What are the management options and medications for plantar fasciitis?

Management of Plantar Fasciitis

The most effective treatment for plantar fasciitis is combining corticosteroid injections with a structured program of plantar fascia stretching and strengthening exercises, which provides superior outcomes compared to either treatment alone. 1

Initial Conservative Management

First-Line Treatment Approach

• Start with plantar fascia-specific stretching exercises combined with ice massage and NSAIDs 2, 3
• Stretching should target both the plantar fascia and Achilles tendon 2
• Ice massage applied directly to the painful area provides symptomatic relief 2
• Approximately 80% of patients improve within 12 months with proper conservative treatment 2

NSAID Therapy

• Naproxen or other oral NSAIDs can be used as adjunctive therapy 4, 3
• Evidence shows NSAIDs may provide modest additional pain relief when combined with stretching, heel cups, and night splinting, particularly between 2-6 months of treatment 3
• Use NSAIDs at the lowest effective dose for the shortest duration necessary due to cardiovascular and gastrointestinal risks 4
• Avoid NSAIDs in patients with history of ulcers, cardiovascular disease, or those taking anticoagulants 4

Additional Conservative Measures

• Viscoelastic heel cups provide cushioning and may reduce symptoms 3
• Night splints are commonly used, though evidence for superiority over placebo is limited 2
• Recommend load reduction including cushioning shoes, insoles, and temporary abstinence from running/jumping activities 1

Advanced Treatment for Persistent Cases

Corticosteroid Injection Protocol

For patients not responding adequately to initial conservative measures after 4-8 weeks, corticosteroid injections combined with continued stretching/strengthening exercises is the optimal treatment 1

• Administer corticosteroid injections at monthly intervals until ultrasound-measured plantar fascia thickness decreases below 4.0 mm (maximum 3 injections) 1
• The combination of injections plus training shows clinically significant improvements: 40-point reduction in Foot Function Index and 20mm reduction in VAS pain scores compared to training alone 1
• This combined approach demonstrates superior outcomes at both short-term and long-term follow-up (up to 2 years) 1

Important Caveat About Corticosteroids

• While highly effective when combined with exercise, corticosteroid injections have been gradually replaced by alternatives like platelet-rich plasma or dextrose prolotherapy in some practices due to concerns about tissue degeneration with repeated use 5
• Systemic corticosteroids (oral prednisone) are NOT indicated for plantar fasciitis 6

Diagnostic Imaging Considerations

When to Image

• Plantar fasciitis is predominantly a clinical diagnosis based on characteristic morning heel pain and tenderness at the medial calcaneal tubercle 2
• Consider ultrasound for patients with pain persisting beyond 3 months despite treatment 2
• Ultrasound shows good sensitivity (80%) and specificity (88%), with ultrasound elastography showing even higher accuracy (95% sensitivity, 100% specificity) 7
• MRI is the most sensitive imaging modality but is typically unnecessary for routine diagnosis 7

Refractory Cases

Third-Line Options

For patients failing 6-12 months of conservative treatment including injections:

• Extracorporeal shock wave therapy (ESWT) has increasing evidence for efficacy 5
• Transcatheter arterial embolization is an emerging option 5
• Endoscopic plantar fasciotomy may be required for truly recalcitrant cases that limit daily function despite exhausting all nonoperative options 2, 5

Clinical Pearls

• The condition is more accurately termed "plantar fasciopathy" as histology shows degenerative changes rather than inflammation 2, 5
• Risk factors include obesity, prolonged standing, limited ankle dorsiflexion, and both running and sedentary lifestyles 2
• Approximately 90% of patients ultimately improve with nonsurgical treatment 8
• Do not use corticosteroid injections as monotherapy—always combine with structured exercise program for optimal results 1