Orthotics and Injections Won't Fix Your Plantar Fasciitis

What is plantar fasciitis?

Plantar fasciitis is characterized by pain or tenderness along the bottom of the foot, most commonly at the attachment of tissue by the heel. Experiencing pain with taking first steps in the morning or after periods of rest are classic signs of this condition, cited to affect 10% of the population. Some common interventions for this condition include prescription orthotics, wearing supportive footwear, and cortisone (steroid) injections. As a physical therapist, the above “treatments” are in reality, not treatments at all, but rather masking the symptoms for a short period of time. Let’s further discuss each of these “treatments” and why they won't fix your plantar fasciitis.

Custom orthotics fasciitis

First off, research shows that unless you have a very unique foot shape, there is no difference found between expensive custom-made orthotics and standard over-the-counter ones on foot pain. Second, wearing orthotics may help control pain for short periods of time, but long term all this is doing is making your foot dependent on this support. Just as there are muscles in your hands used for gripping, there are muscles in your feet/ankles. If you wear an external device like orthotics to provide foot stability, your own muscles will only get weaker. Now you will have to rely on these orthotics all the time and walking barefoot or wearing dress shoes/sandals will be even more uncomfortable.

Supportive footwear can actually weaken your feet

Similar to wearing orthotics, always wearing supportive/high arch shoes may provide short term pain relief. Long term, these are also making your feet reliant on the support and therefore weakening your own muscles. Now if you are going out and running on hard concrete, it is absolutely ok to wear a more cushioned and supportive shoe. However, while performing other activities such as strength training or when running on softer surfaces, I recommend switching to a less-supportive shoe so that your muscles learn to do the work rather than the shoe.

Research supports the use of a more barefoot style shoe, i.e. wider toe box and less heel-toe drop ratio. Studies show that the typical Western shoe with its narrow toe-box actually changes the natural foot shape over time and lends to creating a bunion shape. This narrowing causes greater force through the heel and ball of your foot and creates less stability in the foot.

B. Foot walking mostly barefoot with wider toe spread = stability A. Foot wearing narrow shoes = bunion forming, foot instability and pain

Check out how the foot and toes fit in different styles of athletic shoes. The first two shoes are much more narrow than the foot shaped shoe, not allowing the toes to spread out. The foot shaped shoe is the most ideal as it can accommodate the entire foot without restricting the toes.

High-cushion shoes with tall heel-toe drop ratios also change the natural mechanics of the foot/ankle complex. A typical cushioned running shoe like Brooks or Hoka have on average 12 mm of extra height on the heel. This decreases the bend in your ankle over time and can contribute to stiffer Achilles tendons and plantar fascia. In contrast, a more barefoot style or zero-drop shoe with a wider toe box is built to match the body’s natural anatomy, improving foot & ankle stability and posture. Some brands I recommend include Altra, Lems, Xero, and Vivo barefoot.

Many athletic shoes are heavily cushioned, elevating the heel above the level of the toes. Thin athletic shoes like the example on the right keep the heel and toes level.

Cortisone steroid injections simply cover up pain

These injections are meant to mask pain for an average of a few weeks to a few months. However, they are not fixing the weakness/instability of the foot. Also, these steroids actually weaken tissue which is why most doctors do not recommend having more than 2-3 injections in the same body area. The latest research shows that both dry needling and platelet-rich plasma (PRP) injections have superior outcomes compared to steroid injections on long term pain, disability, and function.

While there is no problem with the use of short-term over-the-counter orthotics and supportive footwear for pain relief with plantar fasciitis, the true solution to the problem lies in strengthening and stabilizing the foot-ankle complex.

References

I. Dunning J, Butts R, Henry N, et al. Electrical dry needling as an adjunct to exercise, manual therapy and ultrasound for plantar fasciitis: A multi-center randomized clinical trial. Baur H, ed. PLOS ONE. 2018;13(10):e0205405. doi:https://doi.org/10.1371/journal.pone.0205405

II. Tran K, Spry C. Custom-Made Foot Orthoses versus Prefabricated foot Orthoses: A Review of Clinical Effectiveness and Cost-Effectiveness. CADTH Rapid Response Report: Summary with Critical Appraisal. 2019;(1922-8147).

III. D’AoÛt K, Pataky TC, De Clercq D, Aerts P. The effects of habitual footwear use: foot shape and function in native barefoot walkers†. Footwear Science. 2009;1(2):81-94. doi:https://doi.org/10.1080/19424280903386411

IV. Griswold D, Learman K, Ickert E, et al. Comparing dry needling or local acupuncture to various wet needling injection types for musculoskeletal pain and disability. A systematic review of randomized clinical trials. Disabil Rehabil. Published online January 12, 2023:1-15. doi:https://doi.org/10.1080/09638288.2023.2165731