eMedicine Specialties > Sports Medicine > Foot and Ankle

Plantar Fasciitis: Treatment & Medication

Author: Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Contributor Information and Disclosures

Updated: Jan 18, 2008

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

The initial physical therapy program for plantar fasciitis emphasizes stretching of the calf and foot. The stretching program should include wall stretches, with the knee in both the extended and flexed positions.

• To perform a wall stretch, the athlete should stand 3 feet from a wall, placing the hands on the wall. Keeping the toes pointed straight and the heel on the ground, the athlete leans the hips toward the wall, then holds this position for 30-40 seconds (see Image 2).⁵ Stretches targeted at the plantar fascia are particularly important.⁸
• In one study, iontophoresis was found to increase the speed of resolution of plantar fasciitis, although it had no effect on long-term outcome.⁹

Medical Issues/Complications

• Ice is the first-line anti-inflammatory treatment for plantar fasciitis. Icing should be performed after completing exercise, stretching, and strengthening, and this treatment can be applied by ice massage, ice bath, or ice pack.

• For ice massage, the athlete freezes water in a small paper or polystyrene cup and then rubs the ice over the painful heel, using a circular motion and moderate pressure for 5-10 minutes.

• For an ice bath, a shallow pad is filled with water and ice. The athlete soaks the heel for 10-15 minutes. Note: To prevent cold injuries, the athlete should use neoprene toe covers, or keep the toes out of the ice water.

• An ice pack can be made by placing crushed ice in a plastic bag that is wrapped in a towel. The use of crushed ice allows the ice pack to be molded to the foot and increases the contact area; a good alternative is a bag of prepackaged frozen corn kernels wrapped in a towel. Ice packs are usually placed for 15-20 minutes.

Other Treatment

Resting and correcting training errors are critical to the treatment of plantar fasciitis. Athletes must modify activities that aggravate this condition; such modifications may be as simple as decreasing the amount, frequency, or intensity of the inciting activity(ies). Athletes are more compliant with a decreased level of activity if they are allowed to increase other nonaggravating activities.¹⁰

• Replacing worn-out shoes and selecting appropriate shoes are also important. Runners should replace shoes every 250-500 miles (400-800 km) to maintain optimum shoe cushioning.⁷

• Runners who overpronate and who have pes planus should select motion-control shoes, which typically feature a straight-lasted, board-lasted, or combination-lasted construction; an external heel counter; a wider flare; and extra medial support.⁷

• Runners who have pes cavus should select shoes that have greater cushioning properties.

• All distance runners should practice in training flats that are better cushioned, reserving the lighter weight, less-cushioned racing flats for competition.

• Extracorporeal shock wave therapy (ESWT) has been proposed as a treatment option for plantar fasciitis. There appears to be few, if any, adverse side effects from this treatment modality. However, to date, results from studies are mixed.^{11,12,13,14,15,16,17}

Recovery Phase

Rehabilitation Program

Physical Therapy

A strengthening program that emphasizes intrinsic foot muscle strengthening is added in the next phase of physical therapy. Exercises include towel curls, marble pick-ups, and toe taps.⁵

• For a towel curl, the athlete sits with the affected foot lying flat on the end of a towel that is placed on a smooth surface. The athlete pulls the towel toward the body by using the toes to curl up the towel while keeping the heel on the floor. As the athlete improves, add weight to the far end of the towel to increase the difficulty of this exercise (see Image 3).
• To do marble pick-ups, the athlete places a few marbles on the floor near a cup, picks them up with the toes, and drops them in the cup while keeping the heel on the floor. For a greater challenge, the athlete may try to pick up coins instead of marbles.
• To do toe taps, the athlete lifts all the toes off the floor; while keeping the heel on the floor and the outside 4 toes in the air, repetitively taps just the big toe to the floor (see Image 4). Next, the athlete reverses the process and repetitively taps the outside 4 toes to the floor while keeping the big toe in the air.

Medical Issues/Complications

Anti-inflammatory medications are frequently used to treat plantar fasciitis. Although there is controversy as to whether or not nonsteroidal anti-inflammatory drugs (NSAIDs) actually assist in the physiologic healing process, these agents can be useful as an adjunct to control pain while the individual's plantar fasciitis is being treated with stretching, strengthening, and relative rest (see the Medication section, below).^18,19

Surgical Intervention

For cases that do not respond to conservative treatment, a surgical release of the plantar fascia may be considered. Overall, surgical release has a 70-90% success rate in treating patients with this condition; open, endoscopic, or radiofrequency lesioning techniques may be used.^{20,21,22,23,24,25,26}

Potential complications of surgical intervention include flattening of the longitudinal arch and heel hypoesthesia, as well as those that are associated with plantar fascia rupture and corticosteroid injections. Longitudinal arch strain appears to account for over 50% of the chronic complications.^27,28

Other Treatment (Injection, manipulation, etc.)

