What is the initial treatment for plantar fasciitis?

Initial Treatment for Plantar Fasciitis

The initial treatment for plantar fasciitis should include stretching of the plantar fascia, ice massage, and nonsteroidal anti-inflammatory drugs (NSAIDs). 1

Pathophysiology and Clinical Presentation

• Plantar fasciitis is a common cause of inferior heel pain affecting approximately one in 10 people during their lifetime 1
• The condition is more accurately described as plantar fasciopathy rather than fasciitis, as it is primarily degenerative rather than inflammatory in nature 1
• Typical symptoms include stabbing, non-radiating pain in the proximal medioplantar surface of the foot, worst with first steps in the morning and worsening again at the end of the day 1
• Physical examination typically reveals tenderness to palpation at the proximal plantar fascial insertion at the anteromedial calcaneus 1

Conservative Treatment Algorithm

First-Line Treatments (0-3 months)

• Stretching exercises: Implement plantar fascia-specific stretching and calf stretching exercises 2
• Ice massage: Apply to the affected area to reduce pain 1
• NSAIDs: Use for pain management and to potentially reduce inflammation 1
• Activity modification: Decrease cyclical repetitive loading of the plantar fascia during the treatment phase 2
• Appropriate footwear: Supportive shoes with proper cushioning 3

Second-Line Treatments (if no improvement after 4-6 weeks)

• Night splints: May help maintain dorsiflexion during sleep, though evidence shows limited benefit over placebo 1
• Orthotic devices: Custom or over-the-counter inserts to support the arch 2
• Taping: Can provide temporary relief by supporting the plantar fascia 4

Third-Line Treatments (for persistent cases >3 months)

• Imaging: Consider ultrasonography for cases that persist beyond three months despite treatment 1
• Corticosteroid injections: Can provide short-term pain relief but carry risks of fat pad atrophy and plantar fascia rupture 2
• Extracorporeal shock wave therapy (ESWT): Consider for chronic cases unresponsive to other conservative measures 2, 5

Treatment Considerations Based on Physical Examination Findings

• Patients with severe ankle equinus (inability to dorsiflex the ankle past -5°) are nearly 4 times more likely to respond favorably to conservative treatment including Achilles tendon stretching 3
• Patients with heel valgus in relaxed stance and those with less severe first-step pain (≤7 on ordinal scale) may be less responsive to conservative care 3

Prognosis and Expectations

• With proper treatment, approximately 80% of patients with plantar fasciitis improve within 12 months 1
• Conservative treatment is ultimately effective in approximately 90% of patients 6
• Patients should be advised that resolution may take several months even with appropriate treatment 6

When to Consider Advanced Interventions

• For cases that fail to respond to 3-6 months of conservative treatment:
  • Consider ultrasonography-guided focal extracorporeal shock wave therapy 2
  • Noninvasive interactive neurostimulation (NIN) has shown superior results compared to electric shock wave therapy in some studies 5
  • Surgical options such as endoscopic fasciotomy may be considered only after exhausting all non-operative treatment options 1

Common Pitfalls to Avoid

• Overreliance on corticosteroid injections without considering the risks of fat pad atrophy and plantar fascia rupture 2
• Failure to address underlying biomechanical factors such as tight Achilles tendon 6
• Premature consideration of invasive treatments before adequate trial of conservative measures 1
• Neglecting activity modification as part of the comprehensive treatment plan 2