What is the treatment for plantar fasciitis?

Treatment of Plantar Fasciitis

Start immediately with plantar fascia-specific stretching exercises and calf stretching—this is the single most important intervention for plantar fasciitis and should be performed daily. 1

First-Line Conservative Treatment (Weeks 0-6)

The initial approach should combine multiple evidence-based interventions simultaneously:

• Stretching exercises targeting both the plantar fascia and calf muscles form the cornerstone of treatment and must be performed consistently 1, 2
• Ice massage to the affected heel, particularly after activity, helps reduce pain 1
• Over-the-counter heel cushions and arch supports provide immediate symptomatic relief 1
• Weight loss if the patient is overweight or obese, as increased BMI is a significant risk factor 1, 3
• Footwear modifications: avoid flat shoes and barefoot walking entirely 1
• Activity modification to decrease repetitive loading of the plantar fascia during the treatment phase 2
• Padding and strapping of the foot for additional support 1
• Night splints to maintain dorsiflexion during sleep 1

With proper conservative treatment, approximately 80-90% of patients improve within 12 months 3, 4. The natural history favors resolution with conservative measures in about 90% of cases 4.

Second-Line Interventions (After 6 Weeks of Failed Conservative Treatment)

If symptoms persist beyond 6 weeks despite adherence to initial treatment:

• Customized orthotic devices tailored to the patient's specific foot structure 1
• Corticosteroid injections may provide pain relief, though effects are short-lived and carry risks of fat pad atrophy and plantar fascia rupture 1, 2
• Immobilization via casting or fixed-ankle walker-type device during activity 1

Important caveat: While corticosteroid injections can help with pain, weigh the temporary benefit against the risk of complications, particularly fat pad atrophy which can worsen long-term outcomes 2.

Advanced Interventions (For Recalcitrant Cases)

For chronic plantar fasciitis unresponsive to 3-6 months of conservative treatment:

• Ultrasonography-guided focal extracorporeal shock wave therapy (ESWT) is the preferred advanced non-surgical option for recalcitrant cases 1, 2
• Cast immobilization if not previously attempted 1
• Surgical intervention (plantar fasciotomy, either open or endoscopic) should be reserved only when all conservative measures have been exhausted, with success rates of 70-90% 1, 5

Diagnostic Considerations

• Plantar fasciitis is predominantly a clinical diagnosis based on characteristic stabbing, non-radiating pain in the proximal medioplantar foot that is worst with first steps in the morning and worsens at day's end 3
• Physical examination reveals tenderness at the anteromedial calcaneus at the proximal plantar fascial insertion 3
• Ultrasonography is reasonable and inexpensive for patients with pain persisting beyond 3 months despite treatment, with 80% sensitivity and 88% specificity compared to MRI 1, 3

Common Pitfalls to Avoid

• Do not rush to corticosteroid injections in the first 6 weeks—stretching exercises are more important and have better long-term outcomes 1
• Recognize that many "standard" treatments like night splints and orthoses have not consistently shown benefit over placebo in rigorous studies, though guidelines still recommend them 3
• Surgery should truly be a last resort after exhausting all conservative options, as 80-90% of patients improve without it 6, 3, 4