Management of Plantar Fasciitis
Start with patient-directed conservative treatments including plantar fascia stretching, ice massage, oral NSAIDs, and activity modification for several weeks; if pain persists beyond this initial period, escalate to physician-prescribed interventions including physical therapy, foot orthotics, and corticosteroid injections, as 90% of patients improve with conservative management alone. 1, 2
Initial Conservative Management (First-Line)
Begin with the following patient-directed interventions for several weeks 1:
- Plantar fascia stretching exercises - this is the cornerstone of initial treatment 2
- Ice massage to the affected area 1, 2
- Oral NSAIDs for pain control 1, 2
- Rest and activity modification - reduce prolonged standing and high-impact activities 1
- Weight reduction if obesity is present, as increased BMI is a significant risk factor 2
Escalation to Physician-Prescribed Treatments
If symptoms persist after several weeks of initial conservative management, add 1:
- Physical therapy modalities 1
- Foot orthotics or arch supports to address biomechanical abnormalities 1, 3
- Corticosteroid injections for persistent pain 1
- Change of footwear to address contributing factors 3
Important Caveat on Common Treatments
Night splints and standard orthoses have not demonstrated benefit over placebo in rigorous studies, despite their widespread use 2. However, they may still be considered on an individual basis when other treatments fail.
Diagnostic Imaging for Recalcitrant Cases
Reserve imaging for patients with pain persisting beyond 3 months despite treatment 4, 1, 2:
- Ultrasonography is the preferred initial imaging modality - it is reasonable, inexpensive, and shows plantar fascia thickness >4mm with abnormal tissue signal in plantar fasciitis 4, 1
- Ultrasound elastography demonstrates superior diagnostic accuracy (95% sensitivity, 100% specificity) compared to standard ultrasound 4
- MRI is the most sensitive imaging modality but typically unnecessary unless ruling out other heel pathology such as stress fractures or tears 4, 1
Management of Chronic Recalcitrant Plantar Fasciitis (≥6 months)
For patients who fail to improve after exhausting conservative options 1, 2:
- Ultrasonography-guided focal extracorporeal shock wave therapy (ESWT) is recommended for chronic plantar fasciitis unresponsive to conservative treatment 4
- Endoscopic fasciotomy may be required in patients who continue to have pain limiting activity and function despite exhausting all nonoperative treatment options 2
Clinical Diagnosis Criteria
Diagnosis is predominantly clinical, based on 1, 2:
- Stabbing, nonradiating heel pain with first steps in the morning or after prolonged sitting 2
- Pain worsens at the end of the day 2
- Tenderness to palpation of the medial plantar calcaneal region, specifically the proximal plantar fascial insertion at the anteromedial calcaneus 1, 2
- Discomfort elicited by passive ankle/first toe dorsiflexion 1