Comparative effectiveness of minimally invasive therapies for plantar fasciitis: A systematic review and network meta-analysis

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Although a wide range of conservative and minimally invasive treatments are available, the absence of direct comparative evidence has limited clarity about which interventions offer the most durable benefits. We conducted a systematic review and network meta-analysis of 63 randomized controlled trials including 4170 participants to evaluate extracorporeal shock wave therapy, prolotherapy, and injection-based therapies including platelet-rich plasma, botulinum toxin A, corticosteroids, autologous blood, and local anaesthetics. Across short-, medium-, and long-term follow- up, botulinum toxin A provided the greatest short-term improvements in pain and plantar fascia thickness, where prolotherapy was most effective for sustained pain relief. Corticosteroids injection yielded the largest short-term function gains, while platelet-rich plasma supported the long-term improvements in both function and plantar fascia thickness. Extracorporeal shock wave therapy demonstrated broad efficacy across all domains and timepoints. These findings provide updated comparative evidence to guide clinical decision-making, suggesting that treatment strategies for plantar fasciitis should be tailored to symptom duration and therapeutic goals rather than defaulting to one intervention alone. Systematic review registration : PROSPERO CRD420250641285 Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Plantar fasciitis Minimal invasive therapies Conservative therapy Systematic review and Network meta-analysis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 INTRODUCTION Plantar fasciitis is among the most common causes of heel pain, accounting for 11%–15% of all foot-related complaints in primary and sports medicine clinics.[1] Epidemiological data suggest that approximately one million US individuals develop plantar fasciitis every year, with most of these individuals being older adults or athletes, particularly runners.[2,3] Among runners, plantar fasciitis is the third most frequent overuse injury, accounting for 10% of all running-related complications.[4] This condition typically results from repetitive microtrauma and excessive mechanical loading at the plantar fascia’s insertion on the medial calcaneal tubercle, leading to inflammation, collagen degeneration, and compromised shock absorption in the heel pad.[5] These symptoms tend to resolve spontaneously; however, related pain can persist for months or longer, substantially impairing mobility, limiting participation in physical activities, and compromising occupational performance. Chronic plantar fasciitis, defined as symptoms lasting beyond 6 months, occurs in up to 10% of all cases and is associated with poor prognostic outcomes.[1,3,6] Various treatment options are available for alleviating pain and restoring function in plantar fasciitis. Activity modification, stretching exercises, nonsteroidal anti-inflammatory drugs, and foot orthoses are examples of conservative treatment options.[1] Minimally invasive therapies, such as extracorporeal shock wave therapy (ESWT), prolotherapy, platelet-rich plasma (PRP) injection, botulinum toxin A (BTA) injection, local anaesthetic (LA) injection, autologous blood injection, and corticosteroid injection, are selected when first-line treatment has failed. These interventions function through the application of mechanical stimuli, modulation of inflammatory cascades, or promotion of tissue regeneration.[7,8] Robust data from direct head-to-head trials comparing diverse treatment modalities are scarce, limiting clinicians’ ability to determine which approach would yield superior outcomes over different timeframes. Several meta-analyses and systematic reviews have evaluated the efficacy of individual plantar fasciitis treatments.[9–15] However, most of these studies were pairwise comparisons, investigated only short-term outcomes, or had narrow patient inclusion criteria. Consequently, key questions regarding the relative long-term effectiveness of these therapies remain unanswered, particularly in chronic or refractory cases where pain persists despite conservative management. Moreover, treatment guidelines from major organisations, such as the American College of Foot and Ankle Surgeons, the United Kingdom’s National Institute for Health and Care Excellence, and the American Physical Therapy Association, differ in their recommendations, reflecting differences between studies and in the priorities of healthcare systems.[16–19] To address this knowledge gap and support evidence-based decision-making, we performed a comprehensive network meta-analysis (NMA) of randomised controlled trials (RCTs) comparing injectable and device-based interventions for plantar fasciitis. Unlike pairwise meta-analysis, NMA allows for simultaneous comparison of multiple interventions, even those not directly compared in head-to-head trials, thereby establishing a comprehensive hierarchy of effectiveness. This approach is particularly useful for assessing relative long-term effectiveness across diverse treatment modalities and can offer clinicians a complete picture of interventions with superior benefits. The present analysis focused on three clinically meaningful outcomes (pain intensity, foot function, and plantar fascia thickness) across short-, mid-, and long-term follow-up periods. We assessed confidence in the evidence for each comparison by using the Confidence in Network Meta-Analysis (CINeMA) framework[20], aiming to provide an updated, clinically relevant hierarchy of treatment effectiveness. The findings may guide physicians in providing personalised, evidence-based care for plantar fasciitis, which remains a prevalent and disabling condition in both general and athletic populations. METHODS Study registration This systematic review and NMA was registered with International Prospective Register of Systematic Reviews database (identifier: CRD420250641285). The study protocol adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension statement for systematic reviews that incorporate network meta-analyses of healthcare interventions.[21] Data sources and search strategy PubMed, MEDLINE, Embase, Cochrane Library, Web of Science, and CINAHL (through EBSCO) were comprehensively searched for relevant articles published from database inception to February 2025. No language or publication date–related restrictions were applied. The search terms included MeSH and free-text keywords for ‘plantar fasciitis’ and related minimally invasive interventions. Complete search strategies for each database are provided in the online supplementary appendix 1. Article selection criteria We included randomised controlled trials (RCTs) that focused on adults (≥18 years) with plantar fasciitis without a history of surgical intervention. Eligible interventions included ESWT; prolotherapy; and injections of PRP, BTA, LAs, autologous blood, or corticosteroids. Studies were included if they compared these interventions with each other or with conservative treatments (e.g. physiotherapy, stretching, orthoses, taping, or placebo). Studies were required to report at least one of the following primary outcomes: pain intensity, foot function, and plantar fascia thickness. Studies were excluded if they were not randomised; if they were observational studies, case series, reviews, editorials, conference abstracts, or animal studies; if they involved participants aged <18 years; or if they focused on heel pain from causes other than plantar fasciitis. Article selection and data extraction After defining eligibility, we implemented a two-stage selection process. Duplicate records across databases were identified and removed before screening to ensure unique study records. Two reviewers, Tien and Shen, independently screened the titles and abstracts of the identified articles. This was followed by a full-text review of potentially eligible articles. Discrepancies were resolved through between-reviewer discussion or consultation with a third reviewer, Lee. The following data were extracted: first author, publication year, study design, country, inclusion criteria, sample size, participant demographics, intervention and comparator details, follow-up duration, and outcome measures. When studies reported medians, ranges, or interquartile ranges instead of mean ± standard deviation values, summary statistics were estimated using validated methods.[22,23] If key data were missing, corresponding authors were contacted for clarification or additional information. If no response was received after repeated attempts, studies were included with the available data only. Studies published in a language other than English were excluded during the full-text review phase. Risk-of-bias assessment The risk of bias in each included RCT was assessed using the Cochran Risk-of-Bias 2.0 (RoB 2) tool, evaluating five domains: randomisation process, deviations from intended interventions, missing outcome data, measurement of outcomes, and selection of reported results.[24,25] On the basis of questions included in the RoB 2 framework, each domain was rated as having a low risk of bias, some concerns, or a high risk of bias. Certainty of evidence was evaluated using the CINeMA framework (https://cinema.ispm.unibe.ch/), a validated tool for appraising NMA findings. Two reviewers (Tien and Shen) independently performed the assessments, with disagreements resolved through between-reviewer discussion or consultation with a third reviewer (Lee). Outcomes Pain intensity was assessed using a visual analogue scale, numerical rating scale, or the Foot Health Status Questionnaire. Foot function was assessed using validated instruments such as the Foot Function Index, Foot and Ankle Ability Measure, American Orthopaedic Foot and Ankle Society score, Foot Health Status Questionnaire, Foot and Ankle Disability Index, or Maryland Foot Score. Foot Function Index scores were reversed (i.e. higher scores reflected better function). Plantar fascia thickness was measured through imaging studies and reported in millimetres. The outcome measures were stratified by follow-up duration into short-term (≤6 weeks), mid-term (>6 to ≤12 weeks), and long-term (>12 weeks) outcomes. When multiple time points were reported, the measurement closest to the defined cutoff was used. Statistical analysis A frequentist random-effects NMA was performed using the netmeta package in R (version 4.5.0; R Foundation for Statistical Computing, Vienna, Austria).[26] Mean difference and standardised mean difference (SMD) values with corresponding 95% confidence intervals (CIs) were calculated. Treatment comparisons were structured using the pairwise function in R to generate contrast-based data from raw means, standard deviations, and sample sizes of each two-arm comparison. The data were then analysed using the netmeta function.