Treatment of Plantar Fasciitis
Start with conservative treatment consisting of plantar fascia and calf stretching (the most important intervention), 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 therapy. 1
Initial Conservative Treatment (First 6 Weeks)
The condition is self-limited, with 80-90% of patients improving within 12 months with conservative measures alone 2, 3. Begin immediately with:
Stretching exercises: Regular stretching of the calf muscle and plantar fascia is the single most important intervention 1. This should be performed multiple times daily.
Ice massage (cryotherapy): Apply ice directly to the affected medial plantar calcaneal region 1.
Over-the-counter arch supports and heel cushions: These provide immediate cushioning to the heel 1.
Oral NSAIDs: Use for pain control 1.
Activity modification: Avoid flat shoes and walking barefoot, as these exacerbate the condition 1. Rest and reduce prolonged standing 3.
Taping and padding: Provide additional foot support 1.
Intermediate Treatment (After 6 Weeks Without Improvement)
If symptoms persist beyond 6 weeks despite initial conservative measures, escalate treatment 1:
Refer to a podiatric surgeon for evaluation 1.
Customized orthotic devices: These are more effective than over-the-counter devices and can reduce pain while increasing functional ability 1, 4. Evidence shows customized functional foot orthoses provide both pain reduction and improved functional outcomes 4.
Night splints: Use for passive stretching during sleep 1.
Limited corticosteroid injections: Consider in appropriate patients, though be aware these may cause injection-site pain as a side effect 1, 4. Evidence supports pain reduction, but acceptability may be limited by injection discomfort 4.
Immobilization: Use a cast or fixed ankle walker device during activity 1.
Physical therapy: Employ specific modalities 1.
Diagnostic Imaging Considerations
Imaging is rarely needed for initial diagnosis, which is predominantly clinical 2, 3. Reserve imaging for:
When imaging is indicated:
- MRI is the most sensitive study 1
- Ultrasonography has good sensitivity (80%) and specificity (88%) compared to MRI and is more cost-effective 1
Refractory Cases (After 6-12 Months)
For the approximately 10% of patients who fail conservative management after 6-12 months 3, 6, 7:
- Extracorporeal shock wave therapy 3, 5
- Endoscopic plantar fasciotomy for patients with persistent pain limiting activity despite exhausting all nonoperative options 5
Common Pitfalls
The natural history shows 90% of patients improve with nonsurgical treatment, but this can take up to 12 months 3, 6, 7. The key pitfall is premature escalation to invasive treatments before allowing adequate time for conservative measures to work. Conversely, delaying referral beyond 6 weeks without improvement wastes time when more advanced conservative options (customized orthotics, injections) could be initiated 1.