What is the recommended treatment for plantar fasciitis?

Treatment of Plantar Fasciitis

The first-line treatment for plantar fasciitis should include conservative measures such as regular stretching of the calf and plantar fascia, appropriate footwear modifications, and NSAIDs for pain management. 1, 2

Initial Conservative Management

First-line interventions:

• Stretching exercises:

  • Plantar fascia-specific stretching
  • Calf stretching exercises
  • Eccentric exercises (particularly beneficial for tendinopathies)
  • Recommended duration: 8-12 weeks of supervised foot-ankle exercise program 1

• Pain management:

  • NSAIDs (oral or topical) to reduce pain and inflammation
  • Acetaminophen as an alternative for those who cannot take NSAIDs 1
  • Ice massage through a wet towel for 10 minutes to reduce inflammation 1

• Footwear modifications:

  • Shoes with adequate arch support
  • Open-backed shoes to reduce pressure on painful areas
  • Shoes should be 1-2 cm longer than the foot with width equal to foot width at metatarsal phalangeal joints 1

• Activity modification:

  • Relative rest
  • Reduction of activities that exacerbate symptoms
  • Avoid prolonged standing 2

Second-line interventions (if no improvement after 4-6 weeks):

• Orthotic devices:

  • Custom or over-the-counter insoles to redistribute pressure
  • Heel cups or pads 1
  • Viscoelastic heel cups 3

• Night splinting:

  • Maintains dorsiflexion of the ankle during sleep
  • Prevents morning pain and stiffness 3, 2

Advanced Interventions

If conservative treatment fails after 6-8 weeks:

Third-line interventions:

• Corticosteroid injections:

  • Consider for refractory cases
  • Note: Effects are short-lived and must be weighed against risks of fat pad atrophy and plantar fascia rupture 4
  • Avoid injection near the Achilles tendon 1

• Immobilization:

  • Cast or fixed-ankle walker-type device for refractory cases 1

Fourth-line interventions (for chronic cases lasting 6+ months):

• Extracorporeal shock wave therapy:

  • Ultrasonography-guided focal extracorporeal shock wave therapy
  • Useful for chronic plantar fasciitis that hasn't responded to other treatments 4, 2

• Surgical options:

  • Plantar fasciotomy (endoscopic approach preferred)
  • Consider only after exhausting all non-operative treatment options 2
  • 90% of patients improve with conservative techniques without requiring surgery 5

Monitoring and Follow-up

• Evaluate response to treatment every 4-6 weeks
• Monitor for proper technique with stretching exercises
• Assess footwear compliance and orthotic fit 1
• Consider referral to a foot specialist if no improvement occurs after six weeks of conservative treatment 1

Special Considerations

• For diabetic patients:

  • More frequent foot examinations
  • Evaluation for peripheral arterial disease and neuropathy
  • Daily foot inspection and appropriate footwear at all times 1

• For patients with mild infection or mild ischemia:

  • Consider using a removable offloading device to promote healing 6
  • Address infection and/or ischemia first in severe cases

Treatment Efficacy

With proper treatment, approximately 80% of patients with plantar fasciitis improve within 12 months 2, and up to 90% of patients will improve with conservative techniques 5. While NSAIDs may provide some additional benefit when combined with other conservative measures, the evidence suggests that the overall conservative approach (including stretching, appropriate footwear, and activity modification) is the most important factor in successful treatment 3.