What are the treatment options for plantar fasciitis?

Treatment for Plantar Fasciitis

Start with plantar fascia-specific stretching exercises and calf stretches performed daily, combined with ice massage for 5-10 minutes several times daily, and ensure proper footwear with adequate arch support—this conservative approach resolves symptoms in 80% of patients within 12 months. 1, 2

First-Line Conservative Treatment (0-6 weeks)

The American Academy of Family Physicians provides a clear algorithmic approach starting with these interventions 1:

• Plantar fascia-specific stretching exercises performed regularly are the cornerstone of treatment, with evidence showing reduced pain and improved function 1
• Calf stretching exercises should be performed daily to address limited ankle dorsiflexion, a key risk factor 1, 2
• Ice massage applied to the painful area for 5-10 minutes several times daily reduces inflammation 1
• Proper footwear with adequate arch support is essential—avoid flat shoes and barefoot walking entirely 1
• Activity modification to decrease repetitive loading of the plantar fascia during the treatment phase 3

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

If first-line measures fail after 6 weeks, escalate to 1:

• Customized orthotic devices provide superior arch support and cushioning compared to over-the-counter options 1
• Night splinting maintains dorsiflexion during sleep to prevent morning pain 1
• Padding and strapping of the foot for additional support 1
• Corticosteroid injections can provide short-term pain relief but carry significant risks including fat pad atrophy and plantar fascia rupture—use judiciously 1, 3
• Fixed-ankle walker-type devices during activity reduce strain on the plantar fascia 1

Third-Line Treatment (After 3+ months of failed conservative therapy)

For recalcitrant cases 1, 2:

• Extracorporeal shock wave therapy (ESWT) is useful for chronic plantar fasciitis unresponsive to other treatments 1, 3
• Cast immobilization may be considered for severe cases 1
• Surgical intervention (endoscopic fasciotomy) should only be considered after exhausting all nonoperative options 1, 2

Diagnostic Imaging (When Needed)

• Ultrasonography is reasonable and inexpensive for patients with pain persisting beyond 3 months despite treatment 2
• Plantar fasciitis is predominantly a clinical diagnosis—imaging is not needed initially 2

Common Pitfalls to Avoid

• Do not recommend barefoot walking or thin-soled slippers, either indoors or outdoors, as this aggravates the condition 4
• Corticosteroid injections provide only transient benefit and risk fat pad atrophy and fascia rupture—reserve for refractory cases 1, 5, 3
• Many standard treatments like night splints and orthoses have not shown benefit over placebo in some studies, though guidelines still recommend them as second-line options 2
• The natural history shows 90% of patients improve with conservative treatment, though it may take up to 12 months 6

Evidence Quality Note

While approximately 80% of patients improve within 12 months with proper treatment 2, the evidence for specific interventions is variable. Plantar fascia stretching and customized orthotics have the most consistent (though still limited) evidence of benefit 5. The algorithmic approach prioritizes low-cost, low-risk interventions first, escalating only when necessary 1.