[27] Treatments were ranked by P scores from 0 ( worst ) to 1 ( best ). These scores are mathematically equivalent to the Surface Under the Cumulative Ranking scores in Bayesian analyses.[28] Network consistency was assessed globally by using the design-by-treatment interaction model and locally through node-splitting analyses.[29] Interstudy heterogeneity was evaluated in terms of variance (τ²) and the I 2 statistic, with I 2 values of >50% indicating moderate heterogeneity.[30] Sensitivity analyses excluded trials at high risk of bias or requiring imputed means or standard deviations from medians, ranges, or interquartile ranges. Treatment effects were considered robust if exclusions did not materially alter the overall results or treatment ranks. Publication bias was assessed using comparison-adjusted funnel plots for each outcome included in the NMA.[31] In addition, Egger’s test for funnel plots was applied. All analyses were two-tailed, and statistical significance was set at p < 0.05. Patient and public involvement Two individuals with lived experience of plantar fasciitis- one recreational runners and one older adult with chronic symptoms. They were consulted when developing the research question and protocol for this review. Their perspectives informed the selection of minimal invasive intervention, and inclusion of outcomes across different timeframes. The advisory group also discussed the key findings and provide suggestion on a plain language summary. Findings from the research will be disseminated locally and nationally and outreach through musculoskeletal health networks. RESULTS Review sample Initial literature search yielded 4,841 articles. After duplicate removal, 1,876 unique studies were subjected to title and abstract screening. Of these articles, 1,288 did not meet the eligibility criteria. The remaining 588 articles were subjected to full-text review, which resulted in the exclusion of 156 studies because of having irrelevant populations or interventions, 259 for not being RCTs, 17 for being animal studies, 39 for not being published in English, and 54 for lacking sufficient data. Ultimately, 63 RCTs were included in the final analysis (figure 1). Study characteristics The included studies involved a total of 4,170 participants and evaluated nine interventions, including control (conservative) treatment and normal saline injection (placebo). The test interventions included ESWT, dextrose injection (prolotherapy), corticosteroid injection, BTA injection, PRP injection, LA injection, and autologous blood injection. The RCTs were published between 1999 and 2024. Follow-up duration ranged from 3 to 156 weeks. The studies were conducted in various countries, reflecting global interest in the treatment of plantar fasciitis. The distribution by country was as follows: Australia (n = 2),[32,33] Canada (n = 2),[34,35] China (n = 3),[36–38] Denmark (n = 1),[39] Egypt (n = 4),[40–43] Germany (n = 2),[44,45] India (n = 12),[46–57] Iran (n = 8),[58–65] Jordan (n = 1),[66] South Korea (n = 1),[67] Malaysia (n = 1),[68] Mexico (n = 2),[69,70] Nepal (n = 1),[71] Singapore (n = 1),[72] Spain (n = 2),[73,74] Taiwan (n = 2),[75,76] Turkey (n = 11),[77–87] the United Kingdom (n = 3),[88–90] and the United States (n = 4).[91–94] Participants were recruited primarily from primary care facilities or outpatient clinics (online supplemental appendix 2). Study quality Risk of bias was evaluated using RoB 2. Regarding bias due to the randomisation process, 92.1% of the included studies had a low risk, whereas 7.9% had some concerns. Regarding bias due to deviations from intended intervention, 69.8% of the studies had a low risk, 4.8% had some concerns, and 25.4% had a high risk. Regarding bias due to missing outcome data, 82.5% of the studies had a low risk, whereas 17.5% had some concerns. Regarding bias due to measurement of outcomes, 90.5% of the studies had a low risk, whereas 9.5% had some concerns. Regarding bias due to selection of reported results, 98.4% of the studies had a low risk, whereas the remaining 1.6% had a high risk. Overall, 71.4% of the included studies had a low risk of bias, 3.2% had some concerns, and 25.4% had a high risk of bias. These findings indicate that the studies generally had robust methodological quality (figure 2). Short-term outcomes Pain relief Pain relief outcomes were synthesised from 48 RCTs involving 3,123 participants. All interventions were included in this analysis (figure 3a). The NMA revealed no evidence of global inconsistency (Q statistic, p = 0.25). Local inconsistency was observed in comparisons of BTA and corticosteroids with placebo (node-splitting analysis, p < 0.05). The following interventions were significantly more effective than placebo at alleviating pain: BTA injection (SMD: 2.09; 95% CI: 1.28–2.91), PRP injection (SMD: 1.05; 95% CI: 0.22–1.87), ESWT (SMD: 0.94; 95% CI: 0.09–1.80), and corticosteroid injection (SMD: 0.91; 95% CI: 0.12–1.70). Furthermore, BTA injection was significantly more effective than control treatment at reducing pain (SMD: 0.74; 95% CI: 0.05–1.43) (table 1A). On the basis of P score, BTA injection obtained the highest rank (score: 0.95; table 2). Foot function Foot function outcomes were synthesised from 30 RCTs involving 1,855 participants. All interventions were included in this analysis (figure 4a). No significant global (Q statistic, p = 0.99) or local inconsistencies (node-splitting analysis, p > 0.05) were detected. The following treatments were significantly more effective than placebo in improving foot function: autologous blood injection (SMD: 2.03; 95% CI: 0.36–3.71), BTA injection (SMD: 2.39; 95% CI: 1.40–3.39), control treatment (SMD: 2.34; 95% CI: 1.10–3.58), prolotherapy (SMD: 2.47; 95% CI: 1.19–3.76), ESWT (SMD: 2.41; 95% CI: 1.15–3.67), PRP injection (SMD: 2.38; 95% CI: 1.16–3.60), and corticosteroid injection (SMD: 2.48; 95% CI: 1.28–3.67). Compared with LA injection, the following treatments were significantly effective in improving foot function: BTA injection (SMD: 1.81; 95% CI: 0.56–3.07), control treatment (SMD: 1.82; 95% CI: 0.59–3.04), prolotherapy (SMD: 1.95; 95% CI: 0.69–3.21), ESWT (SMD: 1.89; 95% CI: 0.65–3.13), PRP injection (SMD: 1.86; 95% CI: 0.67–3.05), and corticosteroid injection (SMD: 2.01; 95% CI: 0.75–3.28) (table 3A). On the basis of P score, corticosteroid injection obtained the highest rank (score: 0.74), whereas placebo obtained the lowest rank (score: 0.03; table 4). Plantar fascia thickness Plantar fascia thickness outcomes were synthesised from 14 RCTs involving 922 participants. BTA injection, placebo, PRP injection, and corticosteroid injection were included in this analysis (figure 5a). No significant global inconsistency was observed (Q statistic, p = 0.08). Local inconsistency was detected between BTA injection and placebo and between placebo and corticosteroid injection (node-splitting analysis, p < 0.05). BTA injection was significantly more effective than placebo in reducing plantar fascia thickness (SMD: 1.64; 95% CI: 0.56–2.73), and corticosteroid injection was superior to PRP injection (SMD: 0.69; 95% CI: 0.08–1.30) (table 5A). On the basis of P score, BTA obtained the highest rank (score: 0.90), whereas placebo obtained the lowest rank (score: 0.22; table 6). Mid-term outcomes Pain relief Pain relief outcomes were synthesised from 48 RCTs involving 3,360 participants. All interventions were included in this analysis (figure 3b). Global inconsistency was acceptable (Q statistic, p = 0.09). Local inconsistency was detected in comparisons between prolotherapy and placebo and between placebo and corticosteroid injection (node-splitting analysis, p < 0.05). All interventions significantly outperformed placebo in alleviating pain: autologous blood injection (SMD: 1.99; 95% CI: 0.62–3.37), BTA injection (SMD: 2.57; 95% CI: 1.53–3.61), control treatment (SMD: 2.19; 95% CI: 1.12–3.26), prolotherapy (SMD: 5.48; 95% CI: 3.57–7.39), ESWT (SMD: 2.31; 95% CI: 1.27–3.36), LA injection (SMD: 2.36; 95% CI: 0.97–3.75), PRP injection (SMD: 2.45, 1.44–3.47), and corticosteroids (SMD: 1.96; 95% CI: 0.99–2.94). Compared with corticosteroid injection, prolotherapy (SMD: 0.75; 95% CI: 0.02–1.48) and PRP injection (SMD: 0.49; 95% CI: 0.12–0.86) significantly alleviated pain (table 1B). On the basis of P score, prolotherapy with dextrose obtained the highest rank (score: 0.84), whereas placebo obtained the lowest rank (score: 0.0003; table 2). Foot function Foot function outcomes were synthesised from 30 RCTs involving 1,912 participants. All interventions were included in this analysis (figure 4b). Global inconsistency was nonsignificant (Q statistic, p = 0.92). Local inconsistencies were noted in comparisons between BTA and LA injections, between BTA and corticosteroid injections, and between LA and corticosteroid injections (node-splitting analysis, p < 0.05). The following treatments led to significantly greater improvements in foot function than did placebo: autologous blood injection (SMD: 3.00; 95% CI 0.83–5.17), BTA injection (SMD: 2.44; 95% CI: 1.11–3.76), control treatment (SMD: 2.51; 95% CI: 1.10–3.93), prolotherapy (SMD: 2.34; 95% CI: 0.58–4.09), ESWT (SMD: 2.90; 95% CI: 1.45–4.36), and LA injection (SMD: 3.41; 95% CI: 1.52–5.31). Compared with BTA, LA injection (SMD: 2.33; 95% CI: 0.53–4.13) and corticosteroid injection (SMD: 2.47; 95% CI: 0.68–4.27) significantly improved foot function. Furthermore, PRP injection was superior to corticosteroid injection (SMD: 0.76; 95% CI: 0.29–1.22) (table 3B). On the basis of P score, PRP injection obtained the highest rank (score: 0.84), whereas placebo obtained the lowest rank (score: 0.0005; table 4). Plantar fascia thickness Plantar fascia thickness outcomes were synthesised from 16 RCTs involving 1,048 participants. Two of the trials had three-arm designs. The intervention network is depicted in figure 5b. Global inconsistency was nonsignificant (Q statistic, p = 0.89), and no local inconsistency was detected (node-splitting analysis, p > 0.05). The following two interventions significantly outperformed placebo in reducing plantar fascia thickness: BTA injection (SMD: 2.32; 95% CI: 0.55–4.08) and PRP injection (SMD: 1.64; 95% CI: 0.17–3.12). PRP injection was significantly superior to control treatment (SMD: 0.99; 95% CI: 0.03–1.95) and corticosteroid injection (SMD: 0.91; 95% CI: 0.06–1.77) (table 5B). On the basis of P score, PRP obtained the highest rank (score: 0.81), whereas placebo obtained the lowest rank (score: 0.10). The remaining interventions (ESWT, prolotherapy, and corticosteroid injection) obtained intermediate or low ranks (table 6). Long-term outcomes Pain relief Pain relief outcomes were synthesised from 32 RCTs involving 2,142 participants (figure 3c). Global inconsistency was nonsignificant (Q statistic, p = 0.68). Local inconsistencies