Manual Therapy, Injections, Shockwave and Surgery for Heel Pain

Manual soft tissue techniques give short-term benefit with no clear winner, and evidence for joint mobilization is conflicting. A corticosteroid injection, ideally ultrasound-guided, gives a large pain reduction for about four to eight weeks, then no advantage over placebo. Fears of fascia rupture come from older studies without ultrasound guidance. Henrik's FIX-Heel trial tests whether combining an injection with heavy slow resistance training adds benefit; a feasibility study found it acceptable. Shockwave beats placebo, appears to work better in plantar heel pain than in other tendinopathies, and shows a dose-response link with energy output. It worked better without anesthesia. Because it can be costly, Henrik would usually try an injection first. Needle electrolysis shows promise but needs independent research. Surgery, such as gastrocnemius recession or endoscopic fasciotomy, has outperformed stretching and injection in some trials, but adverse events are more serious. The key message is to start simple: advice, a comfortable heel cup or insole, and stretching or heavy slow resistance training.