What is the treatment for plantar fasciitis?

Treatment for Plantar Fasciitis

The first-line treatment for plantar fasciitis should include plantar fascia-specific stretching, calf stretching, appropriate orthotic devices, and activity modification to reduce mechanical stress on the foot. 1

Initial Conservative Management

Stretching Exercises

• Plantar fascia-specific stretch: Pull toes upward and hold for 30 seconds, repeat 3 times, perform 3 times daily
• Calf stretching: Lean against wall with affected leg extended behind, keep heel on ground, hold for 30 seconds, repeat 3 times daily
• These exercises have shown limited but positive evidence of benefit 2

Mechanical Offloading

• Orthotic devices:
  • For patients with no/limited foot deformity (IWGDF risk 1-3): Footwear that accommodates foot shape and fits properly 3
  • For patients with foot deformity or pre-ulcerative lesions: Consider extra-depth shoes, custom-made footwear, or custom-made insoles 3
  • Felted foam in combination with appropriate footwear if other options unavailable 3

Activity Modification

• Decrease cyclical repetitive loading of the plantar fascia during treatment phase 1
• Avoid walking barefoot, in thin-soled slippers, or flip-flops (both indoors and outdoors) 3
• Consider that increasing walking activity by 1000 steps/day may be safe for low/moderate risk patients when using appropriate footwear 3

Additional Conservative Measures

• Ice massage to affected area (roll frozen water bottle under foot for 5-10 minutes)
• NSAIDs for pain relief and to reduce discomfort 4
• Night dorsiflexion splinting to maintain plantar fascia stretch overnight 1

Second-Line Interventions (for persistent symptoms)

Injection Therapy

• Corticosteroid injections can provide short-term pain relief but carry risks of fat pad atrophy and plantar fascia rupture 1
• Should be considered only after failure of initial conservative measures

Advanced Therapies

• Ultrasonography-guided extracorporeal shock wave therapy for chronic cases unresponsive to conservative treatment (typically after 3+ months) 1, 4
• Consider foot-ankle exercise program (8-12 weeks) under supervision of trained healthcare professional 3

Treatment for Recalcitrant Cases (6+ months of failed conservative treatment)

Surgical Options

• Consider digital flexor tenotomy for neuropathic plantar ulcers with flexible toe deformity 3
• For persistent plantar metatarsal head ulcers, consider:
  • Achilles tendon lengthening in combination with offloading device 3
  • Metatarsal head resection with offloading device 3
• Endoscopic fasciotomy may be required for patients with persistent activity-limiting pain despite exhausting non-operative options 4

Monitoring and Follow-up

• Self-monitoring of foot skin temperature once daily (for moderate/high-risk patients) to identify early signs of inflammation 3
• If temperature difference between corresponding regions of left and right foot exceeds 2.2°C for two consecutive days, reduce activity and consult healthcare professional 3
• Daily foot examination for pre-ulcerative lesions or other complications 3

Important Caveats

• With proper treatment, approximately 80% of patients improve within 12 months 4
• Conservative treatment is ultimately effective in approximately 90% of patients 5
• Diagnostic imaging (MRI or ultrasound) should be considered only for symptoms persisting beyond 3 months despite treatment 4, 3
• Avoid premature surgical intervention as most cases resolve with appropriate conservative management

Remember that plantar fasciitis is predominantly a clinical diagnosis characterized by stabbing, non-radiating pain first thing in the morning in the proximal medioplantar surface of the foot, with pain worsening at the end of the day 4.