were detected in comparisons between BTA injection and placebo and between prolotherapy and placebo (node-splitting analysis, p < 0.05). The following treatments significantly outperformed placebo in alleviating pain: autologous blood injection (SMD: 4.08; 95% CI: 2.43–5.73), BTA injection (SMD: 3.16; 95% CI: 1.85–4.47), control treatment (SMD: 4.31; 95% CI: 2.85–5.77), prolotherapy (SMD; 7.10; 95% CI: 5.02–9.18), ESWT (SMD: 4.74; 95% CI: 3.27–6.20), LA injection (SMD: 4.19; 95% CI: 2.61–5.76), PRP injection (SMD: 5.02; 95% CI: 3.61–6.43), and corticosteroid injection (SMD: 4.18; 95% CI: 2.78–5.58). Compared with corticosteroid injection, prolotherapy (SMD: 1.15; 95% CI: 0.10–2.20) and PRP (SMD: 0.93; 95% CI: 0.48–1.38) significantly alleviated pain. PRP injection outperformed BTA injection (SMD: 1.15; 95% CI: 0.12–2.19) (table 1C). On the basis of P score, prolotherapy with dextrose obtained the highest rank (score: 0.93), whereas placebo obtained the lowest rank (score: 0; table 2). Foot function Foot function outcomes were synthesised from 28 RCTs involving 1,720 participants (figure 4c). Global inconsistency was acceptable (Q statistic, p = 0.66). Significant local inconsistencies were noted between BTA and LA injections, between BTA and corticosteroid injections, and between LA and corticosteroid injections (node-splitting analysis, p < 0.05). The following treatments significantly outperformed placebo in improving foot function: autologous blood injection (SMD: 3.65; 95% CI 1.23–6.07), BTA injection (SMD: 2.64; 95% CI: 1.20–4.09), control treatment (SMD: 2.74; 95% CI: 1.14–4.33), prolotherapy (SMD: 2.69; 95% CI: 0.73–4.65), ESWT (SMD: 3.65; 95% CI: 2.00–5.29), LA injection (SMD: 4.96; 95% CI: 2.81–7.11), PRP injection (SMD: 3.73; 95% CI: 2.23–5.24), and corticosteroid injection (SMD: 2.62; 95% CI: 1.12–4.13). ESWT (SMD: 1.02; 95% CI: 0.10–1.95), LA injection (SMD: 2.34; 95% CI: 0.52–4.16), and PRP injection (SMD: 1.23; 95% CI: 0.72–1.73) outperformed corticosteroid injection. However, corticosteroid injection was significantly more effective than BTA injection (SMD: 2.36; 95% CI: 0.38–4.33) (table 3C). On the basis of P score, LA injection obtained the highest rank (score: 0.95), whereas placebo obtained the lowest rank (score: 0.0003; table 4). Plantar fascia thickness Plantar fascia thickness outcomes were synthesised from eight RCTs involving 468 participants (figure 5c). Global consistency was acceptable (Q statistic, p = 0.64), and no significant local inconsistency was detected (node-splitting analysis, p > 0.05). PRP injection led to significantly greater reductions in plantar fascia thickness than did corticosteroid injection (SMD: 0.95; 95% CI: 0.40–1.50) (table 5C). On the basis of P score, PRP obtained the highest rank (score: 0.86), whereas LA injection (score: 0.24) and corticosteroid injection (score: 0.26) obtained the lowest ranks (table 6). Publication bias Publication bias was assessed using comparison-adjusted funnel plots and Egger’s regression test. The funnel plots appeared symmetrical, and Egger’s test revealed no significant asymmetry ( p > 0.05). These findings suggest a low risk of publication bias across the network (online supplemental appendix 3). Confidence in evidence CINeMA framework across six domains: within-study bias, reporting bias, indirectness, imprecision, heterogeneity, and incoherence was assessed the confidence in the evidence. Ratings ranged from very low to high confidence depending on the different comparisons, outcome and follow-up duration. A full CINeMA summary table with domain-level judgements and overall confidence rating is available in online supplemental appendix 4. DISCUSSION Summary of results Our NMA of 63 RCTs established an updated evidence hierarchy for conservative and minimally invasive therapies for plantar fasciitis across three outcome domains: pain relief, foot function, and plantar fascia thickness. The findings offer clear guidance for both acute and chronic cases. Regarding pain relief, BTA injection (P score: 0.95) was most the effective intervention in the short term (< 6 weeks after treatment), followed by PRP injection (P score: 0.75) and ESWT (P score: 0.62), whereas prolotherapy with dextrose was the most effective intervention in both middle term (6–12 weeks) and long term (≥ 12 weeks; P score: 0.84 and 0.93, respectively). Regarding improvement in foot function, corticosteroid injection was the most effective intervention in the short term (P score 0.74), PRP injection in the middle term (P score: 0.84), and LA injection in the long term (P score: 0.95). Regarding reduction in plantar fascia thickness, BTA injection was the most effective intervention in the short term (P score: 0.90), whereas PRP injection was the most effective intervention in both middle and long terms (P score: 0.81 and 0.86, respectively). This NMA is among the first to concurrently synthesise data across pain, foot function, and structural outcomes. Our study provides a comprehensive overview of therapeutic efficacy with direct implication for evidence-based clinical decision-making. The observed temporal and domain-specific efficacy profiles are consistent with known biological mechanisms underlying plantar fasciitis (e.g. microtears, degenerative collagen remodelling, fibroblast dysregulation, and neurogenic inflammation). BTA injection BTA injection was the most effective intervention in alleviating pain and reducing plantar fascia thickness in the short term. This aligns with BTA’s known mechanism of action: it inhibits acetylcholine release at neuromuscular junctions and thus reduces calf muscle spasticity and plantar fascia tension, rapidly alleviating pain. However, consistent with the findings of another meta-analysis[ 95 ], BTA’s benefit appears transient. We observed no sustained superiority of BTA after approximately 3 months. Prolotherapy Prolotherapy with dextrose was the most effective intervention in consistently alleviating pain, particularly in the middle and long terms. This finding supports dextrose’s proposed mechanism of action: dextrose induces a local inflammation response, which promotes fibroblast proliferation, collagen synthesis, and tissue repair, ultimately leading to gradual pain relief.[ 96 ] Therefore, prolotherapy may hold promise for sustained symptom relief, particularly in chronic plantar fasciitis. Corticosteroid injection Corticosteroid injection was the most effective intervention in improving foot function in the short term. Through their anti-inflammatory properties, corticosteroids suppress proinflammatory cytokines and reduce local tissue oedema, leading to rapid symptom relief. The analgesic effect of corticosteroid injection was inferior to that of prolotherapy and PRP injection in middle and long terms. Furthermore, corticosteroid injection exhibited only limited effectiveness in reducing plantar fascia thickness. Repeated steroid injection has been associated with adverse effects such as plantar fascia rupture and fat pad atrophy.[ 97 ] Although corticosteroid injection remains a common intervention for managing acute plantar fasciitis, its long-term use should be prescribed with caution. PRP injection PRP injection yielded favourable mid- and long-term outcomes in terms of pain relief, foot function improvement, and plantar fascia thickness reduction. PRP contains high concentrations of growth factors, including platelet-derived growth factor and transforming growth factor-β. These factors promote angiogenesis, facilitate tissue regeneration, and modulate inflammation.[ 98 ] PRP injection outperformed corticosteroid and BTA injections in facilitating fascial remodelling. Thus, PRP appears to be a bioactive treatment option with sustained effects, having potential for long-term recovery and structural improvement. LA injection LA injection led to marked improvements in foot function, particularly in long term. However, its analgesic effect was relatively modest and short-lived. In terms of pain relief, LA injection ranked lower than dextrose and PRP injections. Furthermore, LA injection exerted a minimal effect on plantar fascia thickness, which suggests that its mechanism of action may be limited to temporary sensory blockade rather than underlying tissue repair. These findings indicate that LA injection leads to temporary functional improvement, likely through a mechanism involving reduced protective muscle guarding or improved tolerance to foot movement. ESWT ESWT exerts its effects through mechanotransduction, which involves nitric oxide–mediated signalling, enhanced neovascularisation, and nociceptor desensitisation, resulting in gradual and lasting improvements in pain relief.[ 99 ] In the present study, ESWT exhibited efficacy across all time points, consistent with the findings of a meta-analysis supporting its long-term effects and noninvasive advantages.[ 100 ] Comparison with prior evidence Our findings both confirm and extend those of prior systematic reviews evaluating minimally invasive therapies for plantar fasciitis. Some of these studies focused on injection or acupuncture,[ 10 , 15 ] whereas others focused on energy-based treatments[ 14 ] or surgical options, excluding conventional treatments.[ 12 ] Studies centred solely on pain or foot function without incorporating structural parameter did not provide a complete picture of clinical evaluation.