Predisposing factors for metatarsal fasciitis include overtraining, obesity, flat feet, limited dorsiflexion of the ankle for various reasons, and ill-fitting footwear. Treatment of metatarsal fasciitis is divided into conservative and invasive treatments. Conservative treatment of metatarsal fasciitis has a cure rate of 85-90%, and in 2010 the American Foot and Ankle Surgery Association recommended conservative treatment methods including weight control, NSAIDS medications, special stretching exercises for the metatarsal fascia, and orthopedic bracing. In addition, extracorporeal shockwave therapy and intramuscular fabric patches have been widely used in clinical practice in recent years. The Foot and Ankle Surgical Association recommends that the above conservative treatments be continued for at least 6 months, which basically relieves most patients’ symptoms. Weight control In individuals with normal arches, the metatarsal fascia is required to bear 15% of the weight of the arch in a standing situation, a value that is higher in individuals with lower arch heights such as flat feet. During walking, plantar flexor tendons and ligaments are involved in the stretching movement of the arch as the gait changes. Therefore, weight control is an effective way to reduce plantar fascia stress. NSAIDS NSAIDS are widely used clinically for the treatment of plantar fasciitis. In fact, in some elderly and sedentary patients with metatarsal fasciitis, inflammation is not the main cause. There is still no effective evidence from a large sample size that NSAIDS have a significant effect on pain relief and functional recovery of the foot in metatarsal fasciitis, but they can be used as a trial treatment if there are no significant contraindications to their use. Special traction treatment of the metatarsal fascia DiGiovanni [12] et al. compared the effect of special traction treatment of the metatarsal fascia with conventional stretching of the Achilles tendon complex (Figure 2) and concluded that special traction treatment of the metatarsal fascia in the non-weight-bearing condition was more effective in the relief of plantar pain than conventional stretching in the weight-bearing condition after eight weeks of trial observation. In a study on chronic plantar fasciitis in 2006 [13], it was reported that plantar fascia specifc stretching was more effective in reducing plantar pain than traditional plantar fascia stretching. Metatarsal stretching under non-weight bearing conditions helps to increase the toughness of fibrous tissues, thus increasing the pain threshold of the metatarsal fascia. Because of the recurrent nature of metatarsal fasciitis, metatarsal fascia specifc stretching is the treatment of choice for chronic recurrent and intractable metatarsal fasciitis. The American Foot and Ankle Surgical Association also recommends specific traction therapy for metatarsal fasciitis in the acute phase, usually supplemented with NSAIDS. Because of the widespread incidence of metatarsal fasciitis and the predominance of middle-aged and elderly people, there are many different types of rehabilitation exercises for the metatarsal fascia. There are many reports in the literature such as iontophoresis and deep plantar tissue massage, but the sample size is limited and most combine multiple treatments, and there is a lack of strong evidence for the effectiveness of a single treatment. In addition, there is no clear evidence to support the use of braking, ice, heat, or iontophoresis. However, based on clinical experience, braking and icing as necessary during the acute phase can effectively reduce soft tissue swelling and provide a good platform for other conservative treatments. Orthotics and night splints Orthotics and night splints prevent internal rotation of the foot, keep the foot in a neutral position, and reduce the stress on the plantar fascia. Studies have shown that 95% of patients experience varying degrees of pain relief after 8 weeks of orthotic wear, and that pain relief is effective regardless of whether the orthotic is custom-made or not, and there is no significant difference in the degree of relief. Recently, an increasing number of trials have shown that curved-sole shoes provide good relief of plantar pain compared to traditional orthotic devices. This effect is related to the role of the plantar fascia in a gait cycle. In a complete gait analysis, the height of the arch undergoes a linear decline until it returns to normal, and the role of the metatarsal fascia in stabilizing the arch during gait is mainly in the fourth phase (when the heel is completely off the ground until the toe is off the ground to complete the last step of walking), when the metatarsal fascia is subjected to The traction force is maximum. The presence of a curved sole shoe, which suspiciously relieves the dorsiflexion of the distal phalanx, reduces the stress on the metatarsal fascia, thereby reducing pain. Extracorporeal shock wave therapy In 2000, the FDA first approved extracorporeal shock wave therapy for plantar fasciitis, and in 2003 it was approved for the treatment of lateral humeral epicondylitis. A retrospective study in 2012 showed that the excellent rate of treatment for plantar pain and restoration of foot function with extracorporeal shockwave therapy ranged from about 34% to 88%. The principle of extracorporeal shock wave is to use low-frequency ultrasound to destroy the plantar fascia tissue and stimulate extracellular repair, thus providing a therapeutic effect. For its repair mechanism can be summarized as the following three points: 1) stimulate the growth of vascular endothelial factor, promote neovascularization, and increase local blood supply; 2) shock wave conduction to the junction of bone and soft tissue, due to their different resistance to compression and tension, ultrasound will produce different forces, thus loosening the metatarsal fascia attached to the heel node stop. 3) ultrasound can selectively destroy the unmyelinated peripheral nerve tissue, so