Plantar Fasciitis: How To Maximize Outcomes With Conservative Therapy

By Brian Fullem, DPM

Plantar fasciitis is often inaccurately referred to as “heel spur syndrome.” Clinicians should no longer use this terminology. Most of the time, the presence or absence of a plantar calcaneal spur has no effect on symptoms or treatment. The term fasciitis may also be a misnomer. Lemont studied the pathology of 50 patients who underwent fascial release surgery.1 The findings did not show any evidence of inflammatory cells within the fascia. The common finding was degeneration of the tissue. The inflammation appears to be in the underlying intrinsic musculature so perhaps the correct term should be fasciosis. The treatment of plantar fasciitis generally begins with the traditional conservative methods. If the symptoms persist, one should progress to extracorporeal shockwave therapy (ESWT). In recent years, endoscopic plantar fasciotomy (EPF) was the treatment of choice for failed conservative therapy. Other current therapies such as cryotherapy and radiofrequency have not yet been sufficiently studied so I will refrain from discussing these modalities.2 When the classic symptoms of post-static dyskinesia with the inferior heel are present, simple treatment methods of stretching, taping, icing, orthotic devices, shoe gear modification, corticosteroid injection(s) and NSAIDs work very well. However, practitioners often fall into the habit of diagnosing all plantar heel pain as plantar fasciitis. In addition to making the proper diagnosis, clinicians also must determine the etiology of the pain. Riddle examined the risk factors associated with plantar fasciitis in 50 patients and found that lack of ankle dorsiflexion (less than or equal to 0 degrees) to be the biggest risk factor.3 Body mass and the amount of time spent on the feet were also significant contributing factors. One can certainly add activity level to this list as this injury is prevalent in the athletic population. Foot type and function may also be contributing factors to this injury. Those with pes planus and pes cavus foot types are the most susceptible to this injury. Treatment typically focuses on reducing the pain and treating the mechanical factors associated with the injury. Typically, one can reduce the patient’s pain by emphasizing NSAIDs, ice, rest and corticosteroid injections. Clinicians may address the mechanical factors via taping, stretching, OTC inserts, custom orthotic devices and shoe gear modifications. More recently, night splints have become more commonplace and ESWT has become the most recent addition to non-surgical treatment. Clinicians should always reserve surgery as a last resort after failed non-surgical therapy. Despite the reported success of endoscopic plantar fasciotomy and other surgical methods, one should exercise caution when considering any surgical approach for this condition.4 Emphasizing The Importance Of Stretching Stretching should be the focus of any treatment plan involving plantar fasciitis. A tight Achilles tendon increases pronation in the foot across the STJ and MTJ, and leads to increased tension of the plantar fascia. Since the fascia does not have any elastic properties, the tissue will typically tear at the insertion when it is overstressed. Anatomically, the Achilles has attachments to the central band of the plantar fascia. Increased tension of the tendon will cause failure at the plantar medial calcaneal tubercle where the fascia originates. This is usually the point of maximal tenderness for patients with plantar fasciitis. There are a couple of confounding issues with stretching. Some patients have an equal amount of dorsiflexion yet they only report symptoms on one side. Also be aware that patients with adequate dorsiflexion can develop plantar fasciitis. In order to maximize effectiveness, one must emphasize proper stretching. One cannot physically stretch the fascia and Achilles tendon without tearing the tissue. There are no elastic fibers within the fascia. Clinicians should discourage patients’ attempts to stretch the foot by hanging off a step or by putting the toes up against a wall to try and stretch the fascia. Any benefits from stretching are going to occur within the muscle. One of the excellent points made by Stark is that a muscle must not be in an active contracting state in order to be stretched properly.5 The heel must be on the ground in order for the gastroc-soleus complex to be properly stretched.

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