[ 11 , 13 ] Our NMA expands the literature in several directions. First, we incorporated a broader range of interventions, including BTA and prolotherapy, which have been underrepresented in prior analyses. Second, we stratified treatment effects into short-, mid-, and long-term outcomes. This revealed time-dependent differences in efficacy that were less evident in previous pooled estimates. A prior review highlighted the early effects of corticosteroid, whereas our results provided insights beyond short-term effects: dextrose and PRP injections outperformed corticosteroid injection in alleviating pain and improving foot function beyond 6 weeks. Finally, the inclusion of plantar fascia thickness as a structural outcome in the present study added a dimension of tissue-level response, which has been rarely examined in other reviews. In summary, our study emphasises the superiority of prolotherapy with dextrose for sustained pain relief, short-term advantages of BTA injection, and structural benefits of PRP injection. Our findings have several major implications for clinical practice. First, intervention for plantar fasciitis should be tailored to timing and treatment goals, such as immediate symptom relief, functional recovery, and long-term tissue remodelling. For patients seeking rapid pain relief, BTA injection may be an effective option, given its rapid effects on pain and plantar fascia thickness. By contrast, prolotherapy with dextrose offers consistent mid- to long-term pain relief. Thus, this intervention may be an ideal option for chronic cases of plantar fasciitis, particularly when corticosteroids are contraindicated. PRP injection confers broad, long-term benefits in terms of both function and tissue regeneration and thus may be suitable for patients with subacute or chronic symptoms. Corticosteroid injection, although helpful for short-term functional gains, is best reserved for acute flares because of safety concerns with repeated use. LA injection can improve function but lacks lasting analgesic or structural benefits. ESWT leads to steady improvements across several domains, which may appeal to patients who prefer less invasive options. Our study supports a personalised, stage-specific treatment strategy for plantar fasciitis and emphasises the need to align intervention type with symptom duration and patient goals. Strengths and limitations This NMA involved a comprehensive synthesis of 63 RCTs evaluating both conservative and minimally invasive therapies for plantar fasciitis. By stratifying outcomes by duration, the analysis offers a nuanced and clinically relevant comparison. The use of a frequentist method with consistency assessment and treatment ranking improved the methodological quality of our study. This study has several limitations. First, moderate to high heterogeneity was noted across comparisons, primarily attributable to the difference in intervention protocol (online supplemental appendix 5). Second, local inconsistencies were noted in some comparisons, particularly involving BTA injection, prolotherapy, and placebo. Third, outcome measurements lacked uniform scoring systems, limiting cross-trial comparability. Finally, structural outcomes were reported in very few RCTs, which limited the power of comparisons. In the future, high-quality, head-to-head RCTs should be conducted to address the current evidence gaps. In addition, review studies should be conducted to compare longitudinal trials of minimally invasive therapies based on standardised protocols. More emphasis should be placed on integrating structural outcomes. For example, image-based evaluations of plantar fascia thickness could be performed to clarify the association between tissue changes and symptom relief. Furthermore, patient-centred outcomes, such as return activity and cost-effectiveness, should be incorporated to guide personalised treatment decisions. Conclusion The present NMA offers updated comparative evidence on conservative and minimally invasive therapies for plantar fasciitis. Prolotherapy with dextrose emerged as the most effective intervention for long-term pain relief. PRP injection and ESWT offered sustained functional and structural benefits. These findings advocate for a shift in therapeutic focus toward regenerative strategies and mechanotransduction-based interventions, tailored to patient needs, symptom chronicity, and integrated rehabilitation approaches. Declarations Acknowledgements We thank all researchers, clinicians, and participants involved in the reviewed studies on plantar fasciitis. Their work has been instrumental in improving our understanding of the condition and its treatment. Our review study relied on many high-quality trials exploring different interventions. We are especially grateful to the authors of the included studies for sharing their findings and making their data available. Their efforts made it possible to bring the evidence together in a meaningful way. We also acknowledge individuals who contributed to the development of network meta-analysis methods, particularly in musculoskeletal and rehabilitation research. Finally, we thank all individuals who supported us during the process, including those who helped with literature search, data collection, and coordination. Funding The research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Competing interests The authors declare no conflicts of interest. Contributors CHT was the first author of this research. The author contributions were as follows: CHT, JJL: study concept and design. CHT, and YLS: title screening; data extraction, and study quality assessment. CHT, YCK, and MCC: data analysis, and interpretation. CHT, and JJL: manuscript preparation and revision. All authors have read and approved the final manuscript. Patient consent for publication Not applicable Ethics approval Not applicable Data availability statement All data are available from the corresponding author upon reasonable request. ORCID IDs Cheng Hao, Tien https://orcid.org/0009-0009-4922-4121 Jason Jiunshiou Lee https://orcid.org/0000-0003-3638-8492 References Buchbinder R. Clinical practice. Plantar fasciitis. N Engl J Med. 2004 May 20;350(21):2159–66. Landorf KB, Keenan AM, Herbert RD. Effectiveness of Foot Orthoses to Treat Plantar Fasciitis: A Randomized Trial. Arch Intern Med. 2006 June 26;166(12):1305–10. Goff JD, Crawford R. Diagnosis and treatment of plantar fasciitis. Am Fam Physician. 2011 Sept 15;84(6):676–82. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002 Apr;36(2):95–101. Chen L. 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Supplementary Files Supplementalcontent.pdf Tables.docx Cite Share Download PDF Status: Published Journal Publication published 14 Feb, 2026 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 07 Jan, 2026 Reviews received at journal 05 Jan, 2026 Reviewers agreed at journal 05 Jan, 2026 Reviewers agreed at journal 03 Jan, 2026 Reviewers agreed at journal 03 Jan, 2026 Reviews received at journal 13 Oct, 2025 Reviewers agreed at journal 23 Sep, 2025 Reviewers agreed at journal 21 Sep, 2025 Reviewers invited by journal 21 Sep, 2025 Editor invited by journal 08 Sep, 2025 Editor assigned by journal 05 Sep, 2025 Submission checks completed at journal 04 Sep, 2025 First submitted to journal 03 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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The digits represent the numbers of trials.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7527438/v1/4112203b9892c7365e78c882.png"},{"id":92733672,"identity":"2d9c9f00-6550-4044-b90a-a88a230d629c","added_by":"auto","created_at":"2025-10-03 16:20:58","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":242464,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eNetwork plot for foot function.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ea. Short-term improvement in foot function\u003c/p\u003e\n\u003cp\u003eb. Mid-term improvement in foot function\u003c/p\u003e\n\u003cp\u003ec. Long-term improvement in foot function\u003c/p\u003e\n\u003cp\u003e*Each node represents an intervention. The digits represent the numbers of trials.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7527438/v1/24594d0eea7bdf5f7ea72e0e.png"},{"id":92733679,"identity":"b44164bf-8598-428a-bb39-dbdfa31ad887","added_by":"auto","created_at":"2025-10-03 16:20:59","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":188327,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eNetwork plot for plantar fascia thickness.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ea. Short-term reduction in plantar fascia thickness\u003c/p\u003e\n\u003cp\u003eb. Mid-term reduction in plantar fascia thickness\u003c/p\u003e\n\u003cp\u003ec. Long-term reduction in plantar fascia thickness\u003c/p\u003e\n\u003cp\u003e*Each node represents an intervention. The digits represent the numbers of trials.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7527438/v1/4ec9410732ca74f84998d54e.png"},{"id":102786196,"identity":"cf2a7b72-4ad6-476a-9aee-9b56d8e482a5","added_by":"auto","created_at":"2026-02-16 16:12:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1724568,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7527438/v1/a87d0a7e-8b8d-4564-a0b6-9d85c6ff73c3.pdf"},{"id":92733667,"identity":"6b6edbf8-2978-412c-8dc1-8a3e27816b9e","added_by":"auto","created_at":"2025-10-03 16:20:58","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1717620,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementalcontent.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7527438/v1/e8eabeacbfe450d50531bdbc.pdf"},{"id":92733666,"identity":"8b5364dd-c2ac-4017-8335-07ad3d5ddec1","added_by":"auto","created_at":"2025-10-03 16:20:58","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":61276,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7527438/v1/5ac35caf10e78f5f6f2ca7b1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative effectiveness of minimally invasive therapies for plantar fasciitis: A systematic review and network meta-analysis","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003ePlantar fasciitis is among the most common causes of heel pain, accounting for 11%–15% of all foot-related complaints in primary and sports medicine clinics.[1] Epidemiological data suggest that approximately one million US individuals develop plantar fasciitis every year, with most of these individuals being older adults or athletes, particularly runners.[2,3] Among runners, plantar fasciitis is the third most frequent overuse injury, accounting for 10% of all running-related complications.[4] This condition typically results from repetitive microtrauma and excessive mechanical loading at the plantar fascia’s insertion on the medial calcaneal tubercle, leading to inflammation, collagen degeneration, and compromised shock absorption in the heel pad.[5] These symptoms tend to resolve spontaneously; however, related pain can persist for months or longer, substantially impairing mobility, limiting participation in physical activities, and compromising occupational performance. Chronic plantar fasciitis, defined as symptoms lasting beyond 6 months, occurs in up to 10% of all cases and is associated with poor prognostic outcomes.[1,3,6]\u003c/p\u003e\n\u003cp\u003eVarious treatment options are available for alleviating pain and restoring function in plantar fasciitis. Activity modification, stretching exercises, nonsteroidal anti-inflammatory drugs, and foot orthoses are examples of conservative treatment options.[1] Minimally invasive therapies, such as extracorporeal shock wave therapy (ESWT), prolotherapy, platelet-rich plasma (PRP) injection, botulinum toxin A (BTA) injection, local anaesthetic (LA) injection, autologous blood injection, and corticosteroid injection, are selected when first-line treatment has failed. These interventions function through the application of mechanical stimuli, modulation of inflammatory cascades, or promotion of tissue regeneration.[7,8] Robust data from direct head-to-head trials comparing diverse treatment modalities are scarce, limiting clinicians’ ability to determine which approach would yield superior outcomes over different timeframes.\u003c/p\u003e\n\u003cp\u003eSeveral meta-analyses and systematic reviews have evaluated the efficacy of individual plantar fasciitis treatments.