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 (First 3 Months)
The following interventions should be implemented immediately:
- Plantar fascia stretching exercises are the cornerstone of treatment, showing limited but meaningful evidence of benefit 2
- Ice massage applied to the proximal medioplantar heel surface helps reduce pain 1
- NSAIDs for symptomatic relief, though the condition is degenerative (fasciopathy) rather than inflammatory 1
- Soft plantar insoles have demonstrated limited evidence of benefit and are low-cost, easy interventions 2
What NOT to Prioritize Initially
Many standard treatments have not shown benefit over placebo, including night splints and orthoses, despite their widespread use 1. This is a critical pitfall—avoid investing heavily in these modalities as first-line options.
Recalcitrant Cases (Beyond 3 Months)
If symptoms persist despite 3 months of conservative treatment:
Diagnostic Imaging
- Obtain ultrasonography as a reasonable and inexpensive tool to confirm the diagnosis, looking for plantar fascia thickness >4mm and abnormal tissue signal 3, 1
- Ultrasound elastography demonstrates 95% sensitivity and 100% specificity if available 3
- MRI is the most sensitive modality but typically unnecessary unless ruling out other pathology 3
Advanced Treatment Options
For persistent pain limiting function:
- Corticosteroid injections show limited evidence of benefit with transient effect 2
- Iontophoresis with steroids similarly demonstrates limited, short-term benefit 2
- Extracorporeal shock wave therapy can be considered, though evidence is lacking 1
Surgical Intervention (Last Resort)
Endoscopic fasciotomy may be required only after exhausting all nonoperative treatment options in patients with continued activity-limiting pain 1. Complete plantar fascia release through a medial longitudinal incision, with resection of prominent heel spurs and degenerated fascia areas, achieved satisfactory results in 89% of surgical cases (24/27) 4.
Important Caveats
- The natural history of plantar fasciitis remains unclear, making it difficult to determine how much symptom resolution is truly due to treatment versus spontaneous improvement 5
- Approximately 90% of patients ultimately respond to nonsurgical treatment, supporting an aggressive conservative approach before considering surgery 5
- The condition is degenerative (fasciopathy) rather than inflammatory, which explains why anti-inflammatory treatments have limited efficacy 1