What are the treatment options for plantar fasciitis?

Treatment of Plantar Fasciitis

Start with an 8-12 week supervised exercise program targeting the foot and ankle, combined with proper footwear, plantar fascia stretching, ice massage, and NSAIDs as first-line therapy. 1, 2

Initial Conservative Management (First 3 Months)

Core Treatment Components

• Exercise therapy: Implement an 8-12 week structured program focusing on plantar fascia and Achilles tendon stretching, ideally supervised by a qualified healthcare professional 1
• Footwear modifications: Ensure properly fitted shoes that accommodate foot shape; avoid walking barefoot or in thin-soled slippers both indoors and outdoors 1
• Ice massage: Apply directly to the painful area, particularly after activity 2, 3
• NSAIDs: Consider oral nonsteroidal anti-inflammatory drugs, though evidence shows modest benefit—pain improves by a factor of 5.2 versus 3.6 with placebo over 6 months, with the greatest effect between 2-6 months 4

Additional Conservative Options

• Heel cups or pads: Viscoelastic heel cups may provide symptomatic relief 4
• Arch supports or orthotics: Can be considered, though evidence for superiority over placebo is limited 2
• Night splints: Commonly used but lack strong evidence of benefit over placebo 2

Important caveat: Approximately 80% of patients improve within 12 months with proper conservative treatment, and symptoms resolve more quickly when treatment begins earlier after symptom onset 2, 3

Diagnostic Imaging (If Pain Persists Beyond 3 Months)

• Ultrasound: Reasonable and cost-effective first imaging choice, showing 80% sensitivity and 88% specificity compared to MRI 5, 1, 2
• MRI: Most sensitive imaging modality for characterizing plantar fascia and ruling out tears or other pathology; reserve for cases where diagnosis remains unclear or surgical planning is needed 5, 1

Recalcitrant Cases (Failure of Conservative Treatment)

Second-Line Interventions

• Corticosteroid injections: Can be considered for persistent symptoms, though long-term efficacy data are limited 2, 3
• Extracorporeal shock wave therapy: Option for refractory cases, though evidence quality is variable 2

Surgical Consideration

• Endoscopic fasciotomy: Reserved for patients with continued activity-limiting pain after exhausting all nonoperative options 2
• Digital flexor tenotomy: Specifically for patients with hammer toe deformity contributing to plantar fascia stress 1

Critical Pitfalls to Avoid

• Do not delay treatment: The interval between symptom onset and treatment initiation directly affects resolution time 2, 3
• Do not rely on single modality: Combine treatments addressing pain reduction, tissue stress reduction, and restoration of strength/flexibility 6
• Do not overlook footwear: Inappropriate shoes perpetuate the condition; this is a modifiable risk factor 1
• Do not assume inflammation: This is plantar fasciopathy (degenerative process), not true fasciitis, which explains why anti-inflammatory treatments show only modest benefit 2, 7

Expected Outcomes

Conservative management is ultimately effective in approximately 90% of patients, though the natural history suggests some spontaneous resolution occurs regardless of treatment 7. The combination of stretching, appropriate footwear, and activity modification forms the foundation of successful management, with other modalities serving as adjuncts 2, 3, 6.