Current Treatment of Plantar Fasciitis
Begin with plantar fascia-specific stretching exercises combined with calf-muscle stretching, ice massage, and NSAIDs as first-line therapy for all patients with plantar fasciitis. 1, 2
Initial Conservative Management (First 6-12 Weeks)
Patient-Directed Interventions
- Stretching exercises are the cornerstone of treatment, specifically targeting the plantar fascia and calf muscles to reduce tension on the fascia 1, 2
- Ice massage (cryotherapy) applied to the heel reduces pain and inflammation 1, 2
- Activity modification including rest and avoidance of prolonged standing, flat shoes, and barefoot walking 1, 2
- Weight loss if BMI is elevated, as obesity is a significant risk factor 2, 3
- Over-the-counter heel cushions and arch supports provide mechanical relief 1, 2
- NSAIDs for pain and inflammation, though evidence shows only modest benefits 1, 2
Critical point: Treatment is more effective when initiated early—the shorter the interval between symptom onset and treatment initiation, the faster the resolution 2, 4. With proper treatment, 80% of patients improve within 12 months 3.
Physician-Prescribed Treatments (If Pain Persists After Several Weeks)
Advanced Conservative Options
- Physical therapy modalities including structured stretching programs 2, 5
- Foot orthotics for biomechanical correction 2, 6
- Night splints to maintain dorsiflexion during sleep, though evidence for benefit over placebo is limited 2, 3
- Corticosteroid injections for persistent symptoms 2, 6
- Padding and strapping of the foot for additional support 1
Important caveat: Many standard treatments like night splints and orthoses have not consistently shown benefit over placebo in recent evidence 3. The combination of multiple techniques generally yields better results than single interventions 5.
Recalcitrant Cases (Symptoms Lasting ≥6 Months)
For Severe, Treatment-Resistant Disease
- Extracorporeal shock wave therapy (ESWT) is effective when other techniques have failed 2, 5, 3
- TNF inhibitors should be considered for disabling enthesitis (including plantar fasciitis) that significantly impacts quality of life and function after failure of other therapies 7, 1
- Endoscopic plantar fasciotomy may be required in patients who continue to have activity-limiting pain despite exhausting all nonoperative options 2, 3
- Referral to a podiatric foot and ankle surgeon for surgical evaluation 1
Clinical pearl: Approximately 90% of patients improve with conservative techniques alone, making surgery necessary in only 10% of cases 2, 6. The natural history suggests this is a self-limiting condition, though symptoms can persist for extended periods without proper treatment 2, 4.
Diagnostic Considerations
Diagnosis is primarily clinical based on characteristic morning heel pain and tenderness at the medial plantar calcaneal region 2, 3. Imaging is reserved for recalcitrant cases:
- Ultrasonography is reasonable and inexpensive for pain persisting beyond 3 months despite treatment, showing increased plantar fascia thickness 2, 3
- MRI is reserved for ruling out other heel pathology in chronic cases 2
Common pitfall: Avoid ordering imaging for initial diagnosis—it is rarely needed and does not change initial management 2, 3.