What are the treatment options for plantar fasciitis?

Treatment for Plantar Fasciitis

Start with plantar fascia-specific stretching exercises combined with calf stretching, ice massage, NSAIDs, and over-the-counter heel cushions—this conservative approach is the cornerstone of initial management and should be maintained for at least 6 weeks before escalating treatment. 1, 2

Initial Conservative Treatment (First 6 Weeks)

The American Academy of Family Physicians emphasizes that regular stretching of the calf muscle and plantar fascia is the single most important intervention for plantar fasciitis. 1 This should be your primary recommendation to patients.

Core first-line interventions include:

• Plantar fascia-specific stretching exercises performed regularly throughout the day to reduce pain and improve function 1, 2
• Calf stretching exercises to address limited ankle dorsiflexion, a known risk factor 1, 2
• Ice massage (cryotherapy) applied directly to the painful area for 5-10 minutes several times daily 1, 2
• Oral NSAIDs for pain control 1
• Over-the-counter arch supports and heel cushions to provide initial support 1
• Foot taping and padding for additional support 1

Critical behavioral modifications:

• Avoid flat shoes and walking barefoot, as this exacerbates the condition 1, 2
• Activity modification to decrease repetitive loading of the plantar fascia 3

The evidence shows that with proper treatment, 80% of patients improve within 12 months, and conservative treatment is ultimately effective in approximately 90% of patients. 4, 5

Intermediate Treatment (After 6 Weeks Without Improvement)

If there is no improvement after 6 weeks, refer to a podiatric surgeon and escalate to second-line interventions. 1

Second-line treatments include:

• Customized orthotic devices, which are more effective than over-the-counter devices 1, 2
• Night splints for passive stretching to maintain dorsiflexion and prevent morning pain 1, 2
• Limited corticosteroid injections in appropriate patients, though these provide only short-term relief and carry risks of fat pad atrophy and plantar fascia rupture 1, 2, 3
• Immobilization with a cast or fixed ankle walker device during activity to reduce strain 1, 2
• Physical therapy with specific modalities 1

Important caveat: While corticosteroid injections can help with pain relief, the effects are short-lived and must be weighed against significant risks. 3 Use these judiciously and only after other conservative measures have failed.

Advanced Treatment (Recalcitrant Cases)

For chronic plantar fasciitis that hasn't responded to 6+ months of conservative treatment:

• Extracorporeal shock wave therapy (ESWT) is useful for chronic cases unresponsive to other treatments 2, 3
• Cast immobilization may be considered for more severe cases 2
• Surgical intervention (endoscopic plantar fasciotomy) should be considered only after exhausting all conservative options, with success rates of 70-90% 2, 6

Diagnostic Imaging Considerations

Imaging is not routinely needed for diagnosis, as plantar fasciitis is predominantly a clinical diagnosis based on characteristic stabbing, nonradiating pain in the morning at the proximal medioplantar surface. 4

When imaging is indicated (pain persisting beyond 3 months despite treatment):

• Ultrasonography is a reasonable and inexpensive first-line imaging tool with 80% sensitivity and 88% specificity 1, 4
• MRI is the most sensitive imaging study, reserved for recalcitrant cases or to rule out other heel pathology 1, 7

Common Pitfalls to Avoid

Do not rush to injections or advanced interventions—the natural history favors conservative management, and many standard treatments like night splints and orthoses have not consistently shown benefit over placebo in all studies. 4 However, the American Academy of Family Physicians still recommends them as part of a stepwise approach. 1, 2

Do not underestimate the importance of stretching—this is the most evidence-supported intervention and should be emphasized repeatedly to patients. 1

Be cautious with corticosteroid injections—while they may provide temporary relief, the risks of fat pad atrophy and plantar fascia rupture are real, and the benefits are transient. 2, 3, 8