What are the treatment options for plantar fasciitis?

Treatment of Plantar Fasciitis

Start with plantar fascia-specific stretching exercises combined with calf stretching, ice massage, and NSAIDs as first-line therapy; for cases failing initial conservative treatment after 3 months, add corticosteroid injections combined with continued structured exercise training. 1, 2, 3

Initial Conservative Treatment (First 3 Months)

Core Interventions

• Plantar fascia-specific stretching exercises performed regularly are the foundation of treatment, targeting reduction of tension on the fascia 1, 2
• Calf-muscle stretching should be performed consistently to address biomechanical contributors 1
• Ice massage (cryotherapy) applied to the affected area reduces pain and inflammation 1
• NSAIDs provide modest pain relief and anti-inflammatory effects, though benefits are limited 1, 2

Mechanical Support Measures

• Over-the-counter heel cushions and arch supports offer mechanical relief 1
• Proper footwear that fits the foot shape is essential; avoid flat shoes, barefoot walking, and thin-soled slippers 1, 4
• Padding and strapping of the foot provides additional support 1

Lifestyle Modifications

• Activity limitation with avoidance of prolonged standing, walking, and running during the treatment phase 2, 5
• Weight loss if indicated to reduce mechanical stress on the plantar fascia 1

Advanced Treatment for Refractory Cases (After 3 Months)

Combination Therapy (Highest Quality Evidence)

The most effective treatment for chronic plantar fasciitis is corticosteroid injection combined with a structured 3-month program of strength training and stretching. 3 This combination showed:

• 40-point greater improvement in Foot Function Index compared to exercise alone (p < 0.001) 3
• 29-point greater improvement compared to injections alone (p < 0.01) 3
• Sustained benefits at 2-year follow-up 3

Corticosteroid Injection Protocol

• Administer injections at monthly intervals until ultrasound-measured plantar fascia thickness decreases below 4.0 mm 3
• Maximum of 3 injections should be given 3
• Important caveat: Weigh benefits against risks of fat pad atrophy and plantar fascia rupture 5
• Effects are short-lived when used as monotherapy without exercise 5

Diagnostic Imaging for Persistent Cases

• Ultrasonography is reasonable and inexpensive for patients with pain persisting beyond 3 months despite treatment 1, 2
• Ultrasound can measure plantar fascia thickness (normal < 4.0 mm) and guide treatment decisions 3

Treatment for Severe, Recalcitrant Cases

Additional Modalities

• Extracorporeal shock wave therapy (ultrasonography-guided focal treatment) is useful for chronic cases 5
• Noninvasive interactive neurostimulation (NIN) showed superior results compared to shockwave therapy in one randomized trial, with >90% patient satisfaction 6

Severe Enthesitis Management

• TNF inhibitors should be considered for severe, disabling plantar fasciitis that significantly impacts quality of life and function after failure of other therapies 1
• The GRAPPA Treatment Recommendations Committee specifically recommends TNF inhibitors for severe enthesitis (including plantar fasciitis) refractory to standard treatments 1

Surgical Referral

• Endoscopic fasciotomy may be required in patients with continued pain limiting activity and function despite exhausting all nonoperative options 2
• Refer to a podiatric foot and ankle surgeon for recalcitrant cases 1

Common Pitfalls to Avoid

• Night splints and standard orthoses have not shown benefit over placebo despite widespread use 2
• Corticosteroid injections alone without exercise provide only short-term relief 5, 3
• Delaying combination therapy: Don't wait beyond 3 months to add corticosteroid injections to exercise programs in non-responding patients 3
• Approximately 80-90% of patients improve within 12 months with proper conservative treatment, so surgical intervention should be reserved for true treatment failures 2, 7