What is the recommended treatment for plantar fasciitis?

Treatment for Plantar Fasciitis

The recommended initial treatment for plantar fasciitis should focus on conservative measures including plantar fascia-specific stretching exercises, calf muscle stretching, ice massage, over-the-counter heel cushions, arch supports, weight loss if indicated, activity modification, and avoidance of flat shoes and barefoot walking, as approximately 90% of patients will respond to these interventions. 1

Initial Conservative Measures (First-line)

1. Stretching Exercises:

   • Plantar fascia-specific stretching exercises
   • Calf muscle stretching
   • Perform these exercises daily, especially before getting out of bed in the morning

2. Self-care Measures:

   • Ice massage to the plantar fascia (10-15 minutes, 2-3 times daily)
   • Weight loss for patients with elevated BMI
   • Activity modification to decrease repetitive loading
   • Avoidance of flat shoes and barefoot walking

3. Supportive Devices:

   • Over-the-counter heel cushions and arch supports
   • Night splints to maintain dorsiflexion during sleep

Physician-Directed Measures (Second-line)

If symptoms persist after 4-6 weeks of consistent conservative treatment:

1. Medication:

   • NSAIDs for pain relief, though evidence for their efficacy is limited 2
   • Consider a trial of oral NSAIDs in conjunction with other conservative measures

2. Orthotic Interventions:

   • Padding and strapping of the foot
   • Custom foot orthoses for patients with significant foot deformities 1

3. Corticosteroid Injections:

   • Consider for patients with significant pain not responding to initial measures
   • Use with caution due to risks of fat pad atrophy and plantar fascia rupture 1, 3
   • Limit to no more than 2-3 injections

Advanced Interventions (Third-line)

For recalcitrant cases (symptoms persisting >3 months despite treatment):

1. Extracorporeal Shock Wave Therapy (ESWT):

   • Particularly effective for chronic cases 1
   • Ultrasonography-guided focal ESWT is recommended

2. Cast Immobilization:

   • Short-term immobilization to reduce stress on the plantar fascia

3. Surgical Intervention:

   • Plantar fasciotomy as a last resort
   • Consider only after failure of all conservative measures for at least 6-12 months 1, 4

Treatment Algorithm

1. Weeks 0-6: First-line conservative measures
2. Weeks 6-12: Add second-line physician-directed measures if needed
3. Beyond 12 weeks: Consider advanced interventions for recalcitrant cases

Important Considerations and Pitfalls

• Diagnostic Uncertainty: If symptoms persist beyond 3 months despite treatment, consider ultrasonography to confirm diagnosis and rule out other pathologies 1

• Special Populations: For patients with diabetes, carefully rule out infectious complications that may require urgent surgical intervention 1

• Realistic Expectations: Inform patients that while 90% will improve with conservative treatment, complete resolution may take 6-12 months 5, 4

• Common Pitfall: Overreliance on corticosteroid injections without addressing biomechanical factors can lead to tissue weakening and potential rupture 3

• Treatment Adherence: The success of conservative measures depends on consistent application and patient compliance with the treatment regimen