What are the treatment options for plantar fasciitis?

Treatment of Plantar Fasciitis

Start all patients with plantar fascia-specific stretching and calf stretching exercises combined with ice massage, as these are the most important initial interventions that should be performed for at least 6 weeks before escalating treatment. 1, 2

First-Line Conservative Treatment (0-6 Weeks)

The initial approach focuses on mechanical stress reduction and inflammation control:

• Plantar fascia-specific stretching and calf-muscle stretching exercises are the cornerstone of treatment and should be 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 1, 2
• Avoid flat shoes and barefoot walking to reduce strain on the plantar fascia 1, 2
• Over-the-counter heel cushions and arch supports provide immediate symptomatic relief 2
• Weight loss should be recommended if the patient is overweight or obese 2
• NSAIDs can be used for pain control 3

With proper first-line treatment, 80% of patients improve within 12 months 3. The natural history suggests approximately 90% of patients ultimately respond to conservative treatment 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 compared to over-the-counter options, with evidence showing 62% pain reduction at 52 weeks and better long-term compliance 2, 5
• Night splints to maintain dorsiflexion during sleep help prevent morning pain 1, 2
• Padding and strapping of the foot for additional support 1, 2
• Corticosteroid injections can provide short-term pain relief but carry significant risks including fat pad atrophy and plantar fascia rupture, so effects must be weighed carefully 1, 6
• Fixed-ankle walker-type devices during activity to reduce plantar fascia strain 1, 2

Foot orthoses are the preferred second-line intervention based on superior long-term outcomes (19 of 23 patients still using orthoses at 12 months versus 1 of 28 still using night splints), better compliance, and fewer side effects 5.

Third-Line Treatment (Recalcitrant Cases)

For chronic plantar fasciitis unresponsive to 6+ months of conservative treatment:

• Extracorporeal shock wave therapy (ESWT), particularly ultrasonography-guided focal ESWT, is the preferred advanced intervention for recalcitrant cases 1, 2, 6
• Cast immobilization may be considered if not previously attempted 1, 2
• Surgical intervention (plantar fasciotomy) should only be considered after exhausting all conservative options, with endoscopic fasciotomy reserved for patients with persistent pain limiting activity despite comprehensive nonoperative treatment 1, 2, 3

Diagnostic Considerations for Persistent Cases

• 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 to Avoid

• Do not rush to corticosteroid injections despite their appeal for quick pain relief—the short-lived effects and risks of fat pad atrophy and plantar fascia rupture make them a less favorable option 1, 6
• Do not skip the initial 6-week trial of stretching exercises, as this is the most evidence-based intervention and many patients improve with time 1, 2
• Activity modification to decrease cyclical repetitive loading should be advised throughout treatment regardless of chosen modality 6