How to manage plantar fasciitis?

Management of Plantar Fasciitis

Initial treatment of plantar fasciitis should focus on regular calf-muscle stretching, plantar fascia-specific stretching, cryotherapy, over-the-counter heel cushions, arch supports, activity limitation, and avoidance of barefoot walking or wearing thin-soled footwear. 1

First-Line Conservative Management

Patient-Directed Measures

• Stretching exercises:
  • Plantar fascia-specific stretching: Pull toes toward shin while seated, holding for 10 seconds, repeating 10 times, 3 times daily
  • Calf stretching: Stand facing wall with affected foot behind, lean forward keeping heel on ground, hold 30 seconds, repeat 3 times daily
• Footwear modifications:
  • Avoid walking barefoot, in socks only, or in thin-soled slippers 1
  • Use supportive shoes with adequate arch support
• Activity modification:
  • Reduce high-impact activities
  • Implement rest periods during prolonged standing
• Self-care measures:
  • Ice massage: Roll foot over frozen water bottle for 10-15 minutes, 3-4 times daily
  • Use over-the-counter heel cushions and arch supports 1
  • Weight loss if indicated 1

Provider-Directed Interventions

• NSAIDs: Short-term use for pain management 1, 2
• Padding and strapping: Temporary taping to support arch 1
• Orthotic devices:
  • For patients with foot deformities or pre-ulcerative lesions, consider prescribing extra-depth shoes, custom-made footwear, or custom-made insoles 1

Second-Line Management (If No Improvement After 6 Weeks)

• Custom orthotic devices: Provide better support than over-the-counter options 1
• Night splinting: Maintains dorsiflexion during sleep to prevent morning pain 1, 2
• Corticosteroid injections:
  • Limited number of injections (typically 1-3)
  • Must weigh benefits against risks of fat pad atrophy and plantar fascia rupture 1, 3
  • Use with caution and proper technique
• Immobilization: Consider casting or use of a fixed-ankle walker-type device during activity 1

Third-Line Management (If No Improvement After 2-3 Months)

• Cast immobilization: If not previously used 1
• Extracorporeal shock wave therapy (ESWT):
  • Ultrasonography-guided focal ESWT for chronic cases 1, 3
  • Consider referral for this treatment in recalcitrant cases
• Surgical intervention:
  • Plantar fasciotomy may be considered when all conservative measures fail 1, 2
  • Endoscopic fasciotomy for patients with persistent activity-limiting pain despite exhausting non-operative options 2

Special Considerations

For Diabetic Patients with Plantar Fasciitis

• Non-removable knee-high offloading devices are first choice for offloading in patients with diabetic foot complications 1
• For patients unable to tolerate knee-high devices, consider removable knee-high walkers 1
• Avoid conventional footwear or standard therapeutic footwear alone for offloading 1

For Recalcitrant Cases

• Consider Achilles tendon lengthening for patients with plantar forefoot ulcers when conservative treatment fails 1
• Digital flexor tenotomy may be considered for toe ulcers when conservative treatment fails 1

Monitoring and Follow-up

• Evaluate response to treatment every 4-6 weeks
• If symptoms persist beyond 3 months despite treatment, consider ultrasonography to confirm diagnosis and rule out other conditions 2
• Most patients (approximately 90%) will improve with conservative treatment within 12 months 2, 4

Common Pitfalls to Avoid

• Overreliance on corticosteroid injections without addressing biomechanical factors
• Failure to emphasize consistent stretching regimen
• Premature progression to invasive treatments before adequate trial of conservative measures
• Neglecting to address contributing factors such as inappropriate footwear or excessive weight-bearing activities

Remember that plantar fasciitis is predominantly a clinical diagnosis with characteristic morning pain that improves with initial ambulation but worsens throughout the day 2. With proper adherence to the treatment protocol, most patients will experience significant improvement.