What is the recommended management for plantar fasciitis?

Management of Plantar Fasciitis

The recommended first-line treatment for plantar fasciitis includes stretching exercises, ice massage, activity modification, and nonsteroidal anti-inflammatory drugs (NSAIDs), followed by orthotic devices and night splints if initial measures fail. 1, 2, 3

Initial Assessment and Diagnosis

• Key diagnostic findings:

  • Stabbing, non-radiating pain in the proximal medioplantar surface of the foot
  • Pain is typically worst with first steps in the morning or after prolonged sitting
  • Tenderness to palpation at the anteromedial calcaneus (plantar fascial insertion)
  • Pain elicited by passive ankle/first toe dorsiflexion

• Diagnostic imaging is rarely needed initially; consider ultrasonography for cases that persist beyond 3 months despite treatment 3

Treatment Algorithm

Step 1: Patient-Directed Treatments (First 4-6 weeks)

• Stretching exercises:
  • Plantar fascia-specific stretching
  • Achilles tendon stretching
• Ice massage: Apply ice to painful area for 15-20 minutes, 3-4 times daily
• Activity modification: Reduce activities that exacerbate symptoms
• NSAIDs: For pain control and to reduce discomfort 4
• Footwear modification: Avoid barefoot walking, use supportive shoes

Step 2: If No Improvement After 4-6 Weeks, Add:

• Foot orthoses/arch supports: To reduce biomechanical stress
• Night splints: To maintain dorsiflexion during sleep
• Physical therapy modalities: Including manual therapy techniques

Step 3: For Persistent Cases (2-3 Months Without Improvement)

• Corticosteroid injections: For significant pain relief, though effects may be temporary
• Immobilization: Consider cast immobilization or use of a fixed-ankle walker-type device 1

Step 4: For Recalcitrant Cases (>6 Months Without Improvement)

• Extracorporeal shock wave therapy
• Noninvasive interactive neurostimulation: Shown to be effective in chronic cases 5
• Surgical intervention: Consider plantar fasciotomy when all conservative measures fail 1, 3

Evidence-Based Treatment Effectiveness

• Conservative treatments are successful in approximately 90% of patients within 12 months 2
• Dynamic splinting has shown significant improvement in pain scores compared to standard care alone 6
• NSAIDs combined with conservative treatment may provide better pain relief and decreased disability compared to conservative treatment alone 4
• Noninvasive interactive neurostimulation has demonstrated superior results compared to shock wave therapy in chronic cases 5

Important Considerations and Pitfalls

• Avoid prolonged corticosteroid injections as they may lead to plantar fascia rupture and fat pad atrophy
• Do not use footbaths as they can induce skin maceration 1
• Recognize that plantar fasciitis is not truly inflammatory (fasciopathy is more accurate) 3
• Address risk factors: obesity, excessive foot pronation, prolonged standing, and limited ankle dorsiflexion
• Consider other diagnoses if pain persists despite appropriate treatment (heel fat pad atrophy, tarsal tunnel syndrome, stress fracture)

Prevention of Recurrence

• Continued stretching exercises
• Appropriate footwear with adequate arch support
• Weight management if overweight/obese
• Gradual return to activities with proper warm-up
• Avoid walking barefoot, especially on hard surfaces

For patients with plantar fasciitis associated with inflammatory arthritis or specific conditions like ankylosing spondylitis, additional treatment considerations may be needed, including disease-modifying medications 1.