What are the best management options for a patient with plantar fasciitis?

Management of Plantar Fasciitis

Start with conservative therapy consisting of plantar fascia-specific stretching exercises combined with ice massage, oral NSAIDs, and activity modification for several weeks, as this approach resolves symptoms in 90% of patients. 1

Initial Conservative Management (First-Line Treatment)

Patient-Directed Interventions

• Plantar fascia-specific stretching exercises are the cornerstone of treatment, showing limited but consistent evidence of benefit 2, 3
• Ice massage applied to the medial plantar heel region for pain relief 1, 4
• Oral analgesics (NSAIDs) for symptomatic relief 1, 4
• Activity modification to decrease cyclical repetitive loading of the plantar fascia, particularly reducing prolonged standing, walking, and running 2
• Rest during the acute phase 1

Supportive Measures

• Full-length silicone insoles should be prescribed as first-line orthotic intervention, as they demonstrate effectiveness in reducing pain and improving function 5
• Calf stretching exercises to address limited ankle dorsiflexion, a known risk factor 2, 4

Continue this conservative approach for at least 3 months before escalating treatment, as 80% of patients improve within 12 months with proper conservative management. 4

Second-Line Treatment (If Conservative Measures Fail After Several Weeks)

Physician-Prescribed Interventions

• Physical therapy modalities including supervised stretching programs 1
• Night dorsiflexion splinting to maintain stretch on the plantar fascia overnight 2
• Foot orthotics (custom or prefabricated) for biomechanical correction 1

Corticosteroid Injections

• Ultrasound-guided corticosteroid injection demonstrates superior short-term outcomes compared to insoles alone, with significant improvements in pain scores, function, and plantar fascia thickness at 1 month 5
• However, effects are short-lived and must be weighed against risks of fat pad atrophy and plantar fascia rupture 2
• Reserve for patients who have failed initial conservative measures 1

Important caveat: Corticosteroid injections provide temporary relief but carry significant risks, so use judiciously and only after conservative measures have been exhausted 2.

Third-Line Treatment (Recalcitrant Cases After 6+ Months)

Advanced Interventions

• Ultrasonography-guided focal extracorporeal shock wave therapy (ESWT) for chronic plantar fasciitis unresponsive to conservative treatment 2, 4
• Endoscopic plantar fasciotomy may be required in patients with persistent pain limiting activity and function despite exhausting all nonoperative options 4

Diagnostic Imaging (When Indicated)

Imaging is NOT needed for initial diagnosis

• Diagnosis is primarily clinical based on characteristic morning heel pain and medial plantar calcaneal tenderness 1, 4

Reserve imaging for specific situations:

• Ultrasonography is reasonable and inexpensive for recalcitrant cases (pain persisting beyond 3 months despite treatment), showing plantar fascia thickness >4mm and abnormal tissue signal 6, 4
• Ultrasound elastography demonstrates superior diagnostic accuracy (95% sensitivity, 100% specificity) compared to standard ultrasound 6
• MRI is the most sensitive imaging modality but typically unnecessary unless ruling out other heel pathology such as stress fractures or tears 7, 6

Common Pitfalls to Avoid

• Do not use night splints as first-line treatment - many standard treatments including night splints have not shown benefit over placebo 4
• Avoid premature surgical intervention - 90% of patients improve with conservative techniques, so exhaust all nonoperative options first 1
• Do not rely on imaging for initial diagnosis - this is a clinical diagnosis; imaging is reserved for recalcitrant cases or diagnostic uncertainty 1, 4
• Recognize that plantar fasciopathy (not fasciitis) is the appropriate descriptor as the condition is degenerative rather than inflammatory 4