Treatment of Plantar Fasciitis
The recommended first-line treatment for plantar fasciitis includes stretching of the plantar fascia, ice massage, and nonsteroidal anti-inflammatory drugs (NSAIDs), with 90% of patients improving with conservative measures within 12 months. 1
Understanding Plantar Fasciitis
Plantar fasciitis is a common cause of heel pain affecting approximately 1 million people per year. It is characterized by:
- Sharp, stabbing pain in the proximal medioplantar surface of the foot
- Pain that is worst with first steps in the morning or after prolonged sitting
- Tenderness to palpation at the medial plantar calcaneal region
- Pain elicited by passive ankle/first toe dorsiflexion
Risk Factors
- Obesity
- Excessive foot pronation
- Excessive running
- Prolonged standing
- Limited ankle dorsiflexion
- High body mass index
Treatment Algorithm
Step 1: Initial Patient-Directed Treatments (0-6 weeks)
- Plantar fascia-specific stretching: Stretch the plantar fascia by pulling the toes toward the shin for 10 seconds, repeated 10 times, three times daily 1
- Calf stretching: Stretch the Achilles tendon and calf muscles
- Ice massage: Apply ice to the affected area for 15-20 minutes, especially after activity
- Oral NSAIDs: For pain relief and potentially improved outcomes when combined with other conservative measures 2
- Activity modification: Decrease repetitive loading of the plantar fascia
Step 2: Physician-Prescribed Treatments (if pain persists after 6 weeks)
- Foot orthotics: Provide arch support to distribute pressure more evenly
- Night splints: Maintain ankle dorsiflexion during sleep
- Physical therapy modalities: Including ultrasound therapy
- Corticosteroid injections: Consider for short-term pain relief, but be aware of potential risks including fat pad atrophy and plantar fascia rupture 3
Step 3: Advanced Interventions (for recalcitrant cases >6 months)
- Extracorporeal shock wave therapy: Ultrasonography-guided focal therapy for chronic cases 3
- Surgical intervention: Endoscopic fasciotomy may be considered when all conservative measures have failed 1
Monitoring and Follow-up
- Reassess after 6-8 weeks of initial treatment
- If symptoms persist, progress to more advanced interventions
- Most patients (80%) will improve within 12 months with proper treatment 1
Avoiding Common Pitfalls
- Overtreatment: Avoid unnecessary invasive procedures before trying conservative measures
- Inadequate stretching: Ensure proper technique and consistency with stretching protocols
- Premature return to activity: Gradually increase activity as symptoms improve
- Neglecting underlying factors: Address obesity and biomechanical issues
- Diagnostic imaging: Rarely needed for initial diagnosis; reserve ultrasonography or MRI for recalcitrant cases or to rule out other heel pathology 4
Special Considerations
- For patients with diabetes, assess for peripheral neuropathy and vascular status
- Patients with significant foot deformities may require custom orthotics
- Addressing obesity through weight management can significantly improve outcomes
By following this structured approach to the management of plantar fasciitis, most patients will experience significant improvement in pain and function without requiring invasive interventions.