Treatment of Plantar Fasciitis
Start with plantar fascia stretching exercises combined with ice massage and oral NSAIDs for several weeks, as this conservative approach resolves symptoms in 90% of patients within 12 months. 1, 2
Initial Conservative Management (First-Line Treatment)
Patient-directed therapies should be implemented immediately:
- Plantar fascia-specific stretching exercises performed daily, particularly before taking first steps in the morning 1, 2
- Ice massage applied to the medial plantar heel for 10-15 minutes 1
- Oral NSAIDs for pain control and to facilitate continued activity modification 1
- Activity modification including rest from aggravating activities (running, prolonged standing) 1, 3
- Achilles tendon stretching as limited ankle dorsiflexion is a key risk factor 2
These interventions should be tried for several weeks before escalating treatment 1.
Second-Line Interventions (If Pain Persists Beyond 4-6 Weeks)
When initial conservative measures fail, add physician-prescribed treatments:
- Physical therapy with supervised stretching and strengthening programs 1, 4
- Foot orthotics or arch supports to address biomechanical abnormalities 1, 3
- Corticosteroid injections into the plantar fascia insertion at the medial calcaneus 1, 2
Note on night splints: While commonly prescribed, night splints have not demonstrated benefit over placebo in recent evidence 2. However, they may be considered in recalcitrant cases as part of a multimodal approach 1.
Diagnostic Imaging Considerations
Imaging is NOT needed for initial diagnosis, which is primarily clinical based on characteristic morning heel pain and tenderness at the medial plantar calcaneal insertion 1, 2.
Consider ultrasonography if:
- Pain persists beyond 3 months despite appropriate treatment 2
- Diagnosis remains uncertain 1
- Ultrasound shows plantar fascia thickness >4mm and abnormal tissue signal 5, 1
MRI is reserved for:
- Ruling out alternative diagnoses (stress fracture, nerve entrapment, plantar fascia tear) 5, 1
- Recalcitrant cases where other pathology is suspected 1
Treatment for Chronic Recalcitrant Cases (≥6 Months)
For patients failing conservative treatment after 6 months:
- Extracorporeal shock wave therapy (ESWT) can be considered, particularly when other techniques have failed 1, 4, 2
- Endoscopic plantar fasciotomy may be required for patients with persistent pain limiting function despite exhausting all nonoperative options 2
Important caveat: Evidence for these advanced interventions is limited, and surgical options should be reserved for truly refractory cases 2.
Key Clinical Pearls
Risk factors to address concurrently:
- Obesity - weight reduction counseling 1, 2
- Prolonged standing occupations - workplace modifications 1
- Tight Achilles tendon - aggressive stretching program 2, 6
- Biomechanical abnormalities (pes planus, pes cavus) - orthotic intervention 3, 6
Timeline expectations:
- Symptoms typically improve within weeks to months with conservative treatment 1
- 80-90% of patients improve within 12 months with appropriate conservative management 1, 2, 6
- Shorter interval between symptom onset and treatment initiation correlates with faster resolution 3
Common pitfall: The condition is not inflammatory but rather a degenerative process (plantar fasciopathy), though the term "plantar fasciitis" remains in common use 2, 6.