What is the initial treatment for plantar fasciitis?

Initial Treatment for Plantar Fasciitis

The initial treatment for plantar fasciitis should include patient-directed measures such as regular calf-muscle stretching, ice massage, over-the-counter heel cushions and arch supports, weight loss (if indicated), activity limitation, and avoidance of flat shoes and barefoot walking. 1

First-Line Conservative Measures

Self-Care Interventions

• Stretching exercises:
  • Plantar fascia-specific stretching
  • Calf stretching (Achilles tendon)
  • Perform multiple times daily, especially before first steps in the morning
• Ice massage: Apply ice to the affected area for 15-20 minutes, especially after activity
• Footwear modifications:
  • Avoid flat shoes and barefoot walking
  • Use supportive shoes with good arch support
  • Consider over-the-counter heel cushions and arch supports
• Activity modification:
  • Limit prolonged standing and walking
  • Reduce high-impact activities temporarily
  • Weight loss if indicated (reduces mechanical stress on the plantar fascia)

Medication

• NSAIDs (oral): Can be used for pain relief and to reduce inflammation 2
  • While one study showed a trend toward improved pain relief with NSAIDs (celecoxib) when combined with conservative treatment, the difference was not statistically significant at 1,2, or 6 months

Treatment Algorithm

For Mild to Moderate Symptoms (First 6 Weeks)

1. Implement all self-care interventions listed above
2. Consider NSAIDs for pain control
3. If no improvement after 6 weeks, progress to additional interventions

For Persistent Symptoms (Beyond 6 Weeks)

If no improvement occurs after six weeks of initial treatment, additional measures include:

• Customized orthotic devices
• Night splinting to maintain ankle dorsiflexion during sleep
• Padding and strapping of the foot
• Corticosteroid injections (limited number, used judiciously due to risk of fat pad atrophy and plantar fascia rupture) 1, 3

Clinical Pearls and Pitfalls

Key Physical Examination Findings

• Tenderness to palpation at the anteromedial calcaneus (proximal plantar fascial insertion)
• Limited ankle dorsiflexion (interestingly, patients with severe ankle equinus were nearly 4 times more likely to respond favorably to conservative treatment including Achilles stretching) 4
• Heel valgus in relaxed stance (associated with poorer response to conservative treatment) 4

Common Pitfalls

• Delayed diagnosis: The classic symptom is stabbing, nonradiating pain first thing in the morning in the proximal medioplantar surface of the foot 5
• Inadequate stretching: Proper technique and consistency are essential
• Premature return to high-impact activities: Can lead to symptom recurrence
• Overreliance on corticosteroid injections: Should be limited due to potential complications

When to Consider Referral

If no improvement occurs after 2-3 months of comprehensive conservative treatment, consider:

• Referral to a podiatric foot and ankle surgeon
• Additional treatment options such as:
  • Cast immobilization or use of a fixed-ankle walker-type device
  • Extracorporeal shock wave therapy
  • Surgical intervention (plantar fasciotomy) as a last resort 1

Most cases of plantar fasciitis (approximately 80%) will improve within 12 months with proper conservative treatment 5, making it important to reassure patients while emphasizing adherence to the treatment plan.