From the Guidelines
Chronic plantar fasciitis should be diagnosed and treated with a multimodal approach, prioritizing conservative measures such as rest, ice, stretching exercises, and orthotic inserts, as these methods have been shown to improve symptoms and quality of life 1.
Diagnosis
The diagnosis of chronic plantar fasciitis typically involves pain at the medial heel that is worst with the first steps in the morning or after periods of rest. Imaging studies, such as weightbearing radiographs, may be useful in confirming the diagnosis, with a sensitivity of 85% and a specificity of 95% for plantar fasciitis 1.
Treatment
Treatment begins with conservative measures, including:
- Rest and ice to reduce inflammation
- Stretching exercises for the plantar fascia and Achilles tendon, such as calf stretches and plantar fascia-specific stretches by pulling the toes toward the shin for 30 seconds, repeating 3-5 times, several times daily
- Orthotic inserts with good arch support to redistribute pressure away from the painful area
- Over-the-counter NSAIDs like ibuprofen (400-800mg three times daily with food) or naproxen (220-440mg twice daily) to manage pain and inflammation for short periods
- Night splints that keep the foot dorsiflexed during sleep to prevent morning tightness
- Physical therapy focusing on stretching, strengthening, and proper gait mechanics
Persistent Cases
For persistent cases, corticosteroid injections (typically methylprednisolone 20-40mg with lidocaine) may provide temporary relief, though limited to 2-3 injections per year due to risk of fascia rupture 1. Extracorporeal shock wave therapy is another option for resistant cases. Surgery is rarely needed but may be considered after 6-12 months of failed conservative treatment.
Key Considerations
The condition results from repetitive microtrauma causing degeneration at the fascia's attachment to the calcaneus, with inflammation playing a secondary role, which explains why addressing biomechanical factors through stretching and support is crucial for long-term improvement 1.
From the Research
Diagnosis of Chronic Plantar Fasciitis
- The diagnosis of chronic plantar fasciitis is primarily based on history and physical examination 2.
- Patients may present with heel pain with their first steps in the morning or after prolonged sitting, and sharp pain with palpation of the medial plantar calcaneal region 2.
- Diagnostic imaging is rarely needed for the initial diagnosis of plantar fasciitis, but ultrasonography and magnetic resonance imaging can be used to rule out other heel pathology or in recalcitrant cases 2.
Treatment of Chronic Plantar Fasciitis
- Conservative treatments, such as rest, activity modification, ice massage, oral analgesics, and stretching techniques, can be tried for several weeks 2.
- If heel pain persists, physician-prescribed treatments such as physical therapy modalities, foot orthotics, night splinting, and corticosteroid injections can be considered 2.
- Ninety percent of patients will improve with these conservative techniques 2, 3.
- For patients with chronic recalcitrant plantar fasciitis, extracorporeal shock wave therapy or plantar fasciotomy can be considered 2.
- Extracorporeal shock wave therapy has been shown to be effective in treating plantar fasciitis, with comparable results to other modalities 4.
- Corticosteroid injection, extracorporeal shock wave therapy, and radiofrequency thermal lesioning are all safe and effective treatment options for chronic plantar fasciitis, with similar outcomes up to 1 year 5.
Risk Factors and Prevention
- Obesity, excessive foot pronation, excessive running, and prolonged standing are risk factors for developing plantar fasciitis 2.
- Biomechanical abnormalities in the foot, such as tight Achilles tendon, pes cavus, and pes planus, can also contribute to the development of plantar fasciitis 3.
- Activity modification and the use of orthotics or other supportive devices can help prevent plantar fasciitis in individuals with these risk factors 2, 6.