that nerve conduction is blocked. In a small number of patients with metatarsal fasciitis, the presence of entrapment of the medial plantar fasciculus branch to the medial plantar cutaneous nerve is found, and ultrasound reduces nerve sensitivity to nociception, which in turn cooperates to reduce pain in metatarsal fasciitis. Extracorporeal shock wave therapy can be seen as a non-invasive treatment between conservative and surgical treatment. It does not involve the risks and trauma of surgery and is more effective than local hormone injections in reducing the pain of metatarsal fasciitis. Because of the mechanism and characteristics of extracorporeal shock wave therapy, it is recommended as a treatment for chronic and intractable metatarsal fasciitis, and can be used as a trial treatment before surgery after repeated conservative treatment has failed. Secondly, although the use of topical NSAIDS alone cannot completely penetrate into the metatarsal fascia, extracorporeal shock wave therapy with topical NSAIDS (e.g., fotarolimus) can effectively increase the therapeutic effect of metatarsal fasciitis. This result may be related to the rapid absorption of the acute inflammation produced during extracorporeal shockwave therapy by fotarine to facilitate better tissue repair. Intramuscular Cloth Patch In 1980, the Japanese scholar Kenzo Kase invented the Intramuscular Cloth Patch. The original design was to “bring the masseur’s hand home”. It uses a claw-shaped patch that resembles the shape of the plantar fascia and is applied to the sole of the foot to create folds in the skin, moderately increasing the deep lymphatic flow and blood circulation between the skin and the muscles, thereby reducing the edema of the plantar fascia and increasing the speed of repair. The results of some randomized controlled trials support the efficacy of intramuscular patch in relieving pain in the short term, but it is not obvious for functional improvement, and long-term use of intramuscular patch will produce skin discomfort, so intramuscular patch is not used as a long-term treatment for plantar fasciitis for the time being. Hormone therapy Hormones were previously considered to be an effective treatment for intractable plantar fasciitis. In the Ball et al. immediate symptomatic trial, the hormonal treatment group had significantly better analgesia than the placebo group at week 6 and 12 follow-up, as well as a significant decrease in the thickness of the metatarsal fascia on imaging. The decrease in thickness resulted in higher longitudinal stress on the metatarsal fascia, which indirectly increased the pain threshold of the metatarsal fascia. The American Foot and Ankle Surgical Association lists topical hormone injections as the first-line treatment for acute metatarsal fasciitis. The side effects of local hormone injections are mainly pain at the injection site and repeated injections may cause rupture of the metatarsal fascia, while others, such as atrophy of the fat pad, rarely occur. In order to prevent or reduce complications, it is recommended to avoid the plantar skin and to improve the efficacy of the treatment with ultrasound-assisted positioning. Given the rapid onset and duration of hormone therapy and the low side effects, topical hormone therapy is the preferred option for metatarsal fasciitis and is recommended in combination with specific traction therapy of the plantar fascia, especially for patients who wish to return to normal work quickly. Platelet-rich plasma is obtained by adding an anticoagulant to the platelet-rich plasma and then centrifuging the blood twice. After primary centrifugation, the blood is stratified, with the lowermost layer being red blood cells, the middle layer being colloids, and the uppermost volume being plasma. The upper layer is centrifuged twice and divided into the upper half of PPP and the lower half of platelet-rich plasma for local injection therapy. Platelets contain dense bodies and alpha particles, which can release stored platelet-derived growth factor (PGDF) upon platelet stimulation, and PGDF has the function of promoting angiogenesis and fiber repair [28]. Therefore, the essence of platelet-rich plasma topical injection therapy topical injection is to promote the repair process of the metatarsal fascia. Although randomized controlled trials with large sample sizes are still lacking, the side effects of platelet-rich plasma topical injection therapy, mainly injection-related pain, may be a good treatment for metatarsophalangeal fasciitis, especially chronic metatarsophalangeal fasciitis, in the limited studies that have been conducted. Surgical treatment may be considered in patients with a disease duration of 6-12 months, when multiple and varied conservative treatments have failed, and when other secondary factors of metatarsal fasciitis (ankylosing spondylitis, Reiter’s syndrome, rheumatoid arthritis, etc.) have been excluded. It must be noted, however, that about 35% of patients still experience recurrent symptoms after surgical treatment. This is because such patients often experience anxiety after enduring recurrent episodes of plantar pain that interfere with daily activities. Therefore, clinical treatment of patients with metatarsal fasciitis requires extra caution, and psychological factors need to be considered in the assessment of surgical indications. The heel spur is no longer an indication for surgery, but it should be noted that a branch of the lateral plantar nerve runs between the deep surface of the toe flexor and the heel spur and the adjacent plantar facet muscle. Studies have shown that a small number of patients (1-2%) have symptoms related to nerve entrapment degeneration, and in these patients, a portion of the spur can be removed along with the release of the nerve entrapment and removal of the attached portion of the plantar fascia. The medial bundle of the metatarsal fascia is surgically removed, and if the middle bundle is damaged, the weight-bearing capacity of the arch is reduced by 25%.