What is the best treatment plan for a patient with plantar fasciitis?

Treatment of Plantar Fasciitis

Start with plantar fascia-specific stretching, ice massage, and NSAIDs as first-line therapy, recognizing that 80-90% of patients will improve with conservative treatment within 12 months. 1, 2

Initial Conservative Management (First 6-12 Weeks)

Core Treatment Components

• Plantar fascia-specific stretching exercises should be performed daily, as this is one of the most evidence-supported interventions 3, 2
• Calf stretching to address Achilles tendon tightness, a common contributing factor 1, 3
• Ice massage applied to the heel for pain relief 1, 2
• Oral NSAIDs (such as celecoxib) can provide additional pain relief and decrease disability, particularly between 2-6 months of treatment, though improvement also occurs with conservative measures alone 4
• Activity modification to reduce repetitive loading of the plantar fascia during the treatment phase 3

Adjunctive Measures

• Appropriate orthotics for patients with biomechanical abnormalities like excessive foot pronation, pes cavus, or pes planus 3, 5
• Viscoelastic heel cups may provide cushioning 4
• Weight reduction if obesity is present, as this is a significant risk factor 1, 5

Second-Line Treatments (If Pain Persists Beyond 6-12 Weeks)

Physical Therapy Modalities

• Night dorsiflexion splinting to maintain stretch of the plantar fascia overnight 4, 3
• Formal physical therapy if patient-directed treatments fail 1

Corticosteroid Injections

• Consider for persistent pain, but recognize that effects are short-lived 3
• Weigh risks carefully: fat pad atrophy and plantar fascia rupture are potential complications 3
• Should not be considered a definitive solution but rather a temporizing measure 3

Diagnostic Imaging (Only If Needed)

When to Image

• Reserve imaging for recalcitrant cases lasting beyond 3 months despite treatment 1, 2
• Use imaging to rule out other heel pathology when diagnosis is uncertain 1

Imaging Modality Selection

• Ultrasonography is reasonable and inexpensive, with 80% sensitivity and 88% specificity compared to MRI 6, 7, 2
• MRI is the most sensitive imaging study for plantar fasciitis diagnosis 6, 7
• Ultrasound elastography shows even higher diagnostic accuracy (95% sensitivity, 100% specificity) 6, 7

Refractory Cases (Pain Persisting ≥6 Months)

Advanced Interventions

• Extracorporeal shock wave therapy (ESWT) for chronic plantar fasciitis unresponsive to conservative measures 1, 3
• Endoscopic plantar fasciotomy may be required only after exhausting all nonoperative options 2

Key Clinical Pearls

Diagnostic Features

• Classic presentation: stabbing, non-radiating pain in the proximal medioplantar foot, worst with first steps in the morning or after prolonged sitting 1, 2
• Physical exam: tenderness to palpation at the medial plantar calcaneal region and anteromedial calcaneus 1, 2
• Provocative test: pain elicited by passive ankle/first toe dorsiflexion 1

Common Pitfalls to Avoid

• Do not routinely use night splints as standard treatment—evidence does not show benefit over placebo 2
• Do not rely solely on corticosteroid injections given short-lived effects and complication risks 3
• Do not order imaging initially—diagnosis is primarily clinical 1, 2
• Recognize this is a degenerative process (plantar fasciopathy), not inflammatory, despite the "-itis" terminology 2

Prognosis

• 90% of patients improve with conservative treatment 1, 5
• 80% improve within 12 months with proper treatment 2
• The condition is self-limiting in most cases 1