What is the best treatment for plantar fasciitis?

Best Treatment for Plantar Fasciitis

Start with an 8-12 week supervised exercise program targeting plantar fascia-specific stretching combined with appropriate supportive footwear, as this forms the evidence-based foundation for managing plantar fasciitis. 1

Initial Conservative Management (First-Line Treatment)

Exercise and Stretching Protocol

• Implement plantar fascia-specific stretching exercises as the cornerstone of treatment, which have demonstrated limited but consistent evidence of benefit 2
• Add calf stretching exercises to the regimen, as these complement plantar fascia stretching 3
• Continue this program for 8-12 weeks under supervision of a qualified healthcare professional 1
• Apply ice massage to the affected area for symptomatic relief 4, 5

Footwear Modifications

• Prescribe appropriate footwear that conforms to the patient's foot shape to reduce mechanical stress on the plantar fascia 1
• Avoid walking barefoot or wearing thin-soled slippers, both indoors and outdoors 1
• Consider plantar soft insoles, which have demonstrated limited evidence of benefit 2

Activity Modification

• Reduce cyclical repetitive loading of the plantar fascia during the treatment phase 3
• Modify activities that involve prolonged standing or running 4
• Use oral analgesics (NSAIDs) for pain control during the initial weeks 4, 5

Second-Line Interventions (If Pain Persists Beyond 3 Months)

Diagnostic Imaging

• Order ultrasonography as a reasonable and cost-effective diagnostic tool when pain persists beyond three months despite conservative treatment 5
• MRI can be reserved for characterizing the plantar fascia and ruling out other pathology, though it is more expensive 6

Advanced Conservative Treatments

• Consider corticosteroid injections for short-term pain relief, recognizing that effects are transient and must be weighed against risks of fat pad atrophy and plantar fascia rupture 3, 2
• Iontophoresis with steroids shows limited evidence of benefit with transient effects 2
• Physical therapy modalities can be prescribed at this stage 4

Important caveat: Night splints and standard orthoses have not shown benefit over placebo in quality studies, despite their widespread use 5

Third-Line Options (Recalcitrant Cases After 6-12 Months)

For Chronic Plantar Fasciitis

• Refer for ultrasonography-guided focal extracorporeal shock wave therapy in patients with chronic plantar fasciitis unresponsive to conservative measures 3
• Consider endoscopic fasciotomy only when pain continues to limit activity and function despite exhausting all nonoperative treatment options 5

Expected Outcomes and Timeline

• 80-90% of patients improve with conservative treatment within 12 months 4, 5, 7
• Most patients respond to initial patient-directed treatments within several weeks 4
• The condition is self-limiting, though the natural history without treatment remains unclear 7

Critical Pitfalls to Avoid

• Do not rush to invasive procedures; 90% of patients improve with conservative techniques 4
• Avoid overreliance on night splints and standard orthoses, as evidence does not support their efficacy 5
• Do not perform corticosteroid injections without counseling patients about fat pad atrophy and rupture risks 3
• Recognize that plantar fasciitis is a degenerative process (fasciopathy), not an inflammatory condition, despite its name 5