What are the recommended physiotherapy exercises for plantar fasciitis?

Physiotherapy Recommendations for Plantar Fasciitis

Plantar fascia-specific stretching exercises are superior to standard Achilles tendon stretching for chronic plantar fasciitis and should be the primary physiotherapy intervention. 1

Core Exercise Protocol

Plantar Fascia-Specific Stretching (Primary Intervention)

• Perform non-weight-bearing plantar fascia stretches as the foundation of treatment, which have demonstrated significantly better outcomes than Achilles stretching for first-step morning pain and worst pain 1
• Execute the stretch by crossing the affected leg over the opposite knee, pulling the toes back toward the shin to create tension along the plantar fascia 1
• Frequency: Perform stretches multiple times daily, particularly before taking first steps in the morning 1
• This tissue-specific approach addresses the actual pathology rather than just associated structures 1

Calf and Achilles Stretching (Adjunctive)

• Add gastrocnemius-soleus stretching to the plantar fascia-specific program, though evidence shows this alone is less effective than plantar fascia stretching 1, 2
• Weight-bearing calf stretches can supplement but should not replace plantar fascia-specific exercises 1
• Moderate-quality evidence suggests plantar fascia-specific stretching produces larger pain score reductions than calf stretching alone 2

Supervised vs. Home-Based Programs

Supervised outpatient physiotherapy with manual therapy produces superior outcomes compared to home exercise alone. 3

Supervised Outpatient Protocol (Preferred)

• Combine exercise with hands-on techniques: myofascial release, joint mobilization, and soft tissue mobilization performed twice weekly for 8 weeks 3
• This approach demonstrates significantly better improvements in pain (VAS), function (FFI), balance, proprioception, foot sensation, and flexibility compared to home programs 3
• Superior outcomes persist at 6-month follow-up 3
• The active, supervised approach aligns with general rehabilitation principles favoring active over passive interventions 4

Home Program Components (If Supervised Care Unavailable)

• Structured foot-ankle-hip exercise program with weekly follow-ups for 8 weeks 3
• Patient education on self-management techniques and activity modification 5, 6
• While home programs show improvement, results are inferior to supervised care 3

Strengthening and Functional Training

• Include strengthening exercises targeting foot intrinsic muscles, ankle stabilizers, and hip musculature as part of comprehensive management 5, 3
• Address proprioception deficits and dynamic balance impairments through specific exercises 3
• Eccentric exercises may be beneficial, extrapolating from evidence in other tendinopathies 4

Activity Modification

Advise activity modification to decrease cyclical repetitive loading during the treatment phase regardless of chosen modality. 6

• Reduce prolonged standing, walking, and running that aggravate symptoms 6
• Avoid complete immobilization to prevent muscular atrophy and deconditioning 4
• Allow continuation of activities that do not worsen pain 4

Treatment Duration and Progression

• Implement 8-week initial treatment programs with reassessment at that timepoint 1, 3
• For chronic cases (symptoms >10 months), expect gradual improvement rather than immediate resolution 1
• If symptoms persist beyond 3 months despite conservative treatment, consider advanced imaging and alternative interventions 7

Common Pitfalls to Avoid

• Do not rely solely on Achilles tendon stretching as this is inferior to plantar fascia-specific stretching for chronic cases 1
• Avoid prescribing only passive modalities (ultrasound, heat, massage) without active exercise components 4
• Do not recommend complete rest, as tensile loading stimulates appropriate collagen production and alignment 4
• Recognize that home programs alone, while beneficial, produce inferior results to supervised care with manual therapy 3

Adjunctive Supportive Measures

• Provide patient education on condition pathophysiology and self-management strategies 5, 6
• Consider prefabricated soft insoles as part of comprehensive management 1
• Night dorsiflexion splinting can be added for persistent cases 6
• Cryotherapy (ice through wet towel for 10-minute periods) provides short-term pain relief 4