[9–15] However, most of these studies were pairwise comparisons, investigated only short-term outcomes, or had narrow patient inclusion criteria. Consequently, key questions regarding the relative long-term effectiveness of these therapies remain unanswered, particularly in chronic or refractory cases where pain persists despite conservative management. Moreover, treatment guidelines from major organisations, such as the American College of Foot and Ankle Surgeons, the United Kingdom’s National Institute for Health and Care Excellence, and the American Physical Therapy Association, differ in their recommendations, reflecting differences between studies and in the priorities of healthcare systems.[16–19]\u003c/p\u003e\n\u003cp\u003eTo address this knowledge gap and support evidence-based decision-making, we performed a comprehensive network meta-analysis (NMA) of randomised controlled trials (RCTs) comparing injectable and device-based interventions for plantar fasciitis. Unlike pairwise meta-analysis, NMA allows for simultaneous comparison of multiple interventions, even those not directly compared in head-to-head trials, thereby establishing a comprehensive hierarchy of effectiveness. This approach is particularly useful for assessing relative long-term effectiveness across diverse treatment modalities and can offer clinicians a complete picture of interventions with superior benefits. The present analysis focused on three clinically meaningful outcomes (pain intensity, foot function, and plantar fascia thickness) across short-, mid-, and long-term follow-up periods. We assessed confidence in the evidence for each comparison by using the Confidence in Network Meta-Analysis (CINeMA) framework[20], aiming to provide an updated, clinically relevant hierarchy of treatment effectiveness. The findings may guide physicians in providing personalised, evidence-based care for plantar fasciitis, which remains a prevalent and disabling condition in both general and athletic populations.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis systematic review and NMA was registered with International Prospective Register of Systematic Reviews database (identifier: CRD420250641285). The study protocol adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension statement for systematic reviews that incorporate network meta-analyses of healthcare interventions.[21]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData sources and search strategy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePubMed, MEDLINE, Embase, Cochrane Library, Web of Science, and CINAHL (through EBSCO) were comprehensively searched for relevant articles published from database inception to February 2025. No language or publication date–related restrictions were applied. The search terms included MeSH and free-text keywords for ‘plantar fasciitis’ and related minimally invasive interventions. Complete search strategies for each database are provided in the online supplementary appendix 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eArticle selection criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe included randomised controlled trials (RCTs) that focused on adults (≥18 years) with plantar fasciitis without a history of surgical intervention. Eligible interventions included ESWT; prolotherapy; and injections of PRP, BTA, LAs, autologous blood, or corticosteroids. Studies were included if they compared these interventions with each other or with conservative treatments (e.g. physiotherapy, stretching, orthoses, taping, or placebo). Studies were required to report at least one of the following primary outcomes: pain intensity, foot function, and plantar fascia thickness.\u003c/p\u003e\n\u003cp\u003eStudies were excluded if they were not randomised; if they were observational studies, case series, reviews, editorials, conference abstracts, or animal studies; if they involved participants aged \u0026lt;18 years; or if they focused on heel pain from causes other than plantar fasciitis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eArticle selection and data extraction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter defining eligibility, we implemented a two-stage selection process. Duplicate records across databases were identified and removed before screening to ensure unique study records. Two reviewers, Tien and Shen, independently screened the titles and abstracts of the identified articles. This was followed by a full-text review of potentially eligible articles. Discrepancies were resolved through between-reviewer discussion or consultation with a third reviewer, Lee.\u003c/p\u003e\n\u003cp\u003eThe following data were extracted: first author, publication year, study design, country, inclusion criteria, sample size, participant demographics, intervention and comparator details, follow-up duration, and outcome measures.\u003c/p\u003e\n\u003cp\u003eWhen studies reported medians, ranges, or interquartile ranges instead of mean ± standard deviation values, summary statistics were estimated using validated methods.[22,23] If key data were missing, corresponding authors were contacted for clarification or additional information. If no response was received after repeated attempts, studies were included with the available data only. Studies published in a language other than English were excluded during the full-text review phase.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRisk-of-bias assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe risk of bias in each included RCT was assessed using the Cochran Risk-of-Bias 2.0 (RoB 2) tool, evaluating five domains: randomisation process, deviations from intended interventions, missing outcome data, measurement of outcomes, and selection of reported results.[24,25] On the basis of questions included in the RoB 2 framework, each domain was rated as having a low risk of bias, some concerns, or a high risk of bias. Certainty of evidence was evaluated using the CINeMA framework (https://cinema.ispm.unibe.ch/), a validated tool for appraising NMA findings. Two reviewers (Tien and Shen) independently performed the assessments, with disagreements resolved through between-reviewer discussion or consultation with a third reviewer (Lee).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePain intensity was assessed using a visual analogue scale, numerical rating scale, or the Foot Health Status Questionnaire.\u003c/p\u003e\n\u003cp\u003eFoot function was assessed using validated instruments such as the Foot Function Index, Foot and Ankle Ability Measure, American Orthopaedic Foot and Ankle Society score, Foot Health Status Questionnaire, Foot and Ankle Disability Index, or Maryland Foot Score. Foot Function Index scores were reversed (i.e. higher scores reflected better function).\u003c/p\u003e\n\u003cp\u003ePlantar fascia thickness was measured through imaging studies and reported in millimetres.\u003c/p\u003e\n\u003cp\u003eThe outcome measures were stratified by follow-up duration into short-term (≤6 weeks), mid-term (\u0026gt;6 to ≤12 weeks), and long-term (\u0026gt;12 weeks) outcomes. When multiple time points were reported, the measurement closest to the defined cutoff was used.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA frequentist random-effects NMA was performed using the netmeta package in R (version 4.5.0; R Foundation for Statistical Computing, Vienna, Austria).[26] Mean difference and standardised mean difference (SMD) values with corresponding 95% confidence intervals (CIs) were calculated. Treatment comparisons were structured using the pairwise function in R to generate contrast-based data from raw means, standard deviations, and sample sizes of each two-arm comparison. The data were then analysed using the netmeta function.[27]\u003c/p\u003e\n\u003cp\u003eTreatments were ranked by P scores from 0 (\u003cem\u003eworst\u003c/em\u003e) to 1 (\u003cem\u003ebest\u003c/em\u003e). These scores are mathematically equivalent to the Surface Under the Cumulative Ranking scores in Bayesian analyses.[28] Network consistency was assessed globally by using the design-by-treatment interaction model and locally through node-splitting analyses.[29] Interstudy heterogeneity was evaluated in terms of variance (τ²) and the \u003cem\u003eI\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e statistic, with \u003cem\u003eI\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e values of \u0026gt;50% indicating moderate heterogeneity.[30]\u003c/p\u003e\n\u003cp\u003eSensitivity analyses excluded trials at high risk of bias or requiring imputed means or standard deviations from medians, ranges, or interquartile ranges. Treatment effects were considered robust if exclusions did not materially alter the overall results or treatment ranks.\u003c/p\u003e\n\u003cp\u003ePublication bias was assessed using comparison-adjusted funnel plots for each outcome included in the NMA.[31] In addition, Egger’s test for funnel plots was applied. All analyses were two-tailed, and statistical significance was set at \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient and public involvement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo individuals with lived experience of plantar fasciitis- one recreational runners and one older adult with chronic symptoms. They were consulted when developing the research question and protocol for this review. Their perspectives informed the selection of minimal invasive intervention, and inclusion of outcomes across different timeframes. The advisory group also discussed the key findings and provide suggestion on a plain language summary. Findings from the research will be disseminated locally and nationally and outreach through musculoskeletal health networks. \u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eReview sample\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInitial literature search yielded 4,841 articles. After duplicate removal, 1,876 unique studies were subjected to title and abstract screening. Of these articles, 1,288 did not meet the eligibility criteria. The remaining 588 articles were subjected to full-text review, which resulted in the exclusion of 156 studies because of having irrelevant populations or interventions, 259 for not being RCTs, 17 for being animal studies, 39 for not being published in English, and 54 for lacking sufficient data. Ultimately, 63 RCTs were included in the final analysis (figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe included studies involved a total of 4,170 participants and evaluated nine interventions, including control (conservative) treatment and normal saline injection (placebo). The test interventions included ESWT, dextrose injection (prolotherapy), corticosteroid injection, BTA injection, PRP injection, LA injection, and autologous blood injection. The RCTs were published between 1999 and 2024. Follow-up duration ranged from 3 to 156 weeks. The studies were conducted in various countries, reflecting global interest in the treatment of plantar fasciitis. The distribution by country was as follows: Australia (n = 2),[32,33] Canada (n = 2),[34,35] China (n = 3),[36\u0026ndash;38] Denmark (n = 1),[39] Egypt (n = 4),[40\u0026ndash;43] Germany (n = 2),[44,45] India (n = 12),[46\u0026ndash;57] Iran (n = 8),[58\u0026ndash;65] Jordan (n = 1),[66] South Korea (n = 1),[67] Malaysia (n = 1),[68] Mexico (n = 2),[69,70] Nepal (n = 1),[71] Singapore (n = 1),[72] Spain (n = 2),[73,74] Taiwan (n = 2),[75,76] Turkey (n = 11),[77\u0026ndash;87] the United Kingdom (n = 3),[88\u0026ndash;90] and the United States (n = 4).