Treatment of Plantar Fasciitis
Start with patient-directed conservative treatments including plantar fascia-specific stretching, ice massage, and NSAIDs for several weeks; if pain persists beyond 3 months, add physician-prescribed interventions such as physical therapy and foot orthotics, and consider ultrasonography-guided extracorporeal shock wave therapy before any surgical intervention. 1, 2
Initial Conservative Management (First-Line)
Begin with patient-directed treatments that can be self-administered for several weeks 3:
- Plantar fascia-specific stretching exercises are the cornerstone of treatment and should be performed consistently 4, 5
- Ice massage to the affected area helps reduce pain 3, 4
- Oral NSAIDs (such as celecoxib) provide modest pain relief and decreased disability, particularly between 2-6 months of treatment, though the effect is not dramatically superior to placebo 6
- Activity modification to decrease repetitive loading of the plantar fascia during the treatment phase 5
- Rest from aggravating activities 3, 7
This conservative approach is successful in approximately 80-90% of patients within 12 months 3, 4.
Physician-Prescribed Interventions (Second-Line)
If heel pain persists after several weeks of initial treatment, escalate to 3:
- Physical therapy modalities including supervised stretching programs 3
- Foot orthotics or special orthotic insoles 3, 5, 7
- Night dorsiflexion splinting (though evidence shows limited benefit over placebo) 4, 5
- Corticosteroid injections can provide short-term pain relief but carry risks of fat pad atrophy and plantar fascia rupture, so benefits must be weighed carefully 5
Diagnostic Imaging for Recalcitrant Cases
For pain persisting beyond 3 months despite conservative treatment, obtain imaging 2, 4:
- Ultrasonography is the preferred initial imaging modality, showing plantar fascia thickness >4mm and abnormal tissue signal 1, 2
- Ultrasound elastography demonstrates superior diagnostic accuracy (95% sensitivity, 100% specificity) compared to standard ultrasound 1, 2
- MRI is the most sensitive modality but typically unnecessary unless ruling out other pathology such as stress fractures or plantar fascia tears 1, 2
Advanced Treatment for Chronic Cases
For chronic plantar fasciitis (≥6 months) unresponsive to conservative treatment 3, 4:
- Ultrasonography-guided focal extracorporeal shock wave therapy (ESWT) is recommended by the American College of Radiology and should be considered before surgical intervention 1, 2, 5
- Endoscopic fasciotomy or plantar fasciotomy should be reserved only for patients who continue to have activity-limiting pain despite exhausting all nonoperative options 3, 4, 7
Common Pitfalls to Avoid
- Do not rush to imaging in the initial presentation; diagnosis is primarily clinical based on characteristic morning heel pain and tenderness at the medial plantar calcaneal region 3, 4
- Be cautious with corticosteroid injections due to risks of complications that may worsen long-term outcomes 5
- Do not proceed to surgery prematurely; only 10-20% of patients require interventions beyond conservative care 3, 7
- Recognize that many "standard" treatments like night splints have limited evidence over placebo, so focus resources on proven interventions 4