Treatment of Plantar Fasciitis
Begin with plantar fascia-specific stretching exercises combined with activity modification and ice massage, as these conservative measures form the foundation of evidence-based treatment for plantar fasciitis. 1, 2, 3
Initial Conservative Management (First 4-6 Weeks)
First-Line Interventions
- Plantar fascia-specific stretching is the most important initial intervention, with limited but consistent evidence of benefit 2, 3, 4
- Activity modification to decrease repetitive loading of the plantar fascia should be implemented immediately, regardless of other treatments chosen 5
- Ice massage applied to the heel can provide symptomatic relief 2, 3
- NSAIDs for pain control during the acute phase 2, 3
- Taping can provide temporary relief by supporting the plantar fascia 1
Adjunctive Measures with Limited Evidence
- Plantar soft insoles have demonstrated limited evidence of benefit and are reasonable to try given low cost and ease of use 4
- Calf stretching may help address biomechanical factors 5
- Weight reduction if obesity is present, as increased BMI is a risk factor 2, 3
Second-Line Treatment (If Pain Persists Beyond 4-6 Weeks)
Physician-Directed Interventions
- Physical therapy modalities can be considered 2
- Foot orthotics may be prescribed, though evidence is mixed 2
- Corticosteroid injections provide short-term pain relief but effects are transient and must be weighed against risks of fat pad atrophy and plantar fascia rupture 5, 4
- Ultrasonography-guided injections may improve accuracy if injections are chosen 5
Important Caveats
- Night splints have NOT shown benefit over placebo despite widespread use 3
- Standard orthoses have similarly failed to demonstrate superiority over placebo 3
- Corticosteroid benefits are short-lived, typically lasting only weeks to months 5, 4
Chronic Recalcitrant Cases (≥6 Months)
Advanced Interventions
- Extracorporeal shock wave therapy (ESWT), particularly ultrasonography-guided focal ESWT, is useful for chronic plantar fasciitis unresponsive to conservative treatment 2, 5, 3
- Endoscopic plantar fasciotomy may be required in patients with continued pain limiting activity despite exhausting all nonoperative options 3
Diagnostic Imaging Considerations
When to Image
- Imaging is rarely needed for initial diagnosis, which is primarily clinical 2
- MRI is the most sensitive imaging modality for plantar fasciitis when diagnosis remains uncertain after 3 months of treatment 6
- Ultrasound shows good sensitivity (80%) and specificity (88%) compared to MRI and is a reasonable, inexpensive alternative 6
- Imaging findings include increased plantar fascia thickness (>4mm) and abnormal tissue signal 2
Imaging to Rule Out Other Pathology
- MRI allows accurate characterization of adjacent soft tissues and bones to exclude alternative diagnoses 6
- US elastography shows even higher sensitivity (95%) and specificity (100%) than standard ultrasound for detecting plantar fasciitis 6
Expected Outcomes
- 90% of patients improve with conservative treatment within 12 months 2, 7
- 80% of patients improve with proper treatment within one year 3
- The condition is self-limiting in most cases, though the natural history without treatment remains unclear 7
Critical Clinical Pearls
- Diagnosis is based on stabbing, nonradiating heel pain worst with first morning steps and tenderness at the medial plantar calcaneal insertion 3
- Pain typically worsens at the end of the day after prolonged standing or walking 3
- Passive dorsiflexion of the ankle and first toe elicits discomfort in the proximal plantar fascia 2
- Risk factors include limited ankle dorsiflexion, obesity, and prolonged standing 2, 3