What is the appropriate treatment for plantar fasciitis?

Treatment of Plantar Fasciitis

Start with plantar fascia-specific stretching exercises combined with calf-muscle stretching, ice massage, and arch supports—this conservative approach resolves symptoms in approximately 80-90% of patients within 12 months. 1, 2, 3

Initial Conservative Management (First-Line Treatment)

The foundation of plantar fasciitis treatment is mechanical and anti-inflammatory:

• Stretching exercises are the cornerstone: perform regular calf-muscle stretching and plantar fascia-specific stretching to reduce tension on the fascia 1, 2
• Ice massage (cryotherapy) reduces pain and inflammation 1
• Over-the-counter heel cushions and arch supports provide mechanical relief by redistributing pressure 1
• NSAIDs can be added for pain control, though evidence shows only modest benefits—one randomized controlled trial showed a trend toward improved pain relief when combined with conservative measures, particularly between 2-6 months of treatment 1, 4
• Activity modification: limit standing for prolonged periods and avoid flat shoes and barefoot walking 1
• Weight loss if BMI is elevated, as obesity is a significant risk factor 1, 2
• Padding and strapping of the foot for additional support 1

Important Caveat on Common Treatments

Many standard treatments like night splints and orthoses have not shown benefit over placebo in rigorous studies, despite their widespread use 2. However, one study combining heel cups and night splinting with other modalities showed improvement 4.

Timeline and Expectations

Plantar fasciitis is predominantly a clinical diagnosis with stabbing, non-radiating pain on the proximal medioplantar surface, worst first thing in the morning and at end of day 2. With proper conservative treatment, 80% of patients improve within 12 months 2. The condition is more accurately termed "plantar fasciopathy" since it represents a degenerative process rather than true inflammation 2, 3.

Advanced Treatment for Refractory Cases

If symptoms persist beyond 3 months despite conservative treatment:

• Consider ultrasonography as a reasonable and inexpensive diagnostic tool to confirm the diagnosis 2
• TNF inhibitors should be considered for severe, disabling cases that significantly impact quality of life and function—the GRAPPA Treatment Recommendations Committee specifically recommends TNF inhibitors for severe enthesitis (including plantar fasciitis) that has failed other therapies 1
• Noninvasive interactive neurostimulation (NIN) showed superior results compared to extracorporeal shock wave therapy in a 2017 randomized controlled trial, with >90% patient satisfaction and significant improvements in pain scores and NSAID consumption 5
• Extracorporeal shock wave therapy is an option, though evidence is limited 2
• Corticosteroid injections may be considered, though long-term efficacy data are lacking 2, 3

Surgical Intervention

For truly recalcitrant cases:

• Refer to a podiatric foot and ankle surgeon when conservative and advanced non-operative treatments have been exhausted 1
• Endoscopic plantar fasciotomy (partial or total release) may be required in patients with continued pain limiting activity and function, with success rates of 70-90% 2, 6
• Surgery should only be considered after exhausting all non-operative options, as approximately 90% of patients ultimately respond to conservative treatment 3

Key Clinical Pitfall

Do not rush to invasive treatments—the natural history shows that most cases resolve with time and conservative management. The wide variety of treatments used makes it difficult to determine which specific interventions are truly effective versus natural resolution 3.