What are the treatment options 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, as 80-90% of patients improve with conservative treatment within 12 months. 1, 2

Initial Conservative Treatment (First 3 Months)

Patient-Directed Interventions

• Plantar fascia-specific stretching exercises are the cornerstone of treatment, showing limited but meaningful evidence of benefit 3, 4
• Ice massage applied to the heel for pain relief 1, 2
• Oral NSAIDs for analgesia 1, 2
• Activity modification to decrease repetitive loading of the plantar fascia during the treatment phase 3
• Rest from aggravating activities 1

Physician-Prescribed Interventions (if pain persists after several weeks)

• Calf stretching exercises in addition to plantar fascia stretches 3
• Plantar soft insoles/orthotics have demonstrated limited evidence of benefit 4
• Physical therapy modalities 1

Important caveat: Night splints, despite being commonly prescribed, have not shown benefit over placebo 2. This represents a common pitfall where traditional practice doesn't align with evidence.

Second-Line Treatment (Pain Persisting 3+ Months)

Diagnostic Imaging Before Escalation

• Ultrasonography is reasonable and inexpensive for recalcitrant cases, showing plantar fascia thickness >4mm and abnormal tissue signal 5, 2
• Ultrasound elastography demonstrates superior diagnostic accuracy (95% sensitivity, 100% specificity) compared to standard ultrasound 5
• MRI is the most sensitive modality but typically unnecessary unless ruling out stress fractures or tears 5

Treatment Options for Recalcitrant Cases

• Corticosteroid injections provide short-term pain relief with limited evidence, but effects are transient and must be weighed against risks of fat pad atrophy and plantar fascia rupture 3, 4
• Iontophoresis with steroids shows limited evidence of benefit with transient effect 4
• Ultrasonography-guided focal extracorporeal shock wave therapy (ESWT) is recommended for chronic plantar fasciitis unresponsive to conservative treatment, with supported success rates 5, 3

Surgical Intervention (Pain Persisting 6+ Months)

Reserve surgery only for patients who continue to have pain limiting activity and function despite exhausting all nonoperative options. 2

• Endoscopic fasciotomy may be required in truly refractory cases 2
• Surgical fasciotomy should be used only when conservative measures have failed, with studies showing 81% success with conservative treatment versus 19% requiring surgery 6

Treatment Algorithm Summary

1. Weeks 0-4: Plantar fascia stretching + ice massage + NSAIDs + activity modification 1, 2, 3
2. Weeks 4-12: Add calf stretching + soft insoles/orthotics + physical therapy 3, 4
3. Month 3+: Obtain ultrasonography; consider corticosteroid injection or ESWT 5, 2, 3
4. Month 6+: Consider surgical fasciotomy only if all conservative options exhausted 2, 6

Critical pitfall to avoid: Do not rush to corticosteroid injections or surgery, as 80-90% of patients improve with conservative treatment alone within 12 months 1, 2. The condition is self-limiting and not inflammatory (more accurately termed plantar fasciopathy) 2.