A new Scientific Reports network meta-analysis — 63 randomized trials, 4,170 patients — just ranked the most-studied minimally invasive treatments for plantar fasciitis head-to-head. The headline finding is that no single procedure wins across every dimension. Botulinum toxin A leads on short-term pain. Prolotherapy leads on sustained relief. Corticosteroid injections produce the largest short-term function gains. Platelet-rich plasma carries long-term function improvement. Shockwave therapy turns in broad, durable benefit. Tien et al., 2026 conclude that treatment should be matched to symptom duration and patient goals, not defaulted to one intervention.

What the comparison did not include is just as important as what it did: foot orthoses. The NMA was designed around minimally invasive procedures — injections and shockwave. The first-line, non-invasive scaffolding that 30 years of randomized trials still recommend before any needle or device sits outside its scope. That doesn’t mean inserts lost. It means they were never on the table, because they aren’t the step the paper was asking about.

Here is what the new evidence actually says, what it doesn’t say, and how to think about where inserts fit before — and alongside — any escalation.

What Tien 2026 actually compared

The systematic review pooled 63 RCTs covering seven minimally invasive interventions: extracorporeal shock wave therapy (ESWT), prolotherapy, platelet-rich plasma (PRP) injection, botulinum toxin A injection, corticosteroid injection, autologous blood injection, and local anesthetic injection. The authors ran a Bayesian network meta-analysis with short-term (under 12 weeks), mid-term (12 weeks to 6 months), and long-term (over 6 months) follow-up nodes. They reported on pain, function, and plantar fascia thickness on ultrasound (Tien et al., 2026).

The pattern that emerged was domain-specific rather than winner-take-all:

Short-term pain. Botulinum toxin A produced the largest pain reductions in the first weeks after treatment, alongside the largest reductions in plantar fascia thickness on imaging.

Sustained pain. Prolotherapy showed the most durable analgesic effect across the long-term follow-up window.

Short-term function. Corticosteroid injection produced the biggest gains in standardized function scores in the first weeks — consistent with what clinicians have long observed about steroid’s fast anti-inflammatory effect, though those gains tend not to be the most durable.

Long-term function and tissue. Platelet-rich plasma carried the strongest long-term improvements in both function and plantar fascia thickness — also consistent with the regenerative-medicine mechanism (concentrated growth factors driving slower tissue remodeling rather than fast symptom suppression).

Broad efficacy. Extracorporeal shock wave therapy was the most consistently effective across pain, function, and timepoint nodes — not always the top single performer, but the most reliable performer across the board.

The clinical translation Tien and colleagues offer is direct: tailor the intervention to the symptom timeline and the goal. A patient who needs to be back on their feet for a wedding next month is a different problem than a patient five months into chronic heel pain with imaging changes who hasn’t responded to first-line care.

The first-line care the NMA assumes is already happening

Network meta-analyses of minimally invasive therapies operate within a treatment hierarchy. The hierarchy isn’t controversial. The 2023 revision of the JOSPT Clinical Practice Guideline on Heel Pain – Plantar Fasciitis lists prefabricated foot orthoses, manual therapy, stretching, and load management among the strong-evidence interventions to start with — before injections, before shockwave, before considering anything more invasive (Koc et al., 2023). Injection-based and device-based therapies sit further down the pathway, for patients who don’t resolve with conservative care or who present with refractory disease.

This is the assumption baked into nearly every comparative-procedures paper, including Tien 2026: the patient population studied is already past the first conservative attempt. The NMA isn’t a competition between “an injection” and “a pair of inserts.” It’s a competition between minimally invasive options for the subset of patients who need a step beyond the conservative basics.

The evidence base for inserts as that conservative basic

The trial that anchors the orthotic recommendation in the modern guideline is Landorf, Keenan, and Herbert (2006), published in Archives of Internal Medicine. The team randomized 136 patients with chronic plantar heel pain to a sham insert, a prefabricated foot orthotic, or a customized orthotic. Across function and pain measures at three months, the real inserts — both prefab and custom — outperformed sham. At 12 months, the between-group differences faded as most of the cohort improved, which is a useful reminder that plantar fasciitis is largely self-limiting on a long enough timeline. What matters clinically is the rate of improvement during the symptomatic window, and inserts measurably accelerated it.

The follow-on question — whether expensive custom orthotics outperform off-the-shelf prefab inserts of comparable design — was addressed in Hawke and colleagues’ 2008 Cochrane review. The summary across studies was that prefabricated and custom orthotics produce similar pain and function outcomes for foot pain conditions including plantar fasciitis. Earlier work by Pfeffer et al. (1999) in Foot & Ankle International had pointed the same direction: in the initial treatment of proximal plantar fasciitis, prefabricated orthoses with stretching outperformed stretching alone, and they did so at parity with — not below — custom-fabricated devices.

The cumulative read from these trials, plus a roughly 25-year stretch of corroborating data, is that prefabricated inserts of appropriate design and support level are clinically equivalent to custom orthotics for most plantar fasciitis patients, at a fraction of the cost. Custom devices have a legitimate role in complex foot architecture, certain post-surgical situations, and severe deformity. They don’t carry a clinical edge in the typical case.

This is the empirical backdrop against which any minimally invasive escalation gets evaluated.

The dominant wrong belief: “An injection will fix it faster”

The most common version of this belief is the corticosteroid heuristic. Steroid injections do produce the largest short-term function gain in Tien 2026, and a patient who feels dramatic relief at four weeks understandably concludes the injection “fixed it.” The complication is durability. Corticosteroid’s function advantage tends to fade at mid- and long-term follow-up. In the longer-window data, the differential winners are the regenerative options (PRP, prolotherapy) and the load-physics intervention (ESWT) — not the fastest anti-inflammatory.

