What is the treatment for plantar fasciitis?

Treatment of Plantar Fasciitis

The most effective treatment for plantar fasciitis involves a stepwise approach starting with conservative measures including plantar fascia-specific stretching, appropriate footwear, ice massage, and NSAIDs, followed by more advanced interventions only for cases that don't respond to initial therapy.

Clinical Presentation and Diagnosis

Plantar fasciitis presents with characteristic symptoms:

• Sharp, stabbing heel pain with first steps in the morning or after prolonged sitting
• Pain at the medial plantar calcaneal region
• Discomfort elicited by passive ankle/first toe dorsiflexion
• Pain that often worsens throughout the day, especially after prolonged standing

Diagnosis is primarily clinical, with imaging (ultrasonography or MRI) reserved for recalcitrant cases or to rule out other pathologies 1.

Treatment Algorithm

First-Line Treatments (0-3 months)

1. Patient-directed conservative measures:

   • Plantar fascia-specific stretching: Most important initial intervention
   • Calf stretching exercises: Performed several times daily
   • Ice massage: Apply to painful area for 5-10 minutes, 3-4 times daily
   • Activity modification: Reduce activities that aggravate symptoms
   • Appropriate footwear: Shoes with good arch support and cushioning
   • NSAIDs: For pain control and to improve function

2. If minimal improvement after 4-6 weeks, add:

   • Foot orthotics: Prefabricated or custom-made to provide arch support
   • Night splints: To maintain ankle dorsiflexion during sleep
   • Physical therapy modalities: Including ultrasound, iontophoresis

Second-Line Treatments (3-6 months)

For patients with persistent symptoms despite 3 months of conservative therapy:

1. Corticosteroid injections:

   • Provides short-term pain relief
   • Caution: Risk of fat pad atrophy and plantar fascia rupture
   • Limit to 2-3 injections with adequate spacing between treatments

2. Extracorporeal shock wave therapy (ESWT):

   • Consider for chronic cases (>6 months) unresponsive to other treatments
   • Ultrasonography-guided focal ESWT shows good results for chronic cases 2

Third-Line Treatments (>6 months)

For truly recalcitrant cases with symptoms persisting beyond 6 months despite comprehensive conservative management:

1. Surgical intervention:
   • Endoscopic or open plantar fasciotomy
   • Reserved for patients with significant functional limitations
   • Consider only after exhausting all non-operative options 3

Special Considerations

Risk Factors to Address

• Obesity: Weight loss counseling for patients with elevated BMI
• Prolonged standing: Recommend appropriate work modifications and breaks
• Foot mechanics: Address excessive pronation with proper footwear/orthotics

Monitoring and Follow-up

• Reassess at 4-6 week intervals to evaluate response to treatment
• Adjust treatment plan based on symptom improvement
• Most patients (approximately 90%) will improve with conservative measures within 12 months 1, 3

Pitfalls to Avoid

1. Overuse of corticosteroid injections: Limit to prevent tissue atrophy and rupture
2. Premature consideration of surgery: Exhaust conservative options first
3. Inadequate stretching technique: Ensure proper instruction on stretching protocols
4. Ignoring biomechanical factors: Address footwear and activity modifications
5. Failure to recognize alternative diagnoses: Consider nerve entrapment, stress fractures, or other heel pathologies in cases not responding to appropriate treatment

With proper treatment adherence, the vast majority of patients with plantar fasciitis will experience significant improvement within a year, though complete resolution of symptoms may take longer in some cases.