Treatment of Plantar Fasciitis
Start with plantar fascia-specific stretching exercises combined with calf-muscle stretching, ice massage, and NSAIDs as first-line therapy, with approximately 80% of patients improving within 12 months using conservative measures alone. 1, 2
Initial Conservative Treatment (First 3-6 Months)
The foundation of plantar fasciitis management is non-invasive and should include:
- Regular plantar fascia-specific stretching exercises and calf-muscle stretching to reduce tension on the fascia—this is the cornerstone of treatment 1, 2
- Cryotherapy (ice massage) applied to the affected area to reduce pain and inflammation 1
- NSAIDs for pain and inflammation control, though evidence shows only modest benefits; celecoxib has shown trends toward improved outcomes when combined with other conservative measures 1, 3
- Over-the-counter heel cushions and arch supports for mechanical relief 1
- Activity modification: limit prolonged standing and avoid flat shoes and barefoot walking 1
- Weight loss if indicated to reduce mechanical stress on the plantar fascia 1
- Padding and strapping of the foot for additional support 1
Important Caveats About Common Treatments
Many standard treatments lack strong evidence: night splints and orthoses have not consistently shown benefit over placebo, despite their widespread use 2. Conservative treatment is ultimately effective in approximately 90% of patients, though the natural history of the condition makes it difficult to determine how much improvement is truly due to treatment versus spontaneous resolution 4.
Treatment for Refractory Cases (After 3-6 Months)
When initial conservative measures fail after 3 months:
- Consider ultrasonography as a reasonable and inexpensive diagnostic tool to confirm the diagnosis and assess severity 2
- For severe, disabling cases that significantly impact quality of life and function, TNF inhibitors should be considered per the GRAPPA Treatment Recommendations Committee 1
- Noninvasive interactive neurostimulation (NIN) has shown superior results compared to extracorporeal shock wave therapy in chronic resistant cases, with >90% patient satisfaction 5
- Corticosteroid injections may be considered, though evidence is limited 2
- Extracorporeal shock wave therapy is an option, though evidence for efficacy is lacking 2
Surgical Intervention (Last Resort)
Refer to a podiatric foot and ankle surgeon for recalcitrant cases that continue to have pain limiting activity and function despite exhausting all nonoperative treatment options 1, 2
- Endoscopic fasciotomy may be required for patients who fail all conservative measures 2
- Complete plantar fascia release through a medial longitudinal incision with resection of prominent heel spurs has shown satisfactory results in approximately 89% of surgical cases (24 of 27 patients) 6
- Surgery should only be considered after at least 12 months of failed conservative treatment 2, 4
Clinical Pitfall to Avoid
Do not rush to invasive treatments—with proper conservative treatment, 80% of patients improve within 12 months 2. The condition is not truly inflammatory (plantar fasciopathy is more accurate), so aggressive anti-inflammatory strategies alone are insufficient 2.