What are the treatment options for a patient with plantar fasciitis?

Treatment for Plantar Fasciitis

Start with conservative therapy consisting of plantar fascia and calf stretching exercises, ice massage, over-the-counter heel cushions, and NSAIDs, escalating to customized orthotics, night splints, and corticosteroid injections only after 6 weeks of failed conservative treatment. 1

Initial Conservative Treatment (First 6 Weeks)

The American Academy of Family Physicians identifies regular stretching of the calf muscle and plantar fascia as the most important intervention for plantar fasciitis 1. This should form the foundation of your treatment approach, as approximately 90% of patients improve with conservative measures 2, 3.

First-Line Interventions

• Stretching exercises: Focus specifically on plantar fascia and calf muscle stretching as the cornerstone of therapy 1
• Ice massage (cryotherapy): Apply directly to the affected area 1
• Over-the-counter arch supports and heel cushions: Use to cushion the heel and provide initial support 1
• Oral NSAIDs: For pain control 1
• Activity modification: Avoid flat shoes and walking barefoot, as this exacerbates the condition 1
• Taping and padding: Provide additional foot support 1

Intermediate Treatment (After 6 Weeks Without Improvement)

If symptoms persist beyond 6 weeks of conservative treatment, the American Academy of Family Physicians recommends escalating care 1:

Second-Line Interventions

• Podiatric referral: Refer to a podiatric surgeon for specialized evaluation 1
• Customized orthotic devices: These are more effective than over-the-counter devices and should replace initial cushions 1
• Night splints: Use for passive stretching during sleep 1
• Corticosteroid injections: Limited injections in appropriate patients (note: evidence shows only transient benefit) 1, 4
• Immobilization: Consider a cast or fixed ankle walker device during activity 1
• Physical therapy: With specific modalities 1

Important Caveat About Corticosteroid Injections

While corticosteroid injections are recommended as a second-line option, evidence demonstrates only limited and short-term benefit 4. Use these judiciously and counsel patients about temporary effects.

Diagnostic Imaging Considerations

Imaging is not needed for initial diagnosis, which is primarily clinical 2. Reserve imaging for:

• Recalcitrant cases lasting beyond 3 months despite treatment 5
• Ruling out other heel pathology 1, 6

When imaging is indicated:

• Ultrasonography: Good sensitivity (80%) and specificity (88%), reasonable and inexpensive first choice 6, 5
• MRI: Most sensitive imaging study, reserved for complex cases 1, 6

Treatment for Chronic Recalcitrant Cases (≥6 Months)

For patients with persistent symptoms beyond 6 months despite exhausting conservative options 2:

• Extracorporeal shock wave therapy: Consider as a non-surgical option 2, 5
• Endoscopic fasciotomy or plantar fasciotomy: May be required when pain continues to limit activity and function 2, 5

Common Pitfalls to Avoid

• Premature escalation: Do not skip the 6-week trial of conservative therapy before advancing to orthotics or injections 1
• Inadequate stretching emphasis: Stretching is the most important intervention—ensure patients understand proper technique and compliance 1
• Inappropriate footwear: Patients must avoid flat shoes and barefoot walking, which worsen symptoms 1
• Over-reliance on injections: Corticosteroid injections provide only temporary relief and should not be the primary treatment strategy 4

Expected Timeline

With proper conservative treatment, 80% of patients improve within 12 months 5. The condition is self-limiting, though the natural history without treatment remains unclear 3.