[91\u0026ndash;94] Participants were recruited primarily from primary care facilities or outpatient clinics (online supplemental appendix 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy quality\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRisk of bias was evaluated using RoB 2. Regarding bias due to the randomisation process, 92.1% of the included studies had a low risk, whereas 7.9% had some concerns. Regarding bias due to deviations from intended intervention, 69.8% of the studies had a low risk, 4.8% had some concerns, and 25.4% had a high risk. Regarding bias due to missing outcome data, 82.5% of the studies had a low risk, whereas 17.5% had some concerns. Regarding bias due to measurement of outcomes, 90.5% of the studies had a low risk, whereas 9.5% had some concerns. Regarding bias due to selection of reported results, 98.4% of the studies had a low risk, whereas the remaining 1.6% had a high risk. Overall, 71.4% of the included studies had a low risk of bias, 3.2% had some concerns, and 25.4% had a high risk of bias. These findings indicate that the studies generally had robust methodological quality (figure 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eShort-term outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePain relief\u003c/p\u003e\n\u003cp\u003ePain relief outcomes were synthesised from 48 RCTs involving 3,123 participants. All interventions were included in this analysis (figure 3a). The NMA revealed no evidence of global inconsistency (Q statistic, \u003cem\u003ep\u003c/em\u003e = 0.25). Local inconsistency was observed in comparisons of BTA and corticosteroids with placebo (node-splitting analysis, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe following interventions were significantly more effective than placebo at alleviating pain: BTA injection (SMD: 2.09; 95% CI: 1.28\u0026ndash;2.91), PRP injection (SMD: 1.05; 95% CI: 0.22\u0026ndash;1.87), ESWT (SMD: 0.94; 95% CI: 0.09\u0026ndash;1.80), and corticosteroid injection (SMD: 0.91; 95% CI: 0.12\u0026ndash;1.70). Furthermore, BTA injection was significantly more effective than control treatment at reducing pain (SMD: 0.74; 95% CI: 0.05\u0026ndash;1.43) (table 1A). On the basis of P score, BTA injection obtained the highest rank (score: 0.95; table 2).\u003c/p\u003e\n\u003cp\u003eFoot function\u003c/p\u003e\n\u003cp\u003eFoot function outcomes were synthesised from 30 RCTs involving 1,855 participants. All interventions were included in this analysis (figure 4a). No significant global (Q statistic, \u003cem\u003ep\u003c/em\u003e = 0.99) or local inconsistencies (node-splitting analysis, \u003cem\u003ep\u003c/em\u003e \u0026gt; 0.05) were detected.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe following treatments were significantly more effective than placebo in improving foot function: autologous blood injection (SMD: 2.03; 95% CI: 0.36\u0026ndash;3.71), BTA injection (SMD: 2.39; 95% CI: 1.40\u0026ndash;3.39), control treatment (SMD: 2.34; 95% CI: 1.10\u0026ndash;3.58), prolotherapy (SMD: 2.47; 95% CI: 1.19\u0026ndash;3.76), ESWT (SMD: 2.41; 95% CI: 1.15\u0026ndash;3.67), PRP injection (SMD: 2.38; 95% CI: 1.16\u0026ndash;3.60), and corticosteroid injection (SMD: 2.48; 95% CI: 1.28\u0026ndash;3.67). Compared with LA injection, the following treatments were significantly effective in improving foot function: BTA injection (SMD: 1.81; 95% CI: 0.56\u0026ndash;3.07), control treatment (SMD: 1.82; 95% CI: 0.59\u0026ndash;3.04), prolotherapy (SMD: 1.95; 95% CI: 0.69\u0026ndash;3.21), ESWT (SMD: 1.89; 95% CI: 0.65\u0026ndash;3.13), PRP injection (SMD: 1.86; 95% CI: 0.67\u0026ndash;3.05), and corticosteroid injection (SMD: 2.01; 95% CI: 0.75\u0026ndash;3.28) (table 3A). On the basis of P score, corticosteroid injection obtained the highest rank (score: 0.74), whereas placebo obtained the lowest rank (score: 0.03; table 4).\u003c/p\u003e\n\u003cp\u003ePlantar fascia thickness\u003c/p\u003e\n\u003cp\u003ePlantar fascia thickness outcomes were synthesised from 14 RCTs involving 922 participants. BTA injection, placebo, PRP injection, and corticosteroid injection were included in this analysis (figure 5a). No significant global inconsistency was observed (Q statistic, \u003cem\u003ep\u003c/em\u003e = 0.08). Local inconsistency was detected between BTA injection and placebo and between placebo and corticosteroid injection (node-splitting analysis, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBTA injection was significantly more effective than placebo in reducing plantar fascia thickness (SMD: 1.64; 95% CI: 0.56\u0026ndash;2.73), and corticosteroid injection was superior to PRP injection (SMD: 0.69; 95% CI: 0.08\u0026ndash;1.30) (table 5A). On the basis of P score, BTA obtained the highest rank (score: 0.90), whereas placebo obtained the lowest rank (score: 0.22; table 6).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMid-term outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePain relief\u003c/p\u003e\n\u003cp\u003ePain relief outcomes were synthesised from 48 RCTs involving 3,360 participants. All interventions were included in this analysis (figure 3b). Global inconsistency was acceptable (Q statistic, \u003cem\u003ep\u003c/em\u003e = 0.09). Local inconsistency was detected in comparisons between prolotherapy and placebo and between placebo and corticosteroid injection (node-splitting analysis, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05).\u003c/p\u003e\n\u003cp\u003eAll interventions significantly outperformed placebo in alleviating pain: autologous blood injection (SMD: 1.99; 95% CI: 0.62\u0026ndash;3.37), BTA injection (SMD: 2.57; 95% CI: 1.53\u0026ndash;3.61), control treatment (SMD: 2.19; 95% CI: 1.12\u0026ndash;3.26), prolotherapy (SMD: 5.48; 95% CI: 3.57\u0026ndash;7.39), ESWT (SMD: 2.31; 95% CI: 1.27\u0026ndash;3.36), LA injection (SMD: 2.36; 95% CI: 0.97\u0026ndash;3.75), PRP injection (SMD: 2.45, 1.44\u0026ndash;3.47), and corticosteroids (SMD: 1.96; 95% CI: 0.99\u0026ndash;2.94). Compared with corticosteroid injection, prolotherapy (SMD: 0.75; 95% CI: 0.02\u0026ndash;1.48) and PRP injection (SMD: 0.49; 95% CI: 0.12\u0026ndash;0.86) significantly alleviated pain (table 1B). On the basis of P score, prolotherapy with dextrose obtained the highest rank (score: 0.84), whereas placebo obtained the lowest rank (score: 0.0003; table 2).\u003c/p\u003e\n\u003cp\u003eFoot function\u003c/p\u003e\n\u003cp\u003eFoot function outcomes were synthesised from 30 RCTs involving 1,912 participants. All interventions were included in this analysis (figure 4b). Global inconsistency was nonsignificant (Q statistic, \u003cem\u003ep\u003c/em\u003e = 0.92). Local inconsistencies were noted in comparisons between BTA and LA injections, between BTA and corticosteroid injections, and between LA and corticosteroid injections (node-splitting analysis, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05).\u003c/p\u003e\n\u003cp\u003eThe following treatments led to significantly greater improvements in foot function than did placebo: autologous blood injection (SMD: 3.00; 95% CI 0.83\u0026ndash;5.17), BTA injection (SMD: 2.44; 95% CI: 1.11\u0026ndash;3.76), control treatment (SMD: 2.51; 95% CI: 1.10\u0026ndash;3.93), prolotherapy (SMD: 2.34; 95% CI: 0.58\u0026ndash;4.09), ESWT (SMD: 2.90; 95% CI: 1.45\u0026ndash;4.36), and LA injection (SMD: 3.41; 95% CI: 1.52\u0026ndash;5.31). Compared with BTA, LA injection (SMD: 2.33; 95% CI: 0.53\u0026ndash;4.13) and corticosteroid injection (SMD: 2.47; 95% CI: 0.68\u0026ndash;4.27) significantly improved foot function. Furthermore, PRP injection was superior to corticosteroid injection (SMD: 0.76; 95% CI: 0.29\u0026ndash;1.22) (table 3B). On the basis of P score, PRP injection obtained the highest rank (score: 0.84), whereas placebo obtained the lowest rank (score: 0.0005; table 4).\u003c/p\u003e\n\u003cp\u003ePlantar fascia thickness\u003c/p\u003e\n\u003cp\u003ePlantar fascia thickness outcomes were synthesised from 16 RCTs involving 1,048 participants. Two of the trials had three-arm designs. The intervention network is depicted in figure 5b. Global inconsistency was nonsignificant (Q statistic, \u003cem\u003ep\u003c/em\u003e = 0.89), and no local inconsistency was detected (node-splitting analysis, \u003cem\u003ep\u003c/em\u003e \u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003eThe following two interventions significantly outperformed placebo in reducing plantar fascia thickness: BTA injection (SMD: 2.32; 95% CI: 0.55\u0026ndash;4.08) and PRP injection (SMD: 1.64; 95% CI: 0.17\u0026ndash;3.12). PRP injection was significantly superior to control treatment (SMD: 0.99; 95% CI: 0.03\u0026ndash;1.95) and corticosteroid injection (SMD: 0.91; 95% CI: 0.06\u0026ndash;1.77) (table 5B). On the basis of P score, PRP obtained the highest rank (score: 0.81), whereas placebo obtained the lowest rank (score: 0.10). The remaining interventions (ESWT, prolotherapy, and corticosteroid injection) obtained intermediate or low ranks (table 6).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLong-term outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePain relief\u003c/p\u003e\n\u003cp\u003ePain relief outcomes were synthesised from 32 RCTs involving 2,142 participants (figure 3c). Global inconsistency was nonsignificant (Q statistic, \u003cem\u003ep\u003c/em\u003e = 0.68). Local inconsistencies were detected in comparisons between BTA injection and placebo and between prolotherapy and placebo (node-splitting analysis, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05).\u003c/p\u003e\n\u003cp\u003eThe following treatments significantly outperformed placebo in alleviating pain: autologous blood injection (SMD: 4.08; 95% CI: 2.43\u0026ndash;5.73), BTA injection (SMD: 3.16; 95% CI: 1.85\u0026ndash;4.47), control treatment (SMD: 4.31; 95% CI: 2.85\u0026ndash;5.77), prolotherapy (SMD; 7.10; 95% CI: 5.02\u0026ndash;9.18), ESWT (SMD: 4.74; 95% CI: 3.27\u0026ndash;6.20), LA injection (SMD: 4.19; 95% CI: 2.61\u0026ndash;5.76), PRP injection (SMD: 5.02; 95% CI: 3.61\u0026ndash;6.43), and corticosteroid injection (SMD: 4.18; 95% CI: 2.78\u0026ndash;5.58). Compared with corticosteroid injection, prolotherapy (SMD: 1.15; 95% CI: 0.10\u0026ndash;2.20) and PRP (SMD: 0.93; 95% CI: 0.48\u0026ndash;1.38) significantly alleviated pain. PRP injection outperformed BTA injection (SMD: 1.15; 95% CI: 0.12\u0026ndash;2.19) (table 1C). On the basis of P score, prolotherapy with dextrose obtained the highest rank (score: 0.93), whereas placebo obtained the lowest rank (score: 0; table 2).