Physiotherapy Protocol – Bilateral Plantar Fasciitis (LT > RT) with Calcaneal Spurs / Retrocalcaneal Bursitis

Phase 1 (Weeks 1-2): Pain and Inflammation Control

• Ice massage/rolling: frozen water bottle or ice cup rolled under the heel, 10-15 min, 2-3x/day, especially after activity.
• Local modalities (as advised): therapeutic ultrasound over the medial calcaneal tuberosity (~1 MHz, 1.0-1.8 W/cm², 5-8 min) or low-level laser therapy, 3-5 sessions/week for 2 weeks.
• Relative rest: reduce prolonged standing/walking; avoid barefoot walking on hard floors.
• Footwear: soft cushioned chappals/shoes with heel cushion or silicone heel cups, as advised - offloads the plantar fascia insertion and retrocalcaneal bursa.
• Continue prescribed NSAID (Piroxicam) and gastroprotection (Rabeprazole/Domperidone) as directed by the physician for the initial 7 days.

Phase 2 (Weeks 1-4, overlapping): Stretching (core of protocol)

• Gastrocnemius stretch: standing wall lean, back knee straight, heel down, 30-45 sec x 3, both legs, 2-3x/day (this directly addresses his calf pain).
• Soleus stretch: same position with back knee bent, 30-45 sec x 3.
• Plantar fascia-specific stretch (Digiovanni protocol): seated, cross ankle over opposite knee, pull toes back toward shin with hand until stretch felt in arch, hold 10 sec x 10 reps, done before first step in the morning and after prolonged sitting - this is the single most evidence-supported exercise for exactly his complaint pattern (morning pain, pain after long sitting).
• Towel/soda-can roll stretch: seated, roll foot over a can/roller from heel to toes.

Phase 3 (Weeks 2-6): Strengthening

• Intrinsic foot muscle work: towel curls, marble/coin pickups with toes, short-foot exercises.
• Eccentric calf raises: bilateral heel raise, lower slowly on one leg, 3 sets of 10-15, progressing as tolerated - improves Achilles-plantar fascia load tolerance and helps retrocalcaneal bursitis.
• Ankle dorsiflexion range-of-motion exercises.

Phase 4: Gait and Load Management

• Correction of any pronated foot pattern; consider medial arch support/orthotic if spur symptoms persist.
• Gradual return to activity; avoid high-impact loading until morning pain resolves.
• Night splint (dorsiflexion splint) can be added if morning pain remains prominent despite stretching.

Additional notes specific to this case

• Since he has calcaneal spurs on imaging, treatment targets the fascia/soft tissue (spurs themselves are usually incidental, not the pain generator) - so the stretching-based protocol above is appropriate rather than spur-directed treatment.
• Retrocalcaneal bursitis component: add posterior heel off-loading (avoid rigid shoe backs), ice to posterior heel, and gentle Achilles stretching (already covered above) rather than aggressive posterior heel taping.
• Doctor's added note "low protein diet" appears to relate to the uric acid workup done to exclude gout - not part of the physio program itself; that's a separate metabolic/dietary instruction from the physician.
• Reassess at 2-3 weeks; if minimal improvement, consider adding extracorporeal shockwave therapy (ESWT) or corticosteroid injection per physician discretion, before considering more invasive options.

Evidence context (from PubMed, 2024-2025 systematic reviews)

• Physiotherapist-delivered exercise (stretching + strengthening) combined with modalities shows consistent benefit for pain and function in plantar fasciitis - Effect of Different Physiotherapeutic Interventions in Plantar Fasciitis (2025), PMID 40596749.
• A 2025 systematic review/meta-analysis on therapeutic ultrasound for plantar fasciitis found the evidence for ultrasound as an add-on to be mixed/limited (PMID 40785236) - some clinical guidelines (AOPT/AASPT) actually recommend against routine ultrasound to enhance stretching benefit. This doesn't contradict using it as advised by the treating orthopaedist, but stretching exercise remains the higher-certainty intervention and should not be skipped in favor of modalities alone.
• Dry needling also shows promising but still-limited-quality evidence (PMID 39744103) as an adjunct if standard therapy plateaus.