Plantar heel pain

Plantar heel pain, usually diagnosed as plantar fasciitis, is pain under the heel where the plantar fascia, the band of tissue along the sole, attaches to the heel bone. It is typically worst with the first steps in the morning or after rest. The needling trials fall into three groups: dry needling, in which a physiotherapist or podiatrist needles tender trigger points in the calf and sole muscles; manual and electroacupuncture at acupuncture points, including points far from the foot; and Chinese trials that add warm needling, where burning mugwort heats the needle handle.

No Cochrane review

Cochrane has published no review of acupuncture for plantar heel pain. A protocol for one, by Seunghoon Lee and colleagues at Kyung Hee University and the Korea Institute of Oriental Medicine, was registered in 2013 to assess acupuncture, acupressure, electrotherapy and moxibustion. The Bone, Joint and Muscle Trauma Group withdrew it in October 2019, with the authors' agreement, for lack of progress, and states that there are no plans to republish it.

The broader Cochrane review of interventions for plantar heel pain, by Fay Crawford and Colin Thomson, searched to September 2002 and found 19 randomised trials with 1,626 participants, of poor quality overall and not pooled. Its abstract names no acupuncture or needling trial; it found limited evidence for corticosteroid by injection or iontophoresis and concluded that most treatments brought marginal gains over no treatment. Cochrane withdrew it in 2010 as substantially out of date, with discussions under way to split it by type of intervention.

Systematic reviews

At La Trobe University, Cotchett and colleagues found two trials reporting less pain when trigger point dry needling was combined with acupuncture, and one with lidocaine injections, all of poor quality on the Quality Index, a 27-point score of trial reporting and bias. Clark and Tighe, writing from the Peninsula College of Medicine and Dentistry in Plymouth, judged the evidence for acupuncture comparable to that for stretching, night splints or dexamethasone, and asked for trials to follow STRICTA, the reporting standard for acupuncture trials. Thiagarajah in Singapore found that pain fell between four and eight weeks of treatment with no further reduction after, and that the evidence was insufficient for a conclusion about the longer term.

He and Ma at Xinjiang Medical University excluded needling at traditional acupuncture points. They found pain 15.5 points lower on a 100-point visual analogue scale with trigger point needling than with control, but the share of people whose pain counted as a treatment success did not differ (risk ratio 1.15, 95% CI 0.87 to 1.51), and neither did adverse events. Llurda-Almuzara and colleagues at the Universitat Internacional de Catalunya reported pain 1.70 points lower on a 10-point scale in the short term and 1.77 points lower in the long term, and said the small number of trials calls for caution. The trials were at generally low risk of bias, and their disagreement with one another lowered the certainty.

Yang and colleagues in Chengdu found that dry needling added to routine treatment lowered pain and Foot Function Index scores, while against other treatments it improved function but not pain (95% CI −0.66 to 0.06). The network meta-analysis by Asokumaran and colleagues in Malaysia, which compares treatments directly and through common comparators, ranked acupuncture first at one month, 1.33 points better than placebo; at three months no treatment's confidence interval excluded no effect. Li and colleagues compared seven physical therapies, each added to home exercise, and found dry needling's effect on pain still present between six and twelve weeks. Dry needling describes how the method differs from acupuncture.

Two reviews compared dry needling with steroid injection. Sousa Filho and colleagues, pooling six trials across four conditions, rated the evidence very low certainty that injection reduces heel pain more in the short and medium term and needling more in the long term. Guimarães and colleagues, covering every treatment ever trialled, found dry needling among nine that reduced pain against control in the short term, and only shockwave therapy effective in the medium and long term.

Trials

Against sham or another point

• Dry needling against sham, 2014. Cotchett, Munteanu and Landorf at La Trobe University gave 84 people six weekly sessions of real or sham trigger point dry needling, with participants blinded but not the therapist. At six weeks first-step pain was 14.4 mm lower on a 100 mm scale with real needling, a difference smaller than the minimal important difference, the change patients notice. Four people needed treating for one to benefit. Minor transient adverse events followed 32% of real needling appointments and under 1% of sham ones.
• A wrist point against a hand point, 2011. At Hong Kong Baptist University, Zhang, Yip and Li randomised 53 people to 10 sessions over two weeks at PC07 (Daling), at the centre of the wrist crease, or at LI04 (Hegu), chosen as a control because it is held to relieve pain generally. Needles went in on the side opposite the painful heel. At one month morning pain had fallen by 22.6 points against 12.0, favouring PC07; at three and six months the groups differed little. No serious adverse event occurred.

