What is the recommended management for plantar fasciitis?

Management of Plantar Fasciitis

Start with plantar fascia-specific stretching exercises, ice massage, and NSAIDs as first-line therapy, as 80% of patients improve within 12 months with proper conservative treatment. 1

Initial Conservative Management

The following interventions should be implemented immediately upon diagnosis:

• Plantar fascia-specific stretching is the cornerstone of treatment and should be performed consistently 1, 2
• Calf stretching exercises help address limited ankle dorsiflexion, a key risk factor 1, 2
• Ice massage provides symptomatic relief and should be applied to the affected area 1
• NSAIDs can be used for pain control during the acute phase 1, 3
• Activity modification to decrease cyclical repetitive loading of the plantar fascia is essential regardless of treatment modality chosen 2

Additional Conservative Options

If initial measures provide insufficient relief after 4-6 weeks:

• Appropriate orthotics can help redistribute pressure and correct biomechanical abnormalities 2
• Night dorsiflexion splinting may provide benefit, though evidence shows limited superiority over placebo 1, 2
• Weight reduction should be emphasized in patients with elevated BMI, as obesity is a significant risk factor 1

Interventions for Persistent Symptoms (Beyond 3 Months)

When conservative measures fail after 3 months:

• Corticosteroid injections provide short-term pain relief but must be weighed against risks of fat pad atrophy and plantar fascia rupture 2
• Ultrasonography-guided focal extracorporeal shock wave therapy is useful for chronic plantar fasciitis and should be considered for recalcitrant cases 2
• Imaging with ultrasound (80% sensitivity, 88% specificity) or MRI (most sensitive) should be obtained at this point if diagnosis remains uncertain 4, 5

Surgical Management

Surgery is reserved for patients who fail all conservative measures:

• Endoscopic plantar fasciotomy may be required in patients with continued pain limiting activity and function despite exhausting nonoperative options 1, 6
• Success rates for surgical release range from 70% to 90% 6
• Approximately 90% of patients ultimately respond to nonsurgical treatment, making surgery necessary in only 10% of cases 3

Critical Pitfalls to Avoid

• Do not rush to imaging in typical presentations—plantar fasciitis is predominantly a clinical diagnosis based on characteristic stabbing, nonradiating pain in the proximal medioplantar foot that is worst first thing in the morning and at end of day 5, 1
• Avoid overreliance on corticosteroid injections due to risk of complications including plantar fascia rupture 2
• Consider differential diagnoses including calcaneal stress fracture, tarsal tunnel syndrome, plantar fascia rupture, and in adolescents, calcaneal apophysitis 5
• Reserve weightbearing radiographs for cases persisting beyond 3 months or when diagnosis is uncertain (85% sensitivity, 95% specificity) 5