Corticosteroid injections

• In cases of recalcitrant plantar fasciitis, corticosteroid injection may be considered. Other causes of heel pain should also be considered, and a plain radiograph of the foot or calcaneus should always be obtained before injecting steroids.
• A corticosteroid injection may be given through a plantar or a medial approach, with or without ultrasound guidance. Studies have reported success rates of 70% or better.^29,30 Potential risks include plantar fascia rupture, which was found in almost 10% of patients after plantar fascia injection in one case series²⁷ and fat pad atrophy.^27,28 Long-term sequelae were found in approximately 50% the patients with plantar fascia rupture.²⁷

• The use of autologous blood injected into the plantar fascia origin is thought to stimulate an acute inflammatory reaction that leads to reinitiation of the healing process. This treatment has been shown to be effective in limited studies of chronic inflammatory musculotendinous conditions.^31,32,33

Night splints

• Most people naturally sleep with their feet in a plantar-flexed position, which causes the plantar fascia to be shortened. Night splints are designed to keep the ankle in a neutral position during sleep, essentially passively stretching the calf and the plantar fascia for a prolonged period.
• Theoretically, the night splint allows the plantar fascia to heal in the elongated position, which, in turn, decreases the tension on the fascia with the first step in the morning. A night splint can be molded from either plaster or fiberglass casting material, or a prefabricated and commercially produced plastic brace can be used (see Image 5).
• Studies have shown that approximately 80% of patients using night splints had improvement of their plantar fasciitis.^{34,35,36,37,38} The splints are especially useful in individuals who have had symptoms of plantar fasciitis for longer than 12 months.^34,35,36,37

Maintenance Phase

Rehabilitation Program

Physical Therapy

To minimize the chances of reoccurrence of plantar fasciitis, athletes should continue on a maintenance program of daily stretching and/or strengthening at least 2-3 times per week.

Other Treatment

Other treatment may include orthotic devices and arch supports.

• Patients with low arches place increased stress on the plantar fascia with foot strike and have a decreased ability to absorb the forces that are generated by foot strike.⁷ Mechanical corrections for pes planus include taping of the arches, over-the-counter (OTC) arch supports, and custom orthotic devices. Studies have found significant benefit to these conservative treatments when used in appropriate patients.^19,39
• Arch taping can be used as a definitive treatment or as a trial to determine whether the expense of arch supports or orthotics is worthwhile for a patient. Taping may be more cost-effective for the acute onset of plantar fasciitis, whereas OTC arch supports and orthotics may be more cost-effective for chronic or recurrent cases of plantar fasciitis and for the prevention of injuries (the arches must be retaped for each practice or game).
• OTC arch supports usually last a full season; custom orthotic devices should last many seasons. OTC arch supports are especially useful in athletes with acute plantar fasciitis and mild pes planus, particularly adolescents whose rapid foot growth may require one or more new pairs of arch supports per season.
• Custom orthotic devices are designed to control biomechanical risk factors such as pes planus, valgus heel alignment, and leg-length discrepancies. Athletes treated with orthotic devices usually require semi-rigid, three-quarter to full-length orthotic devices with longitudinal arch support to control overpronation and metatarsal head motion, especially of the first metatarsal head.⁴⁰ The main disadvantage in the use of orthotic devices is the cost, which ranges from $75 to $300 or more; frequently, these devices are not covered by insurance.

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Nonsteroidal anti-inflammatory drugs

The use of NSAIDs in chronic inflammatory diseases such as plantar fasciitis is somewhat controversial.¹⁸ NSAIDs may or may not be beneficial to the physiologic processes of soft-tissue healing. However, NSAIDs have been found to be useful in controlling pain (a useful adjunct in allowing more rapid progress with physical therapy) and in controlling acute inflammation. The disadvantages of these medications are many, including the risk of gastrointestinal (GI) bleeding, gastric pain, and renal damage.⁴¹

Ibuprofen (Motrin, Ibuprin, Advil)

Member of the propionic acid group of NSAIDs. Available in low-dose form as an OTC medication. Highly protein bound, metabolized in the liver, and eliminated primarily in the urine. Ibuprofen may reversibly inhibit platelet function.

Naproxen (Aleve, Anaprox, Naprosyn, Naprelan)

Member of the propionic acid group of NSAIDs. Available in low-dose form as an over-the-counter medication. Highly protein bound, metabolized in the liver, and eliminated primarily in the urine. Naproxen may reversibly inhibit platelet function.

Corticosteroids

Corticosteroids are strong anti-inflammatory agents. The general risks involved with the use of these agents include skin atrophy, skin hypopigmentation, soft-tissue atrophy, infection, bleeding, and failure to work. A steroid flare-up, which consists of increased pain for up to several days, may occur in up to 2% of individuals who use corticosteroids.⁴²

Triamcinolone acetonide (Amcort)

Injectable corticosteroid, used to treat localized areas of inflammation. Good evidence exists to suggest that injected corticosteroids alter the long-term pathology of chronic inflammation^18,42 ; however, many patients receive acute symptomatic improvement.⁴² Triamcinolone acetonide is an injectable intermediate-acting, steroid anti-inflammatory agent.

Betamethasone sodium (Celestone, Soluspan)

Injectable corticosteroid, used to treat localized areas of inflammation. No good evidence exists to suggest that injected corticosteroids alter the long-term pathology of chronic inflammation; however, many patients receive acute symptomatic improvement.⁴² Betamethasone sodium is an injectable intermediate-acting, steroid anti-inflammatory agent.

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