Sham acupuncture sets out what an active control point does and does not control for.

Added to usual care

• Recreational athletes, 2011. Karagounis and colleagues in Greece treated 38 men with ice, anti-inflammatory drugs and stretching and strengthening, and added acupuncture for half. The acupuncture group's mean score on a plantar fasciitis pain scale was lower at the final measurement.
• Electroacupuncture, 2012. Kumnerddee and Pattapong in Bangkok gave 30 people with long-standing plantar fasciitis stretching, shoe modification and rescue painkillers, with or without 10 sessions of electroacupuncture, which passes a small current through the needles. Pain fell by at least half in 80% against 13.3%, and the difference in function held at six weeks.
• Electroacupuncture with exercise, 2026. In a multisite trial led from a US military medical centre in Nevada, Moss and colleagues randomised 72 people to a home exercise programme with or without electroacupuncture every two weeks for six weeks. Pain and foot function improved more in the acupuncture group over 12 weeks.

Against a waiting list or another form of acupuncture

• Warm needling, 2021. At a Chinese medicine centre in Hong Kong, Ho and colleagues randomised 80 people, mean age 60, to six sessions of electroacupuncture with warm needling over four weeks or a waiting list. First-step pain and foot function improved more with treatment at two and four weeks, and no study-related adverse event occurred.
• Electro against manual, 2021. In Beijing, Wang and colleagues gave 92 people 12 sessions of electroacupuncture or manual acupuncture. Pain halved in 54.8% and 50.0%, a difference within chance, and no secondary outcome differed through 28 weeks.
• High and low intensity, 2026. The same group randomised 120 people with recalcitrant plantar fasciitis to high-intensity acupuncture, low-intensity acupuncture or a waiting list. At four weeks 56.7% of the acupuncture groups combined were responders against 33.3%. At 16 weeks the high-intensity group's rate was 76.7% against 36.7%, and the low-intensity difference was not significant.

What guidelines say

The clinical practice guideline on heel pain from the Academy of Orthopaedic Physical Therapy and the American Academy of Sports Physical Therapy, by Koc and colleagues and published in December 2023, states that clinicians should use dry needling to trigger points in the calf and the plantar muscles of the foot for short- and long-term pain and long-term function. That is a grade B recommendation, meaning moderate evidence. Its 2014 edition had said, on expert opinion, that trigger point dry needling could not be recommended; the change rests on the 2021 meta-analysis and later trials. The guideline notes that dry needling was usually given alongside stretching and manual therapy, that reported harms were post-needling soreness and bleeding under the skin, and that it makes no recommendation on acupuncture. It is due to be considered for review in 2028.

The American College of Foot and Ankle Surgeons' clinical consensus statement, by Schneider and colleagues and published in 2018 as an update to its 2010 guideline, lists needling among other injection techniques that it rated uncertain, neither appropriate nor inappropriate, because they rested on low-quality studies without long-term follow-up. It does not address acupuncture. Clinical guidelines compares how guideline bodies treat acupuncture across conditions.

What the reviews could not settle

The one sham-controlled dry needling trial above found a difference smaller than patients are expected to notice, alongside far more minor adverse events with real needling. The acupuncture trials compared needling with a waiting list, with usual care alone or with another point, so they cannot separate the needle from the attention and expectation that come with treatment, and the Cochrane review that would have weighed them was never written. The reviews disagree on duration: one found too little evidence to judge beyond eight weeks, while a 2021 meta-analysis reported larger effects in the long term than the short. Against steroid injection the certainty is very low, and the two professional bodies, writing five years apart, reached different verdicts on needling. The tennis elbow page reports a similar split for dry needling at the elbow.

AcuiQ's symptom pages for plantar fasciitis, heel pain, plantar fascia pain and plantar heel pain list the protocols individual studies prescribed, each with its citation.