What is the recommended treatment approach for plantar fasciitis?

Treatment Approach for Plantar Fasciitis

The most effective treatment approach for plantar fasciitis involves a stepwise algorithm starting with conservative measures including plantar fascia-specific stretching, appropriate footwear, and NSAIDs, progressing to more invasive interventions only for recalcitrant cases.

Diagnosis

Plantar fasciitis is primarily diagnosed clinically based on:

• Stabbing, non-radiating heel pain that is worst with first steps in the morning or after prolonged sitting 1
• Tenderness to palpation at the proximal plantar fascial insertion on the anteromedial calcaneus 1
• Pain elicited by passive ankle/first toe dorsiflexion 2

Advanced imaging is rarely needed for initial diagnosis but may be considered for recalcitrant cases:

• MRI is considered the most sensitive imaging study for plantar fasciitis diagnosis 3
• Ultrasound has good sensitivity (80%) and specificity (88%) compared to MRI 3
• Ultrasound elastography shows even higher sensitivity (95%) and specificity (100%) 3

Treatment Algorithm

First-Line Treatments (0-6 weeks)

1. Patient-directed conservative measures:

   • Plantar fascia-specific stretching exercises 2, 4
   • Calf stretching exercises 4
   • Ice massage to the plantar fascia 2
   • Activity modification to decrease repetitive loading 4
   • Oral NSAIDs (may provide additional pain relief when combined with other conservative measures) 5

2. Supportive devices:

   • Appropriate footwear with adequate arch support 4
   • Viscoelastic heel cups 5
   • Night dorsiflexion splinting 4

Second-Line Treatments (6-12 weeks if no improvement)

1. Physician-directed interventions:
   • Custom foot orthotics for biomechanical correction 2
   • Physical therapy modalities 2
   • Corticosteroid injections (effective for short-term pain relief but carry risks of fat pad atrophy and plantar fascia rupture) 4

Third-Line Treatments (>12 weeks for recalcitrant cases)

1. Advanced interventions:
   • Ultrasonography-guided extracorporeal shock wave therapy (ESWT) 4, 1
   • Surgical options (e.g., endoscopic fasciotomy) for cases that fail all conservative measures after 6+ months 2, 1

Prognosis and Expectations

• With proper treatment, approximately 80% of patients improve within 12 months 1
• Conservative treatment is ultimately effective in approximately 90% of patients 6
• Only consider surgical interventions after exhausting all non-operative treatment options 1

Important Considerations and Pitfalls

• Avoid prolonged corticosteroid injections due to risks of plantar fascia rupture and fat pad atrophy 4
• Recognize that plantar fasciitis is more accurately described as plantar fasciopathy since it is not primarily inflammatory 1
• Consider differential diagnoses including stress fractures, nerve entrapment, or fat pad atrophy in cases that don't respond to appropriate treatment 1
• Patients should be counseled that resolution may take 6-12 months despite appropriate treatment 1
• Addressing risk factors such as obesity, prolonged standing, and limited ankle dorsiflexion is crucial for long-term success 1