What is the best treatment for plantar fasciitis?

Best Treatment for Plantar Fasciitis

The best initial treatment for plantar fasciitis consists of plantar fascia-specific stretching, calf stretching, ice massage, and oral NSAIDs, with more than 90% of patients improving with these conservative techniques within 12 months. 1, 2

First-Line Conservative Treatment

Patient-Directed Treatments (Initial 4-6 weeks)

• Stretching exercises:
  • Plantar fascia-specific stretch: Pull toes toward shin while seated, holding for 10 seconds, repeat 10 times, 3 times daily
  • Calf stretching: Stand facing wall with affected foot behind, lean forward keeping heel on ground
• Ice massage: Roll foot over frozen water bottle for 5-10 minutes, 3-4 times daily
• Activity modification: Reduce prolonged standing, running, and high-impact activities
• Oral NSAIDs: May provide additional pain relief when combined with other conservative measures 3
• Appropriate footwear: Shoes with adequate arch support and cushioning

Second-Line Treatment (If pain persists after 4-6 weeks)

Physician-Prescribed Interventions

• Foot orthotics: Custom or over-the-counter arch supports to reduce excessive pronation
• Night splinting: Maintains dorsiflexion of the ankle during sleep to prevent morning pain
• Physical therapy modalities: Including ultrasound therapy and manual techniques
• Corticosteroid injections: Consider for acute pain relief, but be cautious of potential complications such as fat pad atrophy and plantar fascia rupture 4

Third-Line Treatment (For recalcitrant cases >6 months)

• Extracorporeal shock wave therapy (ESWT): Effective for chronic cases that haven't responded to other treatments 2
• Surgical intervention: Plantar fasciotomy may be considered when all conservative measures have failed 1

Treatment Algorithm Based on Duration and Severity

Acute Phase (0-3 months)

1. Start with stretching, ice massage, NSAIDs, and activity modification
2. If minimal improvement after 4-6 weeks, add night splints and orthotics
3. Consider corticosteroid injection if pain is severe and limiting function

Chronic Phase (3-6 months)

1. Continue stretching program and orthotics
2. Physical therapy with focused modalities
3. Second corticosteroid injection if first was beneficial

Recalcitrant Phase (>6 months)

1. Consider ESWT
2. Evaluate for surgical intervention if all conservative measures have failed

Important Considerations and Pitfalls

• Morning pain is characteristic: The hallmark symptom is sharp pain with first steps in the morning or after prolonged sitting 1
• Obesity is a risk factor: Weight loss should be encouraged in overweight patients 2
• Avoid steroid overuse: While effective for short-term pain relief, multiple injections increase risk of plantar fascia rupture 4
• Diagnosis is primarily clinical: Imaging is rarely needed for initial diagnosis and should be reserved for recalcitrant cases or to rule out other pathologies 1
• Patience is required: Even with appropriate treatment, complete resolution may take 6-12 months 2

Remember that plantar fasciitis is predominantly a self-limiting condition, with 80% of patients improving within 12 months with proper conservative treatment 2. Surgical intervention should only be considered after exhausting all non-operative treatment options.