What is the treatment for plantar fasciitis?

Treatment of Plantar Fasciitis

For plantar fasciitis, the most effective first-line treatment is a combination of plantar fascia-specific stretching, appropriate footwear, and offloading interventions, with non-removable knee-high devices being the most effective for severe cases. 1, 2

Diagnosis and Assessment

• Plantar fasciitis presents with:

  • Stabbing, non-radiating pain at the medial plantar heel
  • Pain is typically worst with first steps in the morning or after prolonged sitting
  • Tenderness to palpation at the proximal plantar fascial insertion on the anteromedial calcaneus
  • Pain exacerbated by passive ankle/first toe dorsiflexion

• Imaging is rarely needed for initial diagnosis but may be considered for recalcitrant cases:

  • Radiographs may show thickened plantar fascia and fat pad abnormalities (85% sensitivity, 95% specificity) 1
  • Ultrasonography is reasonable for pain persisting beyond 3 months despite treatment 3

Treatment Algorithm

1. Conservative Measures (First-Line)

• Stretching exercises:

  • Plantar fascia-specific stretch: Cross affected leg over opposite leg while seated, pull toes toward shin until stretch is felt in arch, hold 10 seconds, repeat 10 times, 3 times daily 4
  • Calf stretching: Stand facing wall with affected foot behind, lean forward keeping heel on ground, hold 30 seconds, repeat 3 times daily

• Appropriate footwear:

  • Shoes that accommodate the shape of the feet and fit properly 1
  • Avoid thin-soled slippers and walking barefoot

• Activity modification:

  • Decrease repetitive loading activities
  • Rest and ice massage to affected area

• Offloading interventions:

  • For mild cases: Felted foam in combination with appropriate footwear 1
  • For moderate to severe cases: Consider removable or non-removable knee-high offloading devices 1

2. Intermediate Interventions (If No Improvement After 4-6 Weeks)

• Foot orthotics:

  • Custom-made insoles for those with foot deformities or pre-ulcerative lesions 1
  • Over-the-counter arch supports for those without significant deformities

• Night splints:

  • Maintain dorsiflexion during sleep to prevent morning pain

• Physical therapy modalities:

  • Ultrasound therapy
  • Manual therapy techniques

3. Advanced Interventions (For Recalcitrant Cases)

• Corticosteroid injections:

  • Consider for pain relief, but effects are short-lived
  • Weigh benefits against risks of fat pad atrophy and plantar fascia rupture 4

• Extracorporeal shock wave therapy:

  • Consider for chronic plantar fasciitis (>6 months) that hasn't responded to other treatments 4, 3

• Surgical interventions:

  • Digital flexor tenotomy for toe-related plantar fasciitis 1
  • Plantar fasciotomy may be considered when all conservative measures fail after 6-12 months 3

Special Considerations

For Diabetic Patients with Plantar Fasciitis

• Risk stratification is crucial:

  • For patients with neuropathy and plantar forefoot/midfoot ulcers, non-removable knee-high offloading devices are strongly recommended 1
  • For patients with mild infection or ischemia, removable offloading devices are preferred 1

• Monitor for complications:

  • Regular foot examinations to detect pre-ulcerative lesions
  • Temperature monitoring may help identify early signs of inflammation 1

For Plantar Fasciitis on Toe Pads

• Digital flexor tenotomy is strongly recommended:
  • Particularly effective for neuropathic plantar or apex ulcers on digits 2-5 with flexible toe deformity 1
  • Studies show 92-100% healing rates with mean healing time of 21-40 days 1
  • Low complication rates make this a favorable option 1

Common Pitfalls to Avoid

1. Inadequate offloading: Failure to properly offload the affected area is a primary reason for treatment failure 2

2. Overuse of antimicrobial agents: Antibiotics should only be used when infection is present, not for uncomplicated plantar fasciitis 2

3. Neglecting underlying conditions: Address contributing factors such as obesity, excessive foot pronation, and prolonged standing 5

4. Expecting immediate results: Plantar fasciitis typically improves within 6-12 months with proper treatment; patient education about realistic timelines is important 3

5. Inappropriate footwear: Continuing to wear unsupportive shoes can prolong recovery 1

Remember that 80-90% of patients with plantar fasciitis will improve with conservative measures within 12 months 3, 6. Early intervention leads to faster resolution of symptoms.