Treatment of Plantar Fasciitis
Start with plantar fascia-specific stretching exercises combined with ice massage and NSAIDs as first-line therapy, as 80% of patients improve within 12 months with proper conservative treatment. 1
Initial Conservative Management
The cornerstone of treatment involves three evidence-based interventions that should be initiated simultaneously:
- Plantar fascia-specific stretching exercises are the most important intervention and have demonstrated limited but meaningful evidence of benefit 2
- Ice massage applied to the proximal medioplantar surface provides symptomatic relief 1
- NSAIDs (such as celecoxib) show a trend toward improved pain relief, with pain improving by a factor of 5.2 versus 3.6 with placebo over 6 months, though statistical significance was not reached 3
Supportive Measures
Add these adjunctive therapies to the initial regimen:
- Plantar soft insoles have demonstrated limited evidence of benefit and should be used routinely 2
- Calf stretching exercises complement plantar fascia stretching 4
- Activity modification to decrease cyclical repetitive loading is essential regardless of treatment modality chosen 4
- Proper footwear that fits well and provides adequate support, particularly important in bilateral cases 5
Common Pitfall to Avoid
Night splints and custom orthoses are frequently prescribed but have not shown benefit over placebo in rigorous studies 1. Reserve orthotic support specifically for patients with documented foot deformities 5.
Second-Line Interventions for Persistent Pain (>3 months)
When conservative measures fail after 3 months:
- Corticosteroid injections (local injection or iontophoresis with steroids) provide limited evidence of short-term benefit 2, but weigh this against risks of fat pad atrophy and plantar fascia rupture 4
- Ultrasonography-guided focal extracorporeal shock wave therapy is useful for chronic recalcitrant cases and referrals should be made at this stage 4
- Diagnostic ultrasonography is reasonable and inexpensive for patients with pain persisting beyond 3 months, showing 80% sensitivity and 88% specificity 1, 6
Surgical Consideration
- Endoscopic fasciotomy may be required only in patients who continue to have pain limiting activity and function despite exhausting all nonoperative treatment options 1
Key Clinical Pearls
The diagnosis is predominantly clinical: look for stabbing, nonradiating pain first thing in the morning in the proximal medioplantar surface, worsening at day's end, with tenderness to palpation at the anteromedial calcaneus 1. This is a degenerative fasciopathy, not an inflammatory condition, so the term "plantar fasciopathy" is more accurate 1. Conservative treatment ultimately succeeds in approximately 90% of patients 7.