What is the recommended management approach for a patient with plantar fasciitis in a primary care setting?

Management of Plantar Fasciitis in Primary Care

Begin with conservative therapy consisting of plantar fascia stretching exercises, ice massage, and NSAIDs, as approximately 80-90% of patients will improve with these measures within 12 months. 1, 2

Initial Patient-Directed Treatment (First 4-6 Weeks)

• Rest and activity modification: Reduce prolonged standing and high-impact activities 1
• Ice massage: Apply directly to the medial plantar heel for 15-20 minutes 1
• Oral analgesics: NSAIDs for pain control 1, 2
• Plantar fascia stretching: This is the cornerstone of treatment and should be performed multiple times daily 2

Clinical Diagnosis

The diagnosis is primarily clinical and does not require imaging initially 1. Key diagnostic features include:

• Sharp heel pain with first steps in the morning or after prolonged sitting 1
• Tenderness to palpation at the medial plantar calcaneal region (anteromedial calcaneus) 1, 2
• Pain elicited by passive ankle/first toe dorsiflexion 1
• Stabbing, non-radiating pain that worsens at the end of the day 2

Physician-Prescribed Treatments (If Pain Persists Beyond 4-6 Weeks)

If initial conservative measures fail, escalate to:

• Physical therapy modalities 1
• Foot orthotics 1
• Corticosteroid injections into the plantar fascia 1

Important caveat: Night splints and orthoses have not consistently shown benefit over placebo in recent evidence, despite their widespread use 2. However, they remain reasonable options when other conservative measures fail.

Diagnostic Imaging (Reserved for Specific Situations)

• Ultrasonography is reasonable and inexpensive for patients with pain persisting beyond 3 months despite treatment 2
• Findings include increased plantar fascia thickness and abnormal tissue signal 1
• MRI is reserved for recalcitrant cases or to rule out other heel pathology 1

Recalcitrant Cases (≥6 Months of Failed Conservative Treatment)

For the 10-20% of patients who fail conservative therapy:

• Extracorporeal shock wave therapy (ESWT) 1, 2
• Endoscopic plantar fasciotomy may be required for patients with continued activity-limiting pain despite exhausting all nonoperative options 2

Note: Evidence for these interventions remains limited, and they should only be considered after comprehensive conservative management has failed 2, 3

Risk Factor Modification

Address modifiable risk factors to prevent recurrence 1, 4:

• Obesity: Weight reduction counseling 1
• Limited ankle dorsiflexion: Achilles tendon stretching 2
• Prolonged standing: Workplace modifications 2
• Excessive foot pronation: Consider orthotics if biomechanical abnormalities identified 4

Timeline and Prognosis

• 80% of patients improve within 12 months with proper conservative treatment 2
• 90% or more respond to conservative measures overall 1, 5, 4
• Treatment should be continued for at least 6 months before considering invasive options 1

Critical pitfall: Do not rush to imaging or invasive procedures. The natural history favors resolution with conservative care, and the diagnosis is clinical. Reserve ultrasonography for cases persisting beyond 3 months and invasive treatments for those failing 6+ months of comprehensive conservative therapy 1, 2.