Treatment of Plantar Fasciitis with Mid-Foot Pain
Begin with plantar fascia-specific stretching, ice massage, and NSAIDs as first-line therapy, combined with proper footwear and activity modification. 1, 2
Initial Conservative Management (First 2-3 Months)
Core Treatment Components
- Plantar fascia-specific stretching exercises are the foundation of treatment and should be performed consistently 1, 2
- Ice massage applied to the affected area provides symptomatic relief 2
- NSAIDs may provide modest benefit when combined with conservative measures, though evidence shows improvement occurs in both NSAID and placebo groups when paired with stretching and orthotics 3
- Calf stretching addresses the tight Achilles tendon that commonly contributes to plantar fasciitis 4
Footwear and Orthotic Interventions
- Proper footwear with adequate support is essential—avoid walking barefoot, in socks only, or thin-soled slippers 1
- Extra-depth shoes or custom insoles should be prescribed if foot deformities are present 1
- Heel cups (viscoelastic type) can be incorporated into the treatment regimen 3
- Ensure proper weight distribution when walking, particularly if using assistive devices 5
Activity Modification
- Reduce prolonged standing and high-impact activities during the acute phase 4
- For low-to-moderate risk patients, gradual increase in weight-bearing activity (approximately 1000 steps/day) is safe when using appropriate footwear 1
- Avoid cyclical repetitive loading of the plantar fascia regardless of treatment modality chosen 4
When Initial Treatment Fails (3+ Months)
Diagnostic Imaging
- Ultrasonography is reasonable and inexpensive with 80% sensitivity and 88% specificity for persistent pain beyond 3 months 6, 1, 2
- MRI is the most sensitive imaging study if more detailed evaluation is needed 5, 6
- Ultrasound elastography shows even higher diagnostic accuracy (95% sensitivity, 100% specificity) 6
Advanced Conservative Options
- Night dorsiflexion splints can be added, though evidence for benefit over placebo is limited 2
- Cast immobilization or fixed-ankle walker device may be considered for refractory cases 7
- Continue initial treatment measures while adding these interventions 7
Recalcitrant Cases (No Improvement After Conservative Care)
Injectable Therapies
- Corticosteroid injections provide short-term pain relief but effects are temporary and carry risks of fat pad atrophy and plantar fascia rupture 4
- Platelet-rich plasma or dextrose prolotherapy are increasingly used as alternatives to corticosteroids 8
- Avoid local corticosteroid injections near the Achilles tendon insertion 7
Extracorporeal Shock Wave Therapy (ESWT)
- Ultrasonography-guided focal ESWT is useful for chronic plantar fasciitis cases 4, 8
- Consider referral for ESWT in recalcitrant cases that have exhausted other conservative options 7, 1
Surgical Intervention
- Endoscopic plantar fasciotomy may be required when pain limits activity and function despite exhausting all nonoperative options 2, 8
- Surgery is typically reserved as a last resort, as approximately 80-90% of patients improve with conservative treatment within 12 months 2, 9
Important Clinical Pearls
Common pitfalls to avoid:
- Do not rely solely on NSAIDs—they must be combined with stretching and activity modification for optimal results 3
- Corticosteroid injections provide only temporary relief and should not be used as primary long-term management 4
- Night splints and standard orthoses have limited evidence of benefit over placebo, so prioritize stretching and proper footwear first 2
Expected timeline: With proper treatment, 80% of patients improve within 12 months, and up to 90% respond to conservative management overall 2, 9