\u003c/p\u003e\n\u003cp\u003eFoot function\u003c/p\u003e\n\u003cp\u003eFoot function outcomes were synthesised from 28 RCTs involving 1,720 participants (figure 4c). Global inconsistency was acceptable (Q statistic, \u003cem\u003ep\u003c/em\u003e = 0.66). Significant local inconsistencies were noted between BTA and LA injections, between BTA and corticosteroid injections, and between LA and corticosteroid injections (node-splitting analysis, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05).\u003c/p\u003e\n\u003cp\u003eThe following treatments significantly outperformed placebo in improving foot function: autologous blood injection (SMD: 3.65; 95% CI 1.23\u0026ndash;6.07), BTA injection (SMD: 2.64; 95% CI: 1.20\u0026ndash;4.09), control treatment (SMD: 2.74; 95% CI: 1.14\u0026ndash;4.33), prolotherapy (SMD: 2.69; 95% CI: 0.73\u0026ndash;4.65), ESWT (SMD: 3.65; 95% CI: 2.00\u0026ndash;5.29), LA injection (SMD: 4.96; 95% CI: 2.81\u0026ndash;7.11), PRP injection (SMD: 3.73; 95% CI: 2.23\u0026ndash;5.24), and corticosteroid injection (SMD: 2.62; 95% CI: 1.12\u0026ndash;4.13). ESWT (SMD: 1.02; 95% CI: 0.10\u0026ndash;1.95), LA injection (SMD: 2.34; 95% CI: 0.52\u0026ndash;4.16), and PRP injection (SMD: 1.23; 95% CI: 0.72\u0026ndash;1.73) outperformed corticosteroid injection. However, corticosteroid injection was significantly more effective than BTA injection (SMD: 2.36; 95% CI: 0.38\u0026ndash;4.33) (table 3C). On the basis of P score, LA injection obtained the highest rank (score: 0.95), whereas placebo obtained the lowest rank (score: 0.0003; table 4).\u003c/p\u003e\n\u003cp\u003ePlantar fascia thickness\u003c/p\u003e\n\u003cp\u003ePlantar fascia thickness outcomes were synthesised from eight RCTs involving 468 participants (figure 5c). Global consistency was acceptable (Q statistic, \u003cem\u003ep\u003c/em\u003e = 0.64), and no significant local inconsistency was detected (node-splitting analysis, \u003cem\u003ep\u003c/em\u003e \u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003ePRP injection led to significantly greater reductions in plantar fascia thickness than did corticosteroid injection (SMD: 0.95; 95% CI: 0.40\u0026ndash;1.50) (table 5C). On the basis of P score, PRP obtained the highest rank (score: 0.86), whereas LA injection (score: 0.24) and corticosteroid injection (score: 0.26) obtained the lowest ranks (table 6).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePublication bias\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePublication bias was assessed using comparison-adjusted funnel plots and Egger\u0026rsquo;s regression test. The funnel plots appeared symmetrical, and Egger\u0026rsquo;s test revealed no significant asymmetry (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026gt; 0.05). These findings suggest a low risk of publication bias across the network (online supplemental appendix 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConfidence in evidence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCINeMA framework across six domains: within-study bias, reporting bias, indirectness, imprecision, heterogeneity, and incoherence was assessed the confidence in the evidence. Ratings ranged from very low to high confidence depending on the different comparisons, outcome and follow-up duration. A full CINeMA summary table with domain-level judgements and overall confidence rating is available in online supplemental appendix 4.\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eSummary of results\u003c/h2\u003e\u003cp\u003eOur NMA of 63 RCTs established an updated evidence hierarchy for conservative and minimally invasive therapies for plantar fasciitis across three outcome domains: pain relief, foot function, and plantar fascia thickness. The findings offer clear guidance for both acute and chronic cases. Regarding pain relief, BTA injection (P score: 0.95) was most the effective intervention in the short term (\u0026lt;\u0026thinsp;6 weeks after treatment), followed by PRP injection (P score: 0.75) and ESWT (P score: 0.62), whereas prolotherapy with dextrose was the most effective intervention in both middle term (6\u0026ndash;12 weeks) and long term (\u0026ge;\u0026thinsp;12 weeks; P score: 0.84 and 0.93, respectively). Regarding improvement in foot function, corticosteroid injection was the most effective intervention in the short term (P score 0.74), PRP injection in the middle term (P score: 0.84), and LA injection in the long term (P score: 0.95). Regarding reduction in plantar fascia thickness, BTA injection was the most effective intervention in the short term (P score: 0.90), whereas PRP injection was the most effective intervention in both middle and long terms (P score: 0.81 and 0.86, respectively).\u003c/p\u003e\u003cp\u003eThis NMA is among the first to concurrently synthesise data across pain, foot function, and structural outcomes. Our study provides a comprehensive overview of therapeutic efficacy with direct implication for evidence-based clinical decision-making. The observed temporal and domain-specific efficacy profiles are consistent with known biological mechanisms underlying plantar fasciitis (e.g. microtears, degenerative collagen remodelling, fibroblast dysregulation, and neurogenic inflammation).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eBTA injection\u003c/h2\u003e\u003cp\u003eBTA injection was the most effective intervention in alleviating pain and reducing plantar fascia thickness in the short term. This aligns with BTA\u0026rsquo;s known mechanism of action: it inhibits acetylcholine release at neuromuscular junctions and thus reduces calf muscle spasticity and plantar fascia tension, rapidly alleviating pain. However, consistent with the findings of another meta-analysis[\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e], BTA\u0026rsquo;s benefit appears transient. We observed no sustained superiority of BTA after approximately 3 months.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eProlotherapy\u003c/h2\u003e\u003cp\u003eProlotherapy with dextrose was the most effective intervention in consistently alleviating pain, particularly in the middle and long terms. This finding supports dextrose\u0026rsquo;s proposed mechanism of action: dextrose induces a local inflammation response, which promotes fibroblast proliferation, collagen synthesis, and tissue repair, ultimately leading to gradual pain relief.[\u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e96\u003c/span\u003e] Therefore, prolotherapy may hold promise for sustained symptom relief, particularly in chronic plantar fasciitis.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eCorticosteroid injection\u003c/h2\u003e\u003cp\u003eCorticosteroid injection was the most effective intervention in improving foot function in the short term. Through their anti-inflammatory properties, corticosteroids suppress proinflammatory cytokines and reduce local tissue oedema, leading to rapid symptom relief. The analgesic effect of corticosteroid injection was inferior to that of prolotherapy and PRP injection in middle and long terms. Furthermore, corticosteroid injection exhibited only limited effectiveness in reducing plantar fascia thickness. Repeated steroid injection has been associated with adverse effects such as plantar fascia rupture and fat pad atrophy.[\u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e97\u003c/span\u003e] Although corticosteroid injection remains a common intervention for managing acute plantar fasciitis, its long-term use should be prescribed with caution.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003ePRP injection\u003c/h2\u003e\u003cp\u003ePRP injection yielded favourable mid- and long-term outcomes in terms of pain relief, foot function improvement, and plantar fascia thickness reduction. PRP contains high concentrations of growth factors, including platelet-derived growth factor and transforming growth factor-β. These factors promote angiogenesis, facilitate tissue regeneration, and modulate inflammation.[\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e98\u003c/span\u003e] PRP injection outperformed corticosteroid and BTA injections in facilitating fascial remodelling. Thus, PRP appears to be a bioactive treatment option with sustained effects, having potential for long-term recovery and structural improvement.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eLA injection\u003c/h2\u003e\u003cp\u003eLA injection led to marked improvements in foot function, particularly in long term. However, its analgesic effect was relatively modest and short-lived. In terms of pain relief, LA injection ranked lower than dextrose and PRP injections. Furthermore, LA injection exerted a minimal effect on plantar fascia thickness, which suggests that its mechanism of action may be limited to temporary sensory blockade rather than underlying tissue repair. These findings indicate that LA injection leads to temporary functional improvement, likely through a mechanism involving reduced protective muscle guarding or improved tolerance to foot movement.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003eESWT\u003c/h2\u003e\u003cp\u003eESWT exerts its effects through mechanotransduction, which involves nitric oxide\u0026ndash;mediated signalling, enhanced neovascularisation, and nociceptor desensitisation, resulting in gradual and lasting improvements in pain relief.[\u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e99\u003c/span\u003e] In the present study, ESWT exhibited efficacy across all time points, consistent with the findings of a meta-analysis supporting its long-term effects and noninvasive advantages.[\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e]\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\u003ch2\u003eComparison with prior evidence\u003c/h2\u003e\u003cp\u003eOur findings both confirm and extend those of prior systematic reviews evaluating minimally invasive therapies for plantar fasciitis. Some of these studies focused on injection or acupuncture,[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] whereas others focused on energy-based treatments[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] or surgical options, excluding conventional treatments.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Studies centred solely on pain or foot function without incorporating structural parameter did not provide a complete picture of clinical evaluation.