Approximately 85% to 90% of patients with plantar fasciitis can be successfully treated without surgery. Nonsurgical methods include rest, over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs), stretching, counterstrain technique, orthoses, corticosteroid injections, extracorporeal shock wave therapy (ESWT), and ultrasound therapy.
Although treatment may be required for 6 months or longer, 80% of patients treated conservatively have no long-term recurrence of pain. Current recommendations for the conservative management of plantar fasciitis call for a multimodal, evidence-based approach.
Initial Treatment
Initial treatment should include sufficient foot rest with conservative analgesic use. OTC NSAIDs have been shown to be an adequate means of pain control when used in combination with other forms of treatment. Focused stretching of the Achilles tendon, plantar fascia, and intrinsic muscles of the foot has also been demonstrated to improve pain.
The intermittent application of ice seems to provide some benefit to patients with plantar fasciitis when compared with heat application.
Osteopathic Manipulative Treatment
The osteopathic manipulative treatment technique of counterstrain may provide immediate improvement of plantar fasciitis symptoms; however, maintenance of these results has not been documented. The plantar fascia should be placed in a position of least resistance with passive flexion of the knee and plantar flexion of the ankle and toes.
Orthosis Options
A wide variety of orthosis options are available for the management of plantar fasciitis. The use of shoe inserts, in combination with stretching exercises, has been shown to provide superior short-term improvement in heel pain compared with stretching alone.
The use of posterior-tension night splints has also shown benefit in patients with chronic plantar fasciitis. The suspected therapeutic mechanism of night splinting is the maintenance of ankle dorsiflexion and toe extension, creating a constant mild stretch on the plantar fascia.
Corticosteroid Injections
Corticosteroid injections should be considered with caution, owing to a potentially unfavorable risk-to-benefit ratio for patients with plantar fasciitis. The risks associated with corticosteroid injection include skin and fat pad atrophy, infection, and plantar fascia rupture.
Extracorporeal Shock Wave Therapy (ESWT)
There are limited data available regarding ESWT for the management of plantar fasciitis. Nonetheless, in clinical trials, the addition of high-energy shock waves to standard therapies demonstrated a statistically significant improvement in symptoms at 3 months.
Ultrasound Therapy
Ultrasound therapy has recently been investigated for the management of refractory plantar fasciitis. Although there is presently insufficient evidence to support its efficaciousness, studies suggest it is relatively safe.
Surgical Treatments
Partial or complete plantar fasciotomy is indicated only after at least 6 to 12 months of conservative treatment has failed. Before proceeding with surgery, the differential diagnosis must be revisited to consider other causes of subcalcaneal pain. Surgical release of greater than 40% of the plantar fascia may have detrimental effects on other ligamentous and bony structures in the foot.
Nevertheless, a significant portion of patients who undergo surgical intervention after failed conservative treatment report substantial or complete reduction in heel pain.
