Plantar Fasciitis: How To Maximize Outcomes With Conservative Therapy
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. Stark’s method of stretching may actually be enhancing the stretch reflex of the posterior muscle group by contracting the anterior muscles. However, there are many different methods of stretching including proprioceptive neuromuscular facilitation (PNF). Dynamic methods and other types of stretching involve another person or a rope. Static stretching is the safest, easiest method and appears to be just as effective as any other methods available.6 It is important to have the patient perform the stretches multiple times during the day. I recommend three different sessions of stretching, three to five minutes each session, daily. A Closer Look At Taping Benefits Taping the foot can be effective in diagnosing the injury but can also help reduce pain.7,8 Patients usually experience some relief of symptoms with taping. If the patient does not feel relief after taping and symptoms have not improved within a few weeks after taping, clinicians may need to reevaluate the diagnosis of plantar fasciitis. When it comes to taping, I combine a low-dye tape with a plantar rest strap, using 1-inch and 2-inch tape. I often instruct my patients how to tape their foot with the plantar rest strap tape job (see http://www.docfullem.com/index.php?option=content&task=view&id=10). One of my patients qualified for the Olympic marathon trials after taping his foot for two years in conjunction with stretching, icing and work with an active release therapy performed by a chiropractor. He refused to get custom orthotic devices despite a chronic low-level fasciitis. The patient performed the taping himself before running his 10 to 15 miles per day. Anecdotally, there may be a correlation between the success of taping and the future success of custom foot orthoses. When Should You Employ Night Splints? Night splints are an additional adjunctive therapy that one should always consider in any plantar fasciitis treatment plan.9 I typically add this treatment if there has not been an improvement within the first three weeks after stretching, icing, taping, NSAIDs and the use of good supportive shoes. I only use NSAIDs if the patient’s symptoms are less than three months in duration. However, I limit the use of NSAIDs to two weeks or less. Compliance is the one negative with night splints. The majority of the devices are bulky and cumbersome, and make it difficult for a person to sleep. The Strassburg sock™ is less bulky but patients may sometimes experience pain in the toes or even nerve damage if it is pulled too tight. Are Corticosteroid Injections Worthwhile? Corticosteroid injections are an important adjunct when it comes to treating plantar heel pain. While one should be judicious with these injections, in my experience, these injections are more effective early in the treatment plan. One should reserve subsequent injections based on the relative effectiveness of the initial injection. If the patient does not have improvement of initial symptoms after a few days, then additional injection therapy will probably not work. Most of the literature on using these injections for plantar fasciitis focuses on the negative side effects including rupture, nerve injury and infection.10-13 However, one very interesting study involved the analysis of the plantar fascia via ultrasound imaging after corticosteroid injection. The study by Genc, et. al., measured the fascia thickness and patient symptoms in 