The deeper version of the wrong belief is that plantar fasciitis is an inflammatory process that needs to be calmed down. Modern histopathology consistently shows the chronic form is fasciosis — degenerative collagen disorganization at the calcaneal insertion, not classic acute inflammation. That’s why anti-inflammatory single shots tend to give short relief and recurrence rather than resolution: they suppress symptoms in tissue that has structurally changed. Mechanically distributing the load away from the degenerated tissue, which is what a well-supported insert does during the thousands of steps a day someone takes, is doing different work than blocking inflammation. The two strategies aren’t alternatives; they’re different rungs on a ladder, used in different sequences.

There’s a corollary belief worth naming as well: that imaging changes — a thickened plantar fascia on ultrasound, a heel spur on X-ray — mean a more invasive intervention is required. The Tien 2026 data actually pushes the other direction. Several of the interventions studied, including PRP and botulinum toxin A, produced measurable reductions in fascia thickness on follow-up imaging without surgery. And clinicians have long observed that heel spurs themselves are typically a downstream marker of chronic traction, not the pain generator. The treatment target remains the load environment around the fascia, not the spur on the film.

Sequencing — what this looks like in practice

A typical evidence-aligned pathway for a patient presenting with plantar heel pain looks something like this. First-line for most cases (Koc et al., 2023): manual therapy, stretching protocols targeting both the plantar fascia and the gastrocnemius-soleus complex, activity modification, and a supportive foot orthotic worn during weight-bearing hours. Most patients improve within several weeks to a few months on this combination — historically the JOSPT guideline and a long tail of cohort data describe the majority of plantar fasciitis as self-limiting on conservative care, though “most” isn’t “all” and there is no head-to-head trial of any specific commercial product against another. WYATT MVMT supplies one orthotic option within that first-line category; it isn’t the only one, and the trial evidence underwrites the category, not any single brand.

When first-line care plateaus at roughly three to six months without adequate relief, the Tien 2026 NMA becomes directly relevant. The patient and clinician are now deciding between minimally invasive escalations. The NMA’s practical contribution is that this is no longer a binary “injection or shockwave” choice. It’s a multi-axis choice:

If the goal is the fastest possible pain reduction (with the understanding that durability is moderate), botulinum toxin A leads on the short-term node. If the goal is the most durable single-treatment analgesia, prolotherapy carries the long-term pain node. If the goal is functional return for an athlete or worker on a deadline, corticosteroid leads at the short-term function node but the patient should know the trade-off. If the goal is long-term tissue remodeling alongside function, PRP carries those nodes. If the goal is broad, mechanically grounded improvement without an injection, shockwave is the most consistent performer (Tien et al., 2026).

None of these displace the orthotic. They sit on top of it. In nearly all of the trials that fed Tien’s analysis, patients continued some form of conservative foot support during the escalation arm.

What this means for someone with new plantar heel pain

The clinically useful read of the new NMA, for someone who is one to twelve weeks into their first significant plantar fasciitis episode, is that the menu of advanced options is real, ranked, and ready when it’s needed — but most people won’t need to use it. Strong-evidence first-line care, run consistently for a few months, produces meaningful improvement in the majority of cases. The reason to invest in a supportive insert early, follow a structured calf and plantar fascia stretching routine, manage load (especially the mileage spikes and surface changes that tend to provoke flares), and give the conservative window a fair trial before chasing a procedure is precisely that the procedures are best reserved for the cases that don’t resolve on the basics.

If pain hasn’t materially improved by the three-to-six-month mark on faithful first-line care, the Tien data is the conversation to have with a podiatrist or orthopedic foot specialist — armed with the symptom timeline, the activity goals, and a realistic view of which axis of relief matters most.

The takeaway

Tien 2026 doesn’t change the clinical hierarchy. It refines the second tier. The first-tier work — load management, stretching, manual therapy, and a well-designed foot orthotic — still anchors plantar fasciitis care because that’s the level at which the largest share of patients actually resolve. What the new NMA gives clinicians and informed patients is a sharper map of what to do when first-line care isn’t enough: not one winner, but a domain-by-domain ranking that lets the next step match the symptom timeline and the goal.

For most people reading this with active plantar heel pain, the order of operations is unchanged. Start with the support layer that lives under your foot all day. Add the stretching and load adjustments. Give it the conservative window. Escalate, with this evidence in hand, only if you need to.

Frequently Asked Questions

Q: What does the new meta-analysis say about Botox for plantar fasciitis?

A: The Tien et al. (2026) network meta-analysis ranked Botox among the more effective minimally invasive options for cases that didn't respond to conservative care. But it places it firmly as a step beyond first-line treatment — not a replacement for inserts and stretching.

Q: Is shockwave therapy worth trying for chronic PF?

A: Extracorporeal shockwave therapy (ESWT) has reasonable evidence for chronic PF that hasn't responded to 6+ months of conservative treatment. The meta-analysis ranks it competitively for refractory cases. Cost ranges $200–$600 per session and typically requires 3–6 sessions.

Q: Where do orthotic inserts rank in the evidence hierarchy?

A: The 2023 JOSPT clinical practice guideline gives foot orthoses an 'A' (strong) recommendation as first-line conservative treatment. The new meta-analysis reinforces this by confirming that the more aggressive treatments (Botox, prolotherapy, shockwave) are most useful for people who've already exhausted the conservative basics.

Q: Should I skip inserts and go straight to a more aggressive treatment?

A: No — the evidence clearly favors starting with the conservative ladder (inserts, stretching, activity modification) before escalating. Skipping these steps wastes money on more invasive options that often work better as adjuncts to good foundational support, not alternatives to it.

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