What is the treatment for plantar fasciitis?

Treatment of Plantar Fasciitis

Begin with conservative therapy combining plantar fascia-specific stretching exercises, appropriate footwear, and heel cushions for 6 weeks, escalating to physical therapy, custom orthotics, and night splinting if symptoms persist. 1

Initial Conservative Management (First 6 Weeks)

Patient-Directed Measures

• Initiate regular calf-muscle and plantar fascia stretching exercises performed daily, as this represents the cornerstone of treatment 1, 2
• Apply ice massage to the affected area for pain control 1, 3
• Use over-the-counter heel cushions and arch supports to reduce mechanical stress 1
• Avoid walking barefoot or wearing flat shoes and slippers with thin soles, both indoors and outdoors 1, 2
• Modify activities to reduce prolonged standing and high-impact loading 3, 4
• Pursue weight loss if obesity is a contributing factor 1

Pharmacologic Therapy

• Consider NSAIDs for pain relief, though evidence shows only modest benefit with a trend toward improved outcomes between 2-6 months when combined with conservative measures 5
• NSAIDs provide symptomatic relief but are not curative; their use should be time-limited 5

Mechanical Interventions

• Apply padding and strapping of the foot to offload the plantar fascia 1
• Ensure proper footwear that accommodates foot shape and provides adequate support 2

Escalation if No Improvement After 6 Weeks

Refer to a podiatric foot and ankle surgeon or appropriate specialist for advanced conservative management 1

Physician-Prescribed Treatments

• Prescribe custom orthotic devices for biomechanical correction, which show limited but consistent evidence of benefit 1, 6
• Implement night splinting to maintain ankle dorsiflexion during sleep 1, 3
• Consider corticosteroid injections for short-term pain relief, though effects are transient and carry risks of fat pad atrophy and plantar fascia rupture 1, 4, 6
• Initiate formal physical therapy with supervised exercise programs targeting the foot and ankle over 8-12 weeks 2
• Use casting or fixed-ankle walker-type devices for immobilization in refractory cases 1

Management of Chronic Recalcitrant Cases (≥6 Months)

Advanced Diagnostic Evaluation

• Order ultrasonography as a reasonable, cost-effective diagnostic tool for patients with persistent pain beyond 3 months 2
• Consider MRI to characterize the plantar fascia and rule out other pathology in unclear cases 2

Definitive Treatment Options

• Extracorporeal shock wave therapy (ESWT) represents an evidence-based option for chronic plantar fasciitis unresponsive to conservative measures 3, 4
• Surgical plantar fasciotomy is reserved for the small percentage of patients (approximately 10%) who fail all conservative treatments after 6+ months 1, 3

Critical Clinical Pearls

The natural history shows 90% of patients improve with conservative treatment alone, making aggressive early intervention unnecessary 3, 7

Common Pitfalls to Avoid

• Do not inject corticosteroids directly into the Achilles tendon insertion, as this increases rupture risk 1
• Avoid premature surgical intervention before exhausting 6 months of appropriate conservative therapy 3
• Do not rely solely on NSAIDs without mechanical interventions, as the evidence for NSAIDs alone is weak 5
• Recognize that plantar fasciitis is largely a self-limiting degenerative condition, and overly aggressive treatment may cause more harm than benefit 3, 7

Treatment Algorithm Timeline

• Weeks 0-6: Patient-directed conservative measures with NSAIDs as needed 1
• Weeks 6-12: Add physician-prescribed interventions (orthotics, night splints, consider corticosteroid injection) 1
• Months 3-6: Continue conservative measures, consider ESWT for persistent symptoms 3, 4
• Beyond 6 months: Surgical consultation for fasciotomy only if all conservative measures have failed 1, 3