What are the treatment options for plantar fasciitis?

Treatment of Plantar Fasciitis

The initial treatment of plantar fasciitis should include conservative measures such as regular calf-muscle stretching, cryotherapy, over-the-counter heel cushions, arch supports, weight loss if indicated, activity limitation, and avoidance of flat shoes and barefoot walking, with approximately 90% of patients responding to conservative treatment. 1, 2

First-Line Treatment Options (0-6 weeks)

• Patient-directed measures:

  • Plantar fascia-specific stretching exercises (performed first thing in the morning)
  • Calf muscle stretching multiple times daily
  • Ice massage to the plantar fascia (rolling foot over frozen water bottle for 20 minutes)
  • Over-the-counter heel cushions and arch supports
  • Weight loss if indicated
  • Activity modification to reduce prolonged standing/walking
  • Avoidance of flat shoes and barefoot walking

• Physician-directed measures:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief
  • Padding and strapping of the foot
  • Corticosteroid injections in appropriate patients (limited use due to risk of fat pad atrophy and plantar fascia rupture) 1, 3

Second-Line Treatment Options (6 weeks - 3 months)

If no improvement occurs after six weeks, consider:

• Referral to a podiatric foot and ankle surgeon
• Continue first-line treatments
• Add customized orthotic devices
• Night splinting to maintain dorsiflexion
• Limited corticosteroid injections (with caution)
• Casting or use of a fixed-ankle walker-type device during activity 1, 4

Third-Line Treatment Options (>3 months)

For recalcitrant cases after 3 months of treatment:

• Cast immobilization if not previously used
• Extracorporeal shock wave therapy (particularly effective for chronic cases)
• Surgical intervention (plantar fasciotomy) as a last resort 1, 5

Treatment Algorithm Based on Duration and Response

1. Acute phase (0-6 weeks):

   • Begin with stretching, ice, NSAIDs, and footwear modifications
   • Assess response at 6 weeks

2. Subacute phase (6 weeks - 3 months):

   • If improving: continue initial treatments until resolution
   • If not improving: add customized orthotics, night splints, and consider corticosteroid injection

3. Chronic phase (>3 months):

   • If improving: continue effective treatments
   • If not improving: consider extracorporeal shock wave therapy or surgical options 4, 5

Efficacy of Treatments

• Conservative treatments are effective in approximately 80-90% of patients within 12 months 2, 4, 5
• NSAIDs may provide additional pain relief when used with a conservative treatment regimen, though evidence shows only modest benefit over placebo 6
• Corticosteroid injections provide short-term relief but carry risks of fat pad atrophy and plantar fascia rupture 2, 3
• Extracorporeal shock wave therapy is useful for chronic cases not responding to conservative treatment 2, 3

Common Pitfalls and Caveats

• Avoid overuse of corticosteroid injections due to risk of plantar fascia rupture
• Don't neglect stretching exercises, which are foundational to treatment
• Be aware that improvement may take time (up to 12 months), even with appropriate treatment
• Consider diagnostic imaging (ultrasound or MRI) only for recalcitrant cases or to rule out other heel pathologies 2, 5
• In patients with diabetes, rule out infectious complications that may require urgent surgical intervention 2

Special Considerations

• For patients with biomechanical anomalies (flat feet or high arches), customized orthotics may be particularly beneficial 2
• Activity modification to decrease repetitive loading should be advised during the treatment phase regardless of chosen treatment modality 3