Heel pain from the very first step in the morning is one of a runner's most common complaints and, it seems, the most googled one: searches for how to treat a “heel spur” keep climbing. A whole industry is built on that demand: insoles, night splints, shock waves, injections, lasers. In February 2026 Scientific Reports published a network meta-analysis that for the first time compared the main methods not with placebo one by one but with each other. The result turned out to be less clear-cut, and more useful, than the advertising of any clinic.

A spur and the fascia are not the same thing

The plantar fascia is a dense band of connective tissue running from the heel bone to the bases of the toes. It works like a bowstring: it holds up the arch of the foot and returns energy at push-off. When the tissue is overloaded where it attaches to the heel, plantar fasciitis develops — or, more precisely, fasciopathy: biopsies show not so much inflammation as degeneration of collagen.

A “spur” is a bony outgrowth on the heel bone, visible on an X-ray. There is a link with fasciitis, but it is weaker than people assume. Johal and Milner (Foot and Ankle Surgery, 2011) compared the radiographs of 19 patients with fasciitis and 19 people who had come in with an ankle sprain: spurs were found in 89% of the patients — and in 32% of those whose heels did not hurt at all. In other words, a third of healthy people carry a spur and never know it. What needs treating is not the outgrowth on the image but the overloaded fascia.

The first line is load, not rest

The most cited work on conservative treatment is the RCT by Michael Rathleff and colleagues (Scandinavian Journal of Medicine and Science in Sports, 2014). 48 patients with ultrasound-confirmed fasciitis were given insoles and split into two groups: daily stretching of the fascia, or strength work every other day — single-leg heel raises with a towel under the toes (to put the fascia on stretch), done slowly, with a rucksack in the hands as strength grew.

At three months the foot function index in the strength group was 29 points lower (95% CI 6–52; p = 0.016) — a noticeable difference. But by 6 and 12 months the groups had levelled out: both recovered to roughly the same point. The honest conclusion is less catchy than “strengthen the foot and it will all go away”: strength work speeds up the exit from pain, but it does not change the outcome a year later.

An important practical detail from later work by Riel and colleagues (Journal of Physiotherapy, 2019): a protocol in which patients picked the load by feel worked just as well as a rigidly prescribed progression. Counting kilograms is optional — what matters is doing it regularly.

What the 2026 network meta-analysis compared

Tien and colleagues gathered 63 randomised trials with 4,170 participants and built a network of comparisons between shockwave therapy, prolotherapy and injections: platelet-rich plasma (PRP), botulinum toxin type A, corticosteroids, autologous blood, local anaesthetics.

The main conclusion: there is no universal winner, and who wins depends on the time frame.

Botulinum toxin A gave the greatest short-term improvement in pain and in fascia thickness on ultrasound.
Prolotherapy was the best at making pain relief last.
Corticosteroids produced the biggest gain in function in the short run — and only in the short run.
PRP held on to improvements in function and fascia thickness better than the rest over the long run.
Shockwave therapy showed broad effectiveness across every domain and every time frame — that is, it was not the best in any single category, but it did not fail in any either.

The authors put it plainly: the strategy should be matched to how long the symptoms have lasted and to the goal, rather than one method being prescribed by default.

What this ranking does not say

The network rests on indirect comparisons. There are almost no head-to-head trials of “botox versus PRP” — the model reconstructs them through a shared placebo node. That is a legitimate technique, but confidence in such estimates is lower than in a direct RCT.

There is no conservative arm in the network. Exercise and insoles were not included, so you cannot conclude from it that an injection beats strength work. It answers a different question: if a procedure has been decided on, which one.

Steroids come at a price. Fast pain relief in exchange for known risks — rupture of the fascia and atrophy of the heel fat pad. For a runner who has a long run in two weeks, that is a bad trade.

The natural course is benign. Most cases resolve within 6–18 months with no procedure at all. Any method applied in the ninth month will look effective.

How to apply this

Start with strength work, not rest. Single-leg heel raises with a towel under the toes, every other day, slowly: 3 seconds up, 2 seconds hold, 3 seconds down. Three sets, with the load rising as you get stronger. This is the protocol from Rathleff's study.
Do not throw out running altogether. Cut your volume to the level at which morning pain does not grow from day to day, and drop strides and hill running — those load the fascia hardest of all.
Give it three months. Judging the effect of the exercises any earlier makes no sense: in the RCT the difference appeared precisely at the third month.
Discuss procedures after 3–6 months of honest conservative work, not instead of it. If the goal is to get out of pain for the long haul, shock waves look like the most balanced choice; a corticosteroid makes sense as a one-off measure before an important race, with the risk understood.
Do not go looking for a spur on an X-ray as the explanation. A third of people without pain have one, and its size does not determine the prognosis.
Check foot strength objectively — a simple test of how many heel raises you can do to failure in the strength tests gives you a clear reference point before and after a course of treatment.

The bottom line

Plantar fasciitis is tissue degeneration from overload, not inflammation; a “spur” is found in 89% of people with fasciitis and in 32% of those without pain, so treating the X-ray is pointless.
Strength work with a towel under the toes every other day gives a 29-point head start on the foot function index by the third month, but levels out with stretching by a year — it speeds up the exit from pain rather than changing the outcome.
The network meta-analysis of 63 RCTs and 4,170 people: botulinum toxin is best in the short run for pain, corticosteroids for function, prolotherapy keeps pain relief going longer, PRP wins over the long run, and shockwave therapy works evenly across all time frames.
The method is worth choosing to fit how long the symptoms have lasted and the goal; none of this cancels conservative work — it was not part of the comparison network at all.

Sources: Tien Y.-C., Chiu Y.-H., Shen P.-C., Ko C.-Y., Lee C.-Y. “Comparative effectiveness of minimally invasive therapies for plantar fasciitis: a systematic review and network meta-analysis”. Scientific Reports, 2026;16. DOI: 10.1038/s41598-026-40038-z · Rathleff M.S., Mølgaard C.M., Fredberg U. et al. “High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up”. Scandinavian Journal of Medicine and Science in Sports, 2015;25(3):e292-300. DOI: 10.1111/sms.12313 · Riel H., Vicenzino B., Olesen J.L. et al. “Self-dosed and pre-determined progressive heavy-slow resistance training have similar effects in people with plantar fasciopathy: a randomised trial”. Journal of Physiotherapy, 2019;65(3):144-151. DOI: 10.1016/j.jphys.2019.05.011 · Johal K.S., Milner S.A. “Plantar fasciitis and the calcaneal spur: Fact or fiction?”. Foot and Ankle Surgery, 2012;18(1):39-41. DOI: 10.1016/j.fas.2011.03.003