Treatment of Plantar Fasciitis
The recommended first-line treatment for plantar fasciitis is regular calf-muscle and plantar fascia-specific stretching exercises combined with ice massage, over-the-counter heel cushions/arch supports, and avoidance of flat shoes and barefoot walking. 1
Initial Conservative Management (First 6 Weeks)
The cornerstone of treatment focuses on mechanical interventions rather than anti-inflammatory approaches, as plantar fasciitis is more accurately described as plantar fasciopathy—a degenerative rather than inflammatory condition. 2
Primary interventions include:
- Stretching exercises: Regular calf-muscle and plantar fascia-specific stretching are the most important initial intervention 1
- Ice massage: Apply to the affected area, especially after activity 1
- Footwear modifications: Use over-the-counter heel cushions and arch supports; avoid flat shoes and barefoot walking 1
- Weight reduction: If the patient is overweight or obese 1
- Padding and strapping: Basic supportive treatment to reduce mechanical stress 1
- Night splints: Maintain dorsiflexion during sleep 1
Important clinical context: With proper treatment, 80% of patients improve within 12 months, and conservative treatment is ultimately effective in approximately 90% of patients. 2, 3 Symptoms typically resolve more quickly when treatment begins earlier after symptom onset. 4
Secondary Interventions (After 6 Weeks Without Improvement)
If symptoms persist despite initial conservative measures:
- Customized orthotic devices: Tailored to the patient's specific foot structure 1
- Corticosteroid injections: Can be considered at this stage 1
- Immobilization: Via casting or fixed-ankle walker-type device during activity 1
Critical evidence on corticosteroid injections: The highest quality recent evidence demonstrates that corticosteroid injections combined with controlled training (strength training and stretching) produces superior outcomes compared to either treatment alone. 5 This combination showed a mean difference of 40 points in Foot Function Index and 20 mm improvement in VAS function pain compared to training alone, with benefits sustained at 2-year follow-up. 5 This represents a paradigm shift from using injections as standalone therapy.
Advanced Interventions (For Recalcitrant Cases)
For cases that don't respond to previous treatments:
- Extracorporeal shock wave therapy (ESWT): Particularly ultrasonography-guided focal ESWT 1
- Cast immobilization: If not previously attempted 1
- Surgical intervention: Plantar fasciotomy or endoscopic fasciotomy when all conservative measures have failed 1, 2
Diagnostic Considerations
Clinical diagnosis is predominant: Symptoms are stabbing, non-radiating pain first thing in the morning in the proximal medioplantar surface of the foot, worsening at day's end. 2 Physical examination reveals tenderness to palpation of the proximal plantar fascial insertion at the anteromedial calcaneus. 2
Imaging: Ultrasonography has good sensitivity (80%) and specificity (88%) compared to MRI and is reasonable for patients with pain persisting beyond 3 months despite treatment. 1, 2
Common Pitfalls to Avoid
- Don't rely solely on NSAIDs: While commonly used, they address symptoms rather than the underlying degenerative process 2
- Don't use corticosteroid injections alone: The evidence strongly supports combining injections with controlled training for superior outcomes 5
- Don't assume inflammation is the primary pathology: This is a degenerative fasciopathy, not fasciitis, which should guide treatment expectations 2
- Don't delay stretching exercises: These are the most important initial intervention and should begin immediately 1