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

Treatment of Plantar Fasciitis

Start with conservative therapy consisting of plantar fascia-specific stretching, calf stretching, heel cups, and activity modification for several weeks; if symptoms persist beyond 3 months, add physical therapy modalities, orthotics, night splints, or consider corticosteroid injections, reserving ultrasonography-guided extracorporeal shock wave therapy (ESWT) for chronic recalcitrant cases. 1, 2, 3

Initial Patient-Directed Conservative Treatment (First Several Weeks)

Begin immediately with this combination approach, as 90% of patients improve with conservative measures 2, 4:

• Plantar fascia-specific stretching exercises performed daily, focusing on the plantar fascia and Achilles tendon 2, 3
• Activity modification to decrease cyclical repetitive loading—reduce prolonged standing, walking, and running during the treatment phase 3
• Ice massage applied to the heel 2
• Viscoelastic heel cups for cushioning 5
• Oral NSAIDs (such as celecoxib) may provide modest additional pain relief and decreased disability, though evidence shows only a trend toward benefit rather than statistically significant improvement 5

Physician-Prescribed Treatments (If Pain Persists After Initial Weeks)

Escalate to these interventions when patient-directed measures prove insufficient 2:

• Physical therapy modalities including supervised stretching programs 2
• Custom foot orthotics or arch supports to address biomechanical abnormalities 2, 6
• Night dorsiflexion splinting to maintain stretch during sleep 2, 3
• Corticosteroid injections for pain relief, though effects are short-lived and carry risks of fat pad atrophy and plantar fascia rupture—use judiciously 3

Advanced Treatment for Chronic Recalcitrant Cases (≥6 Months)

For patients failing conservative therapy after 6 months 2, 3:

• Ultrasonography-guided focal extracorporeal shock wave therapy (ESWT) is the recommended next step, supported by the American College of Radiology for chronic plantar fasciitis unresponsive to conservative treatment 1, 3
• Plantar fasciotomy should be reserved only for surgical candidates who have failed all conservative measures including ESWT 2, 6

Diagnostic Imaging Considerations

Imaging is not needed for initial diagnosis, which relies on clinical presentation: heel pain with first morning steps or after prolonged sitting, and tenderness at the medial plantar calcaneal region 2:

• Ultrasonography is reasonable and cost-effective for recalcitrant cases (>3 months), showing plantar fascia thickness >4mm; ultrasound elastography demonstrates superior accuracy (95% sensitivity, 100% specificity) 1, 7
• MRI is the most sensitive imaging modality but typically unnecessary unless ruling out stress fractures, tears, or other heel pathology 7, 1, 2

Critical Pitfalls to Avoid

• Do not rush to imaging for straightforward presentations—diagnosis is clinical 2
• Avoid overreliance on corticosteroid injections due to risks of fat pad atrophy and fascia rupture; reserve for selected cases 3
• Do not proceed to surgery without exhausting conservative options for at least 6 months, as 90% of patients respond to non-operative treatment 2, 4
• Address underlying risk factors including obesity, excessive foot pronation, and biomechanical abnormalities throughout treatment 2