What are the treatment options for plantar fasciitis?

Treatment Options for Plantar Fasciitis

The most effective treatment for plantar fasciitis is a combination of corticosteroid injections and controlled training (strength training and stretching), which provides superior outcomes in both short and long-term management compared to either treatment alone. 1

Initial Conservative Treatments

For mild to moderate cases, begin with these first-line interventions:

1. Rest and activity modification

   • Decrease repetitive loading of the plantar fascia 2
   • Avoid prolonged standing, walking, and running 3

2. Stretching exercises

   • Plantar fascia-specific stretching (first thing in the morning and before activity)
   • Calf stretching exercises 2

3. Pain management

   • Ice massage to the affected area
   • Nonsteroidal anti-inflammatory drugs (NSAIDs) 3

4. Footwear modifications

   • Appropriate cushioning shoes with arch support
   • Avoid walking barefoot 2

Intermediate Interventions

If symptoms persist after 2-4 weeks of initial treatment:

1. Orthotic devices

   • Custom or over-the-counter foot orthotics to support the arch 2

2. Night splints

   • Maintain dorsiflexion of the ankle during sleep 2
   • Note: Some studies show limited benefit over placebo 3

3. Physical therapy modalities

   • Supervised strength training program
   • Manual therapy techniques 4

Advanced Interventions for Recalcitrant Cases

For cases not responding to conservative measures after 3-6 months:

1. Corticosteroid injections

   • Particularly effective when combined with controlled training 1
   • Caution: Risk of fat pad atrophy and plantar fascia rupture with repeated injections 2

2. Extracorporeal shock wave therapy (ESWT)

   • Ultrasonography-guided focal ESWT for chronic cases 2
   • Consider for patients who have failed other conservative treatments 3

3. Surgical options

   • Endoscopic fasciotomy may be required for cases that fail all non-operative treatments 3
   • Should only be considered after exhausting conservative options for at least 6-12 months 4

Diagnostic Considerations

• Diagnosis is primarily clinical based on morning pain and tenderness at the medial plantar calcaneal region 4
• Imaging is rarely needed for initial diagnosis
• Consider ultrasonography for cases persisting beyond 3 months despite treatment 3
• MRI is the most sensitive imaging study for diagnosing plantar fascia tears 5

Treatment Algorithm

1. Weeks 0-4: Initial conservative treatments (stretching, ice, NSAIDs, footwear modification)
2. Weeks 4-12: Add orthotic devices, night splints, and structured physical therapy if not improving
3. Months 3-6: Consider corticosteroid injection combined with controlled training program for persistent cases
4. Beyond 6 months: Consider ESWT or surgical consultation for recalcitrant cases

Important Considerations

• With proper treatment, approximately 80% of patients improve within 12 months 3
• Conservative treatment is ultimately effective in approximately 90% of patients 6
• The combination of corticosteroid injections with strength training and stretching provides clinically superior outcomes compared to either treatment alone 1
• Avoid repeated corticosteroid injections due to risk of plantar fascia rupture and fat pad atrophy 2