What are the treatment options for plantar fasciitis?

Treatment of Plantar Fasciitis

Start with plantar fascia-specific stretching exercises and calf stretching as your primary intervention, combined with ice massage and avoidance of flat shoes—this forms the foundation of treatment for the next 6 weeks before escalating therapy. 1, 2

First-Line Conservative Treatment (Weeks 0-6)

The initial approach should focus on mechanical interventions and symptom control:

• Stretching exercises are the most important initial intervention—specifically plantar fascia-specific stretches and calf-muscle stretching performed regularly throughout the day 1, 2
• Ice massage should be applied to the painful area for 5-10 minutes several times daily, especially after activity, to reduce inflammation 1, 2
• Footwear modification requires avoiding flat shoes and barefoot walking to reduce strain on the plantar fascia 1, 2
• Over-the-counter heel cushions and arch supports provide basic mechanical support during this initial phase 2
• Weight loss should be recommended if the patient is overweight or obese 2
• Padding and strapping of the foot offers additional support 1, 2
• Night splints to maintain dorsiflexion during sleep help prevent morning pain 1, 2

With proper treatment, 80% of patients improve within 12 months, and approximately 90% respond to conservative treatment overall 3, 4

Second-Line Treatment (After 6 Weeks Without Improvement)

If symptoms persist after 6 weeks of first-line measures, escalate to:

• Customized orthotic devices tailored to the patient's foot structure provide superior arch support and cushioning compared to over-the-counter options—these show 62% pain reduction at one year versus 48% with night splints alone, with better compliance 2, 5
• Corticosteroid injections can provide short-term pain relief but carry significant risks including fat pad atrophy and plantar fascia rupture—effects are short-lived and must be weighed carefully 1, 2, 6
• Fixed-ankle walker-type devices during activity reduce strain on the plantar fascia 1, 2
• Cast immobilization may be considered for more severe cases 1, 2

Third-Line Treatment (Recalcitrant Cases)

For chronic plantar fasciitis that hasn't responded to previous treatments:

• Extracorporeal shock wave therapy (ESWT), particularly ultrasonography-guided focal ESWT, is useful for recalcitrant cases 1, 2, 6
• Surgical intervention (plantar fasciotomy or endoscopic fasciotomy) should be considered only after exhausting all conservative options when pain continues to limit activity and function 1, 2, 3

Diagnostic Considerations

• Plantar fasciitis is predominantly a clinical diagnosis based on stabbing, nonradiating pain first thing in the morning in the proximal medioplantar surface of the foot, with tenderness at the anteromedial calcaneus 3
• Ultrasonography is reasonable and inexpensive for patients with pain persisting beyond 3 months despite treatment, with 80% sensitivity and 88% specificity compared to MRI 2, 3

Common Pitfalls

• Many standard treatments like night splints and orthoses have not shown benefit over placebo in some studies, though guidelines still recommend them as part of a comprehensive approach 3
• Corticosteroid injections provide only temporary relief and carry real risks—use judiciously 1, 6
• Activity modification to decrease cyclical repetitive loading of the plantar fascia should be advised during treatment regardless of the chosen modality 6