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eOur NMA expands the literature in several directions. First, we incorporated a broader range of interventions, including BTA and prolotherapy, which have been underrepresented in prior analyses. Second, we stratified treatment effects into short-, mid-, and long-term outcomes. This revealed time-dependent differences in efficacy that were less evident in previous pooled estimates. A prior review highlighted the early effects of corticosteroid, whereas our results provided insights beyond short-term effects: dextrose and PRP injections outperformed corticosteroid injection in alleviating pain and improving foot function beyond 6 weeks. Finally, the inclusion of plantar fascia thickness as a structural outcome in the present study added a dimension of tissue-level response, which has been rarely examined in other reviews. In summary, our study emphasises the superiority of prolotherapy with dextrose for sustained pain relief, short-term advantages of BTA injection, and structural benefits of PRP injection.\u003c/p\u003e\u003cp\u003eOur findings have several major implications for clinical practice. First, intervention for plantar fasciitis should be tailored to timing and treatment goals, such as immediate symptom relief, functional recovery, and long-term tissue remodelling. For patients seeking rapid pain relief, BTA injection may be an effective option, given its rapid effects on pain and plantar fascia thickness. By contrast, prolotherapy with dextrose offers consistent mid- to long-term pain relief. Thus, this intervention may be an ideal option for chronic cases of plantar fasciitis, particularly when corticosteroids are contraindicated. PRP injection confers broad, long-term benefits in terms of both function and tissue regeneration and thus may be suitable for patients with subacute or chronic symptoms. Corticosteroid injection, although helpful for short-term functional gains, is best reserved for acute flares because of safety concerns with repeated use. LA injection can improve function but lacks lasting analgesic or structural benefits. ESWT leads to steady improvements across several domains, which may appeal to patients who prefer less invasive options. Our study supports a personalised, stage-specific treatment strategy for plantar fasciitis and emphasises the need to align intervention type with symptom duration and patient goals.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003eThis NMA involved a comprehensive synthesis of 63 RCTs evaluating both conservative and minimally invasive therapies for plantar fasciitis. By stratifying outcomes by duration, the analysis offers a nuanced and clinically relevant comparison. The use of a frequentist method with consistency assessment and treatment ranking improved the methodological quality of our study.\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, moderate to high heterogeneity was noted across comparisons, primarily attributable to the difference in intervention protocol (online supplemental appendix 5). Second, local inconsistencies were noted in some comparisons, particularly involving BTA injection, prolotherapy, and placebo. Third, outcome measurements lacked uniform scoring systems, limiting cross-trial comparability. Finally, structural outcomes were reported in very few RCTs, which limited the power of comparisons.\u003c/p\u003e\u003cp\u003eIn the future, high-quality, head-to-head RCTs should be conducted to address the current evidence gaps. In addition, review studies should be conducted to compare longitudinal trials of minimally invasive therapies based on standardised protocols. More emphasis should be placed on integrating structural outcomes. For example, image-based evaluations of plantar fascia thickness could be performed to clarify the association between tissue changes and symptom relief. Furthermore, patient-centred outcomes, such as return activity and cost-effectiveness, should be incorporated to guide personalised treatment decisions.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe present NMA offers updated comparative evidence on conservative and minimally invasive therapies for plantar fasciitis. Prolotherapy with dextrose emerged as the most effective intervention for long-term pain relief. PRP injection and ESWT offered sustained functional and structural benefits. These findings advocate for a shift in therapeutic focus toward regenerative strategies and mechanotransduction-based interventions, tailored to patient needs, symptom chronicity, and integrated rehabilitation approaches.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all researchers, clinicians, and participants involved in the reviewed studies on plantar fasciitis. Their work has been instrumental in improving our understanding of the condition and its treatment. Our review study relied on many high-quality trials exploring different interventions.\u003c/p\u003e\n\u003cp\u003eWe are especially grateful to the authors of the included studies for sharing their findings and making their data available. Their efforts made it possible to bring the evidence together in a meaningful way.\u003c/p\u003e\n\u003cp\u003eWe also acknowledge individuals who contributed to the development of network meta-analysis methods, particularly in musculoskeletal and rehabilitation research.\u003c/p\u003e\n\u003cp\u003eFinally, we thank all individuals who supported us during the process, including those who helped with literature search, data collection, and coordination.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCHT was the first author of this research. The author contributions were as follows: CHT, JJL: study concept and design. CHT, and YLS: title screening; data extraction, and study quality assessment. CHT, YCK, and MCC: data analysis, and interpretation. CHT, and JJL: manuscript preparation and revision. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient consent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eORCID IDs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCheng Hao, Tien \u0026nbsp; https://orcid.org/0009-0009-4922-4121\u003c/p\u003e\n\u003cp\u003eJason Jiunshiou Lee \u0026nbsp;https://orcid.org/0000-0003-3638-8492\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBuchbinder R. Clinical practice. Plantar fasciitis. 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Open Med. 2016 Aug 12;11(1):242\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eRyskalin L, Morucci G, Natale G, Soldani P, Gesi M. Molecular Mechanisms Underlying the Pain-Relieving Effects of Extracorporeal Shock Wave Therapy: A Focus on Fascia Nociceptors. Life Basel Switz. 2022 May 17;12(5):743.\u003c/li\u003e\n \u003cli\u003eMajidi L, Khateri S, Nikbakht N, Moradi Y, Nikoo MR. The effect of extracorporeal shock-wave therapy on pain in patients with various tendinopathies: a systematic review and meta-analysis of randomized control trials. BMC Sports Sci Med Rehabil. 2024 Apr 24;16(1):93.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 6 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Plantar fasciitis, Minimal invasive therapies, Conservative therapy, Systematic review, and Network meta-analysis","lastPublishedDoi":"10.21203/rs.3.rs-7527438/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7527438/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePlantar fasciitis is a common and often disabling condition that affects both general and athletic populations, with chronic cases significantly impairing function and quality of life. Although a wide range of conservative and minimally invasive treatments are available, the absence of direct comparative evidence has limited clarity about which interventions offer the most durable benefits. We conducted a systematic review and network meta-analysis of 63 randomized controlled trials including 4170 participants to evaluate extracorporeal shock wave therapy, prolotherapy, and injection-based therapies including platelet-rich plasma, botulinum toxin A, corticosteroids, autologous blood, and local anaesthetics. Across short-, medium-, and long-term follow- up, botulinum toxin A provided the greatest short-term improvements in pain and plantar fascia thickness, where prolotherapy was most effective for sustained pain relief. Corticosteroids injection yielded the largest short-term function gains, while platelet-rich plasma supported the long-term improvements in both function and plantar fascia thickness. Extracorporeal shock wave therapy demonstrated broad efficacy across all domains and timepoints. These findings provide updated comparative evidence to guide clinical decision-making, suggesting that treatment strategies for plantar fasciitis should be tailored to symptom duration and therapeutic goals rather than defaulting to one intervention alone.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSystematic review registration\u003c/b\u003e: PROSPERO CRD420250641285\u003c/p\u003e","manuscriptTitle":"Comparative effectiveness of minimally invasive therapies for plantar fasciitis: A systematic review and network meta-analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-03 16:20:54","doi":"10.21203/rs.3.rs-7527438/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-07T09:01:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-05T15:16:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"65675983104358666685733915202527806360","date":"2026-01-05T14:35:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"78754889775672471217180833879213587219","date":"2026-01-04T00:14:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"239854623559871359871771182696573110514","date":"2026-01-03T16:02:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-13T10:46:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"157945504721958150410347380714480153907","date":"2025-09-23T08:10:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"157592642928431345198645718299279370779","date":"2025-09-22T03:50:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-22T00:18:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-08T10:37:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-05T16:13:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-04T05:20:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-09-03T13:10:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a7f4c18a-92ad-411c-ada4-12fe40d30ab1","owner":[],"postedDate":"October 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":55654160,"name":"Health sciences/Diseases"},{"id":55654161,"name":"Health sciences/Health care"},{"id":55654162,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-02-16T16:08:58+00:00","versionOfRecord":{"articleIdentity":"rs-7527438","link":"https://doi.org/10.1038/s41598-026-40038-z","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2026-02-14 15:59:23","publishedOnDateReadable":"February 14th, 2026"},"versionCreatedAt":"2025-10-03 16:20:54","video":"","vorDoi":"10.1038/s41598-026-40038-z","vorDoiUrl":"https://doi.org/10.1038/s41598-026-40038-z","workflowStages":[]},"version":"v1","identity":"rs-7527438","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7527438","identity":"rs-7527438","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}