Treatment of Plantar Fasciitis
Start with plantar fascia-specific stretching exercises combined with calf stretching and plantar soft insoles as first-line therapy, as conservative treatment is effective in approximately 90% of patients. 1, 2
Initial Conservative Management
- Plantar fascia-specific stretching exercises are the cornerstone of treatment, showing limited but meaningful evidence of benefit 3
- Calf stretching should be performed alongside plantar fascia stretches to address biomechanical factors 4
- Plantar soft insoles/orthotics provide support and have demonstrated limited evidence of benefit 3
- Ice massage helps with symptomatic relief 2
- NSAIDs can be used for pain control, though they do not alter the underlying degenerative process 1, 2
- Activity modification to decrease repetitive loading of the plantar fascia is essential regardless of treatment modality chosen 4
Treatment Timeline and Expectations
- With proper treatment, 80% of patients improve within 12 months 2
- Conservative treatment is ultimately effective in approximately 90% of patients, though the natural history is not fully established 1
- Pain typically manifests as stabbing, nonradiating pain in the morning at the proximal medioplantar surface, worsening at day's end 2
Second-Line Interventions for Persistent Cases
When conservative measures fail after 3 months:
- Corticosteroid injections (local or via iontophoresis) show limited evidence of short-term benefit 3, 2
- Critical caveat: Effects are transient and must be weighed against risks of fat pad atrophy and plantar fascia rupture 4
- Ultrasonography is reasonable and inexpensive for diagnostic confirmation in cases persisting beyond 3 months 2
- Ultrasound elastography demonstrates superior diagnostic accuracy (95% sensitivity, 100% specificity) 5
Advanced Treatment for Chronic/Recalcitrant Cases
- Ultrasonography-guided focal extracorporeal shock wave therapy (ESWT) is recommended for chronic plantar fasciitis unresponsive to conservative treatment and should be considered before surgical intervention 5, 4
- Endoscopic fasciotomy may be required in patients with continued activity-limiting pain despite exhausting all nonoperative options 2
Common Pitfalls to Avoid
- Night splints have not shown benefit over placebo despite widespread use 2
- Many standard treatments lack strong evidence, so avoid prolonged trials of ineffective modalities 3
- Do not delay imaging beyond 3 months if symptoms persist, as ultrasonography can confirm diagnosis and guide advanced therapy 5, 2
- MRI is the most sensitive imaging but typically unnecessary unless ruling out stress fractures or plantar fascia tears 5