Treatment of Plantar Fasciitis
Start with conservative therapy consisting of plantar fascia-specific stretching exercises combined with ice massage and oral NSAIDs, as 90% of patients improve with these conservative measures within 12 months. 1, 2
Initial Conservative Treatment (First 3 Months)
Patient-Directed Therapies
- Plantar fascia-specific stretching exercises are the cornerstone of treatment, showing limited but consistent evidence of benefit 3, 2
- Ice massage applied to the heel for pain relief 1, 2
- Oral NSAIDs (such as celecoxib) provide modest additional pain relief and decreased disability when combined with stretching, though effects are gradual and most pronounced between 2-6 months 4
- Activity modification to reduce repetitive loading of the plantar fascia during the treatment phase 5
- Rest and avoiding prolonged standing 1
Physician-Prescribed Interventions (If Pain Persists Beyond Several Weeks)
- Plantar soft insoles/orthotics have demonstrated limited evidence of benefit and should be added early 3
- Calf stretching exercises in addition to plantar fascia stretching 1, 5
- Physical therapy modalities 1
- Night dorsiflexion splinting can be considered, though evidence shows no benefit over placebo in some studies 5, 2
Diagnostic Imaging (For Recalcitrant Cases >3 Months)
- Ultrasonography is the preferred initial imaging modality for cases not responding to conservative treatment, showing plantar fascia thickness >4mm and abnormal tissue signal 6, 7, 2
- Ultrasound elastography demonstrates superior diagnostic accuracy (95% sensitivity, 100% specificity) compared to standard ultrasound 8, 6, 7
- MRI is the most sensitive imaging modality but typically unnecessary unless ruling out other pathology such as stress fractures or plantar fascia tears 8, 6, 7
Advanced Treatment (For Chronic Cases ≥6 Months)
Injection Therapy
- Corticosteroid injections provide short-term pain relief with limited evidence of benefit, but must be weighed against risks of fat pad atrophy and plantar fascia rupture 3, 5
- Iontophoresis with steroids shows limited evidence with transient effects 3
Extracorporeal Shock Wave Therapy
- Ultrasonography-guided focal extracorporeal shock wave therapy (ESWT) is recommended for chronic plantar fasciitis unresponsive to conservative treatment 6, 5
- This should be considered before surgical intervention 1, 2
Surgical Options (Last Resort)
- Endoscopic plantar fasciotomy may be required in patients with continued pain limiting activity despite exhausting all nonoperative options 2
- Surgery should only be considered after at least 6 months of failed conservative treatment 1
Key Clinical Pearls
Common pitfall: Avoid relying solely on night splints or standard orthoses as primary treatment, as these have not consistently shown benefit over placebo 2. The evidence strongly supports plantar fascia-specific stretching as the foundation of treatment.
Timeline expectation: With proper conservative treatment, 80% of patients improve within 12 months, so patience and adherence to stretching protocols are critical 2.