What is the recommended treatment for a patient with plantar fasciitis?

Treatment of Plantar Fasciitis

Start with plantar fascia-specific stretching exercises, ice massage, and NSAIDs as first-line therapy, with 90% of patients improving with conservative measures within 12 months. 1, 2

Initial Conservative Management (First 3 Months)

Patient-directed treatments should be implemented immediately:

• Plantar fascia-specific stretching exercises are the cornerstone of treatment, showing limited but consistent evidence of benefit 1, 3
• Ice massage applied to the heel for pain relief 1, 2
• Oral NSAIDs (such as celecoxib) provide modest additional benefit when combined with conservative measures, with pain improving 5.2-fold versus 3.6-fold with placebo at 6 months 4
• Activity modification to decrease repetitive loading of the plantar fascia during the treatment phase 5
• Calf stretching to address limited ankle dorsiflexion, a known risk factor 1, 2

Physician-Prescribed Interventions (If Pain Persists Beyond Several Weeks)

Escalate to these evidence-based treatments:

• Plantar soft insoles or foot orthotics have demonstrated limited evidence of benefit and should be prescribed 1, 3
• Corticosteroid injections provide short-term pain relief but must be weighed against risks of fat pad atrophy and plantar fascia rupture 1, 5
• Night dorsiflexion splinting can be considered, though evidence over placebo is limited 1, 2
• Physical therapy modalities may provide additional benefit 1

Important Caveat on Corticosteroid Injections

While corticosteroid injections (or iontophoresis with steroids) show limited evidence of benefit, their effects are transient and carry significant risks 5, 3. Use judiciously only after other conservative measures have been attempted.

Recalcitrant Cases (Pain Persisting Beyond 6 Months)

For chronic plantar fasciitis unresponsive to conservative treatment:

• Ultrasonography-guided focal extracorporeal shock wave therapy (ESWT) is recommended by the American College of Radiology for chronic cases 6, 5
• Endoscopic fasciotomy may be required in patients who continue to have pain limiting activity despite exhausting all nonoperative options 2

Diagnostic Imaging (Only for Recalcitrant Cases)

Imaging is rarely needed for initial diagnosis but becomes useful when pain persists beyond 3 months:

• Ultrasonography is reasonable and inexpensive, showing plantar fascia thickness >4mm and abnormal tissue signal 6, 1, 2
• 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 6, 1

Clinical Pearls

The diagnosis is predominantly clinical: Look for stabbing, nonradiating pain first thing in the morning in the proximal medioplantar surface of the foot, with tenderness to palpation at the anteromedial calcaneus 2. Pain worsens at the end of the day and can be elicited by passive ankle/first toe dorsiflexion 1.

This is a self-limiting condition with 80% of patients improving within 12 months with proper treatment 2. The key is starting conservative measures early and escalating systematically only when initial treatments fail.