0.8196)
Hyland et al. RCT USA Plantar heel Passive calf and plantar fascia Placebo NRS 1–10 (1 week) 20 (0) I.: −1.7 ± 1.06
[10] pain stretching, 30 s for 3 times. 2 sessions in C: −0.4 ± 1.5 (0.04)
4 days
Radford RCT Australia Plantar heel Calf stretching in standing on a wooden Placebo VAS 0–100 mm (1 92 (0) I: −19.8 ± 26
et al. pain stretching wedge, at least 5 min a day week) C: −13.2 ± 25.2 (0.2196)
[23] for 14 days
Ye et al. RCT China Subacute USGPRF at 42° for 5 min with a needle in Placebo VAS 0–100 mm (3 100 (5) I: −34.1 ± 38.61
[24] plantar heel the medial gastrocnemius trigger-points. months) C: −11 ± 34.85 (0.0022)
pain With anaesthesia
Brook et al. RCT USA Plantar heel PRFE with an antenna worn nightly on Placebo VAS 0–100 mm 70 (0) I: −1.74 ± 3.04
[25] pain the pain area for 7 days. (post treatment) C: 0.2 ± 3.45 (0.709)
Cotchett RCT Australia Subacute Trigger point dry needling of soleus, Placebo VAS 0–100 mm (3 84 (5) I: −46.8 ± 28.52
et al. plantar heel quadratus plantae, flexor digitorum months) C: −28.6 ± 30.38 (0.006)
[26] pain brevis, and abductor halluces muscles. 6
sessions in 6 weeks
Radford RCT Australia Subacute Low dye Taping that decrease stress on Placebo VAS 0–100 mm (1 92 (0) I: −30 ± 34.70
et al. plantar heel plantar fascia, with Leukotape, for 1 week) C: −18 ± 31.86 (0.0875)
[27] pain week
Hyland et al. RCT USA Plantar heel Calcaneal taping with Leukotape that Placebo NRS 1–10 (1week) 21 (0) I: −4.3 ± 2
[10] pain pull the calcaneus medially, to increase C: −0.4 ± 1.5 (0.0001)
the medial longitudinal arch height. For
4 days

Fig. 2. Risk of bias graph.

3.4.3. Orthoses
Two studies used orthoses as an intervention [6,22], with one of the
studies considering 3 types of orthoses: prefabricated insoles, custom
made insoles, and placebo orthoses [22]. The results of this study were
included twice in the meta-analysis, once in the prefabricated orthoses
vs placebo, and another in the custom made orthoses vs placebo. This
resulted in a total number of 144 participants included in the meta-
analysis. The final result of the meta-analysis showed a statistically
significant improvement in pain intensity in favour of the intervention
group in the VAS scale (MD −6.96 [−13.74; −0.18]). I2 showed no
heterogeneity (I2 = 0%) (Fig. 5). This intervention resulted in low
quality evidence, as there was a moderate risk of selection bias, per-
formance bias and attrition bias.
Landorf et al. used prefabricated orthoses in one group and custom
made orthoses in the other intervention group, which were both com-
pared to the placebo [22]. Prefabricated orthoses were Formthotic
(Foot Science International, Christchurch, New Zealand), used fol-
lowing the manufacturer’s. These devices were made of a rigid poly-
ethylene foam, thick enough to support the plantar arch and to avoid
flattening the orthoses. Whereas the custom-made orthoses were made
in an orthotic lab, plastering a patient foot with mesh, while the patient
was present and in a standing position with a neutral foot. A poly-
propylene cast was then modelled over the mesh, and a rigid foam fixed
under the heel. This device was designed to significantly support the
foot and condition its position in relation to the leg. Oliveira et al. used
a total contact insole (TCI) in ethylene vinyl acetate (EVA), whereby a

61
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Fig. 3. Forest plot of ESWT vs the Placebo. ESWT: extracorporeal shock wave therapy.
plaster mesh was placed on the plantar surface of the foot of the patient,
in prone position [6]. Neither of the studies reported information about
eventual adverse effects.
3.4.4. Stretching
Two studies used stretching as a treatment, with a total of 112
participants [10,23]. The meta-analysis showed non statistically sig-
nificant improvements in favour of the intervention group (SMD −0.37
[−0.74; 0.01]). I2 showed small heterogeneity (I2 = 45%), which was
not significant based on the chi-squared test (P = 0.18), which may be
due to the difference in sample sizes between the studies (Fig. 6). As a
result there was moderate quality of evidence for this intervention.
Radford et al. (2007), used calf-muscle stretching, standing on a in-
clined wooden plane for at least 5 min a day for 14 days [23]. Whereas
Hyland et al. (2006) used passive calf muscle stretching and plantar
fascia stretching, dorsiflexing the foot and the first toe in two 30 s
sessions over a 4 days period [10]. These two studies reported in-
formation regarding adverse effects, reporting that none had occurred.
3.4.5. Ultrasound Guided Pulsed Radiofrequency (USGPRF), Pulsed
Radiofrequency Electromagnetic Field (PRFE), Dry-Needling (DN), Low-
dye Taping (LD-Tape), and Calcaneal Taping
Only one RCT was included for each of 5 types of interventions, so
no meta-analysis of these modalities was conducted, as only one study
Fig. 4. Forest plot of Low level laser therapy vs the placebo.
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was reported for each modality [10,24–27] (Fig. 7). These interventions
were: ultrasound-guided PRF, PRFE, dry needling, low dye taping, and
calcaneal taping.
USGPRF (Ye et al. (2015), n = 100) used 5 min of emitted radio
frequencies into calf muscle trigger points under local anaesthesia [24]:
this study method demonstrated a significant reduction in pain scores
(MD −23.10 (−37.90; −8.30); P = 0.002) with a minimum of bias.
The quality of the evidence for this intervention was high. The study
gave the following adverse events: pain after treatment and sweating.
PRFE (Brook et al. (2012), n = 70) required subjects to wear an
antenna, a device (ActiPatch) that emits a safe form of nonionizing
electromagnetic radiation directly above the symptomatic site, for 7
consecutive nights [25]: this study did not reach significance in terms of
pain reduction, although the treatment group gained a greater degree of
pain relief than the placebo controls. The quality of evidence for this
intervention resulted high. The study did not report information about
adverse events.
DN (Cotchett et al. (2014), n = 84) subjects underwent dry-need-
ling of trigger points in soleus, short flexors of the toes, and abductor
halluces muscles for a total of 6 sessions over the course of 6 weeks
[26]: this study demonstrated a significant reduction in pain intensity
in the treated group (MD −18.20 (−31.19; −51.21) P = 0.006).
Moderate quality evidence resulted from this study, as there was a
moderate risk of performance bias. The study reported adverse effects
S. Salvioli et al.
Fig. 5. Forest plot of orthoses vs placebo.
Fig. 6. Forest plot of stretching vs the placebo.
of local bruising and increased pain between 1 and 7 days posttreat-
ment.
LD-Tape (Radford et al. (2006), n = 92). Standardised Leukotape®,
applied to the plantar skin of subjects, from the heel to the metatarsal-
phalangeal joints (MTPJs), and kept in situ for 7 days to reduce stress
on the underlying plantar fascia [27], did not achieve a significant re-
duction in heel pain intensity in the treatment group when compared to
placebo controls (MD −12.00 (−25.61; 1.61), P = 0.08). Moderate
quality evidence resulted from this study, as there was a moderate risk
of performance bias. The study did not report information about ad-
verse effects.
Calcaneal taping Hyland et al (2006). Standardised Leukotape®,
applied to the plantar skin, from the heel to the MTPJs, to maximize the
height of the medial longitudinal arch, and retained in situ for 4 days
[10] reported a highly significant reduction in heel pain intensity due to
this intervention, in comparison to placebo controls (MD −3.9 (−5.40;
−2.40), P < 0.001). Quality of evidence for this intervention was
moderate, as there was a moderate risk of selection bias and sample
subjects could not be blinded. The study did not report information
about eventual adverse events.
4. Discussion
4.1. Synthesis of evidence
There was low quality evidence that shock wave therapies were
more effective than placebo to reduce heel pain intensity, although any
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difference due to different types of wave therapies could not be as-
sessed, because not all the included studies stated which type of wave
treatment was used. There was moderate quality evidence that low-
level laser therapy, dry-needling of lower leg and foot muscle trigger
points, and calcaneal taping were effective in the reduction of persistent
heel pain, high quality evidence that USGPRF achieved heel pain re-
duction, and low quality evidence that orthoses were effective in the
reduction of heel pain. All these interventions gave non-clinical sig-
nificant improvements, considering that the minimal clinical important
difference (MCID) for the VAS scale is −30 mm (CI 95% −36.4,
−23.6) [28].
Finally PRFE, calf-muscle stretching, plantar fascia stretching and
low-dye taping were not effective (i.e results analysis showed they were
no better than placebo) (Table 4).
4.2. Comparison with other systematic review results
Many systematic reviews in the literature had investigated different
conservative treatments for the treatment of plantar heel pain, but were
limited as they only looked at one individual treatment [5,7,29–31].
This systematic review, instead, had considered all of the conservative
interventions available in the literature for this issue. The goal was to
offer clinicians and patients a more complete, evidence-based vision in
choosing the best therapeutic strategy.
The results of this review agreed with the other reviews on the re-
lative efficacy of shock wave therapies [7,31], efficacy of dry-needling
[29], and the non-efficacy of muscular stretching [5,30]. Furthermore
S. Salvioli et al. The Foot 33 (2017) 57–67

Fig. 7. Forest plot of USGPRF vs the placebo, PRFE vs the placebo, dry-needling vs the placebo, low-dye taping vs the placebo and calcaneal taping vs the placebo.

this review included some interventions that were not included in the future studies could achieve larger sample populations, especially when
previous reviews, such as laser therapy, orthoses, USGPRF, PRFE, low- the effectiveness (or not) of stretching, PRFE and low-dye taping is
dye taping, and calcaneal taping. being assessed.

4.3. Limits Brief summary

The high risk of bias revealed in some domains of the Risk of Bias • Plantar heel pain is one of the most common musculoskeletal
Tool of the included studies, and the fact that there was only one RCT pathologies of the foot.
for PRFE, USGPRF, dry-needling, low-dye taping, and calcaneal taping, • Consider shock waves, laser therapy, orthoses, pulsed radio-
had adversely affected the quality of evidence. Lastly, the study search frequency, dry needling and calcaneal taping.
strategy may also not have found all the studies of interest. • Further investigate stretching, pulsed electromagnetic fields and low
dye taping.
5. Conclusions
Funding and potential conflicts of interest
The meta-analysis showed that shock wave therapy, laser therapy,
orthoses, USGPRF, dry-needling and calcaneal taping all showed some None.
beneficial effect in reducing plantar heel pain, in comparison to pla-
cebo, although some interventions did not achieve a significant re- Acknowledgments
duction, and evidence quality was only low or moderate for most in-
terventions. Thus, no firm, evidence-based clinical advice can be given We would like to thank Micheal Jones and Carly Walsh for their
on the relative reduction of plantar heel pain. It would be useful if assistance with language.

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Table 4
Summary of findings.

Outcome Illustrative comparative risks (95% CI) Relative effect (95% № part. Quality (GRADE) Comments
CI) (studies)

Pain on a 0–100 scale. Various
pain scales. (lower score is
better)
Assumed effect with Placebo Corresponding effect with extracorporeal shockwave SMD −0,26 (95% CI 1114 (10 ⊕⊕○○ LOWa,b,c Absolute change: 8,8%
Weighted mean pain in control groups The mean pain in the intervention groups was 8,8 points −0,38 to −0,14) RCTs) (95% CI 7,7% to 10,0%)
was −31,4 points (95% CI −32,2 points lower (95% CI 7,7 to 10,0 points lower) compared with the
up to −30,6). control group.
Assumed effect with Placebo Corresponding effect with laser therapy MD −23,52 (95% CI 94 (2 RCTs) ⊕⊕⊕○ Absolute change: 24,2%
Weighted mean pain in control groups The mean pain in the intervention groups was 24,2 points −33,60 to −13,43) MODERATEa,d (95% CI 22,3% to 26,1%)
was −8,1 points (95% CI −9,7 points up lower (95% CI 22,3 to 26,1 points lower) compared with the
to −6,5). control group.
Assumed effect with Placebo Corresponding effect with orthosis MD −6,96 (95% CI 244 (3 RCTs) ⊕⊕○○ LOWa,b,d Absolute change: 6,3%
Weighted mean pain in control groups The mean pain in the intervention groups was 6,3 points −13,74 to −0,18) (95% CI 5,5% to 7,1%)
was −20,4 points (95% CI −21,0 points lower (95% CI 5,5 to 7,1 points lower) compared with the
up to −19,8). control group.
Assumed effect with Placebo Corresponding effect with stretching SMD −0,37 (95% CI 112 (2 RCTs) ⊕⊕⊕○ MODERATEe Absolute change: 7,7%
Weighted mean pain in control groups The mean pain in the intervention groups was 7,7 points −0,74 to 0,01) (95% CI 6,7% to 8,7%)
was −11,6 points (95% CI −12,6 points lower (95% CI 6,7 to 8,7 points lower) compared with the
up to −10,6). control group.
Assumed effect with Placebo Corresponding effect with ultrasound-guided pulsed MD −23,10 (95% CI 95 (1 RCT) ⊕⊕⊕⊕ HIGH Absolute change: 23,1%
radiofrequency −37,90 to −8,30) (95% CI 8,3% to 37,9%)
Weighted mean pain in control groups The mean pain in the intervention groups was 23,1 points
was −11,0 points (95% CI −21,1 points lower (95% CI 8,3 to 37,9 points lower) compared with the

65
up to −0,88). control group.
Assumed effect with Placebo Corresponding effect with pulsed radiofrequency MD −15,40 (95% CI 70 (1 RCT) ⊕⊕⊕⊕ HIGH Absolute change: 15,4%
electromagnetic field −31,10 to 3,00) (95% CI 3,0% to 31,0%)
Weighted mean pain in control groups The mean pain in the intervention groups was 15,4 points
was −2,0 points (95% CI −15,0 points lower (95% CI 3,0 to 31,0 points lower) compared with the
up to 11,0). control group.
Assumed effect with Placebo Corresponding effect with dry-needling MD −18,20 (95% CI 79 (1 RCT) ⊕⊕⊕○ MODERATEb Absolute change: 18,2%
Weighted mean pain in control groups The mean pain in the intervention groups was 18,2 points −31,19 to −5,21) (95% CI 5,2% to 31,2%)
was −28,6 points (95% CI −38,2 points lower (95% CI 5,2 to 31,2 points lower) compared with the
up to −19,0). control group.
Assumed effect with Placebo Corresponding effect with low-dye taping MD −12,00 (95% CI 92 (1 RCT) ⊕⊕⊕○ MODERATEb Absolute change: 12,0%
Weighted mean pain in control groups The mean pain in the intervention groups was 12,0 points −25,61 to 1,61) (95% CI 1,6% to 25,6%)
was −18,0 points (95% CI −27,5 points lower (95% CI 1,6 to 25,6 points lower) compared with the
up to −8,5). control group.
Assumed effect with Placebo Corresponding effect with calcaneal taping MD −39,00 (95% CI 21 (1 RCT) ⊕⊕⊕○ MODERATEa Absolute change: 39,0%
Weighted mean pain in control groups The mean pain in the intervention groups was 39,0 points −54,00 to −24,00) (95% CI 24,0% to 54,0%)
was −4,0 points (95% CI −15,0 points lower (95% CI 24,0 to 54,0 points lower) compared with the
up to −7,0). control group.

CI: Confidence interval. SMD: standardized mean difference. MD: mean difference. a. risk of selection bias. b. risk of performance bias. c. risk of pubblication bias. d. risk of attrition bias. e. presence of heterogeneity (I2).
GRADE Working Group grades of evidence. High quality: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to
be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect. Very low
quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
Summary of findings: Conservative non-pharmacological interventions compared to Placebo for plantar heel pain.Patient or population: plantar heel pain. Setting: outpatient. Intervention: Conservative non-pharmacological interventions.
Comparison: Placebo.
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S. Salvioli et al. The Foot 33 (2017) 57–67

Appendix A. Medline search strategy

(((((“Fasciitis, Plantar”[Mesh]) OR “Heel Spur”[Mesh])) OR (heel pain[Title/Abstract] OR plantar fascio*[Title/Abstract] OR fasciopath*[Title/

Abstract]))) AND ((((((((((((((“Physical Therapy Modalities”[Mesh]) OR “Acupuncture Therapy”[Mesh]) OR “Cryotherapy”[Mesh]) OR “Laser
Therapy”[Mesh]) OR “Placebos”[Mesh]) OR “Diathermy”[Mesh]) OR “Orthotic Devices”[Mesh])))) OR “Extracorporeal shock wave therapy”[Title/
Abstract]) OR “Extracorporeal shockwave therapy”[Title/Abstract]) NOT “General Surgery”[Mesh])) OR (tap*[Title/Abstract] OR dry needling
[Title/Abstract]).
Filters: Randomized Controlled Trial

Appendix B. Risk of bias summary

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