What are the treatment options for plantar fasciitis?

Treatment Options for Plantar Fasciitis

The initial treatment of plantar fasciitis should focus on conservative measures including regular calf-muscle stretching, plantar fascia-specific stretching, ice massage, over-the-counter heel cushions, arch supports, and activity modification, as approximately 90% of patients respond to these interventions. 1

First-Line Conservative Treatment

Conservative treatment should be the foundation of plantar fasciitis management, with most patients (80%) responding within 12 months 1, 2. The initial approach includes:

• Stretching exercises:

  • Plantar fascia-specific stretching
  • Calf muscle stretching
  • Perform multiple times daily, especially before getting out of bed

• Self-care measures:

  • Ice massage to the plantar fascia (10-15 minutes, 3-4 times daily)
  • Over-the-counter heel cushions and arch supports
  • Weight loss if indicated
  • Activity modification to reduce repetitive loading
  • Avoidance of flat shoes and barefoot walking

• Pain management:

  • NSAIDs for pain relief, though evidence shows only modest benefits beyond conservative treatment alone 3

Second-Line Interventions

For patients who don't respond to initial conservative measures after 4-6 weeks:

• Physician-directed interventions:

  • Padding and strapping of the foot
  • Night splints to maintain dorsiflexion during sleep
  • Custom foot orthoses for biomechanical correction

• Corticosteroid injections:

  • Consider for short-term pain relief
  • Use with caution due to risks of fat pad atrophy and plantar fascia rupture 1
  • Typically limited to 2-3 injections with at least 4-6 weeks between injections

Advanced Interventions for Recalcitrant Cases

For patients with symptoms persisting beyond 3 months despite conservative treatment:

• Diagnostic imaging:

  • Ultrasound is a reasonable and cost-effective diagnostic tool (80% sensitivity, 88% specificity) 1, 4
  • MRI may be considered for persistent diagnostic uncertainty 4

• Extracorporeal shock wave therapy (ESWT):

  • Particularly effective for chronic cases not responding to conservative treatment 1
  • Ultrasonography-guided focal ESWT is recommended

• Immobilization:

  • Cast immobilization may be considered for severe cases

• Surgical intervention:

  • Plantar fasciotomy (preferably endoscopic) as a last resort
  • Reserved for patients with persistent pain limiting activity and function despite exhausting all non-operative options 2

Treatment Algorithm

1. 0-3 months: Conservative measures (stretching, ice, activity modification, OTC supports)
2. 3-6 months: Add physician-directed interventions (custom orthotics, night splints, corticosteroid injections)
3. 6+ months: Consider ESWT or surgical consultation for persistent cases

Common Pitfalls and Caveats

• Corticosteroid injections provide only short-term relief and carry risks of fat pad atrophy and fascia rupture 1, 5
• Many standard treatments like night splints and orthoses have not shown benefit over placebo in some studies 2
• For patients with diabetes, rule out infectious complications that may require urgent surgical intervention 1
• Disproportionate pain relative to clinical findings, especially with systemic symptoms, should raise suspicion for alternative diagnoses like necrotizing fasciitis 1
• The condition is more accurately termed "plantar fasciopathy" as it is not primarily inflammatory 2

Remember that while most patients will eventually respond to conservative treatment, patience is required as resolution may take up to 12 months 1, 2.