How to manage plantar fasciitis?

Management of Plantar Fasciitis

Start with plantar fascia-specific stretching exercises and calf stretching as your primary intervention—this is the most important initial treatment. 1

Initial Conservative Treatment (First 6 Weeks)

The foundation of plantar fasciitis management is conservative therapy, which resolves symptoms in approximately 80-90% of patients within 12 months. 2, 3

Core Interventions (Start Immediately)

• Plantar fascia-specific stretching exercises: This is the single most important intervention and should be performed regularly. 1
• Calf muscle stretching: Regular stretching reduces tension on the fascia. 1, 4
• Ice massage: Apply to the affected area, especially after activity, to reduce pain and inflammation. 1, 4
• Over-the-counter heel cushions and arch supports: These provide immediate mechanical relief. 1, 4
• Activity modification: Avoid flat shoes and barefoot walking entirely. 1, 4
• Weight loss: If the patient is overweight or obese, this reduces mechanical stress on the plantar fascia. 1, 4

Additional Supportive Measures

• Night splints: Maintain dorsiflexion during sleep to prevent morning pain. 1
• Padding and strapping: Provides basic foot support. 1, 4
• NSAIDs: Can be used for pain and inflammation, though evidence shows only modest benefits. 4, 2

Important caveat: While NSAIDs are commonly used, their efficacy is limited and should not be relied upon as primary treatment. 4

Secondary Interventions (After 6 Weeks Without Improvement)

If symptoms persist beyond 6 weeks of initial conservative treatment, escalate to these options:

• Customized orthotic devices: Tailored to the patient's specific foot structure, these show limited evidence of benefit but are reasonable to try. 1, 5
• Corticosteroid injections: Provide pain relief but effects are short-lived (typically transient), and must be weighed against risks of fat pad atrophy and plantar fascia rupture. 1, 6, 5
• Immobilization: Use casting or fixed-ankle walker-type device during activity. 1

Critical pitfall: Corticosteroid injections carry significant risks including fat pad atrophy and plantar fascia rupture, so use judiciously and only after initial conservative measures fail. 6

Advanced Interventions (Recalcitrant Cases)

For chronic plantar fasciitis that fails to respond to the above treatments:

• Extracorporeal shock wave therapy (ESWT): Particularly ultrasonography-guided focal ESWT is effective for recalcitrant cases. 1, 6
• Cast immobilization: If not previously attempted. 1
• TNF inhibitors: Consider for severe cases with disabling symptoms that significantly impact quality of life and function, especially when other therapies have failed. 4
• Surgical intervention: Plantar fasciotomy or endoscopic fasciotomy should be reserved for patients who continue to have pain limiting activity and function despite exhausting all nonoperative options. 1, 2

Diagnostic Considerations

• Clinical diagnosis: Plantar fasciitis is predominantly diagnosed clinically based on stabbing, nonradiating pain first thing in the morning in the proximal medioplantar surface of the foot, with tenderness to palpation at the anteromedial calcaneus. 2
• Ultrasonography: Has good sensitivity (80%) and specificity (88%) compared to MRI and is reasonable for patients with pain persisting beyond 3 months despite treatment. 1, 2

Key point: The condition is more accurately termed "plantar fasciopathy" rather than "fasciitis" because it is not primarily inflammatory but rather a degenerative process. 2