Treatment of Plantar Fasciitis
For plantar fasciitis, begin with conservative therapy including plantar fascia-specific stretching, ice massage, NSAIDs, and activity modification for 6 weeks; if no improvement occurs, add physical therapy, custom orthotics, and consider corticosteroid injections, with the combination of corticosteroid injection plus controlled strength training and stretching providing superior outcomes compared to either treatment alone. 1, 2
Initial Conservative Management (First 6 Weeks)
Patient-directed treatments should be initiated immediately and include 1:
- Regular calf-muscle and plantar fascia-specific stretching (most important intervention) 1, 3
- Ice massage to the affected area 1, 3
- NSAIDs for pain control 1, 3
- Activity modification: rest, limit standing, avoid barefoot walking and flat shoes 1
- Over-the-counter heel cushions and arch supports 1
- Weight loss if indicated (obesity is a significant risk factor) 1, 4
The evidence shows that 90% of patients improve with conservative treatment, though the natural history remains unclear 4, 5. Plantar fasciitis is self-limiting, with 80% of patients improving within 12 months with proper treatment 3.
Escalation at 6 Weeks Without Improvement
Refer to a podiatric foot and ankle surgeon or continue physician-directed care 1:
- Continue all initial treatments 1
- Add customized orthotic devices (not just over-the-counter) 1
- Night splinting (though evidence for benefit over placebo is limited) 1, 3
- Padding and strapping of the foot 1
- Corticosteroid injections (limited number) 1
Critical Evidence on Corticosteroid Injections
The highest quality evidence demonstrates that corticosteroid injections combined with controlled training (strength training and stretching) is superior to either treatment alone 2. This 2019 randomized controlled trial with 2-year follow-up showed:
- Mean difference of 40 points in Foot Function Index between combined treatment versus training alone (p < 0.001) 2
- Mean difference of 29 points between combined treatment versus injections alone (p < 0.01) 2
- Benefits sustained at all time points through 2 years 2
Important caveat: Corticosteroid injections provide short-lived pain relief when used alone and carry risks of fat pad atrophy and plantar fascia rupture 6. Therefore, they should always be combined with controlled training rather than used as monotherapy.
Refractory Cases (2-3 Months Without Improvement)
Continue initial treatments and consider 1:
- Cast immobilization if not previously used 1
- Fixed-ankle walker-type device during activity 1
- Ultrasonography-guided focal extracorporeal shock wave therapy for chronic cases 6
Chronic Recalcitrant Plantar Fasciitis (≥6 Months)
For patients failing all conservative measures 1, 4:
- Extracorporeal shock wave therapy 1, 4, 6
- Surgical plantar fasciotomy (endoscopic fasciotomy may be required) 1, 3
- Re-evaluate for alternative diagnoses 1
Diagnostic Imaging Considerations
Imaging is rarely needed for initial diagnosis, which is primarily clinical 4, 3. However, for pain persisting beyond 3 months despite treatment 3:
- Ultrasound is reasonable and inexpensive (80% sensitivity, 88% specificity) 7, 3
- Ultrasound elastography has higher accuracy (95% sensitivity, 100% specificity) 7
- MRI is most sensitive but reserved for recalcitrant cases or ruling out other pathology 7, 4
Key Clinical Pitfalls
Avoid these common errors:
- Do not use corticosteroid injections as monotherapy—always combine with controlled training 2
- Do not inject corticosteroids near the Achilles tendon insertion (risk of rupture) 1
- Do not rely on night splints or standard orthotics alone—evidence for benefit over placebo is lacking 3
- Do not delay referral beyond 6 weeks of failed conservative therapy 1
- Activity modification with load reduction is essential during treatment regardless of chosen modality (cushioning shoes, insoles, abstaining from running/jumping) 6, 2