What is the best treatment approach for plantar fasciitis?

Plantar Fasciitis Treatment

Begin with plantar fascia-specific stretching exercises combined with calf stretching and ice massage for 5-10 minutes several times daily, while avoiding flat shoes and barefoot walking—this first-line approach should be maintained for 6 weeks before escalating treatment. 1

First-Line Conservative Management (0-6 Weeks)

The initial treatment strategy focuses on three core interventions that address the underlying biomechanical stress and inflammation:

• Stretching exercises: Implement plantar fascia-specific stretches and calf stretching exercises daily to reduce pain and improve function 1, 2
• Ice massage: Apply ice directly to the painful area for 5-10 minutes multiple times per day to reduce inflammation 1
• Footwear modification: Avoid flat shoes, thin-soled slippers, and barefoot walking both indoors and outdoors to reduce strain on the plantar fascia 1, 3

Important caveat: Approximately 80% of patients improve within 12 months with proper conservative treatment, and nonsurgical management is ultimately effective in about 90% of cases 4, 2. The stabbing, nonradiating pain is typically worst first thing in the morning and worsens again at the end of the day 2.

Second-Line Treatments (6-12 Weeks)

If symptoms persist after 6 weeks of first-line therapy, escalate to:

• Orthotic devices: Start with over-the-counter prefabricated orthotics for arch support and cushioning; custom orthotics may provide additional benefit but should be reserved if prefabricated options fail 1, 5
• Night splinting: Use dorsiflexion splints to maintain foot position during sleep and prevent morning pain 1, 6
• Padding and strapping: Apply supportive taping or padding to reduce plantar fascia strain 1
• Activity modification: Decrease cyclical repetitive loading activities during the treatment phase 6

Corticosteroid injection considerations: While injections can provide short-term pain relief, they carry significant risks including fat pad atrophy and plantar fascia rupture—use judiciously and only after other second-line options have been attempted 1, 6

Diagnostic Imaging (If Pain Persists Beyond 3 Months)

• Ultrasonography: This is a reasonable and inexpensive diagnostic tool for patients whose pain persists beyond three months despite treatment 2
• Physical examination findings are typically limited to tenderness at the anteromedial calcaneus where the plantar fascia inserts 2

Third-Line Treatments (Recalcitrant Cases)

For chronic plantar fasciitis unresponsive to 12 weeks of conservative management:

• Extracorporeal shock wave therapy (ESWT): Useful for chronic cases that haven't responded to other treatments 1, 6
• Cast immobilization: Consider for more severe cases requiring complete offloading 1
• Surgical intervention: Endoscopic plantar fasciotomy should only be considered after exhausting all nonoperative treatment options, with success rates of 70-90% 1, 7

Common Pitfalls to Avoid

• Do not use therapeutic ultrasound or low-intensity laser therapy: These modalities have shown unsatisfactory results in controlled trials 5
• Avoid magnetic insoles: There is no evidence supporting their use for plantar fasciitis 5
• Do not rush to surgery: Surgical intervention should only occur after a comprehensive trial of conservative measures, as the natural history favors resolution with time 4
• Beware of corticosteroid complications: Fat pad atrophy and plantar fascia rupture are real risks that can worsen long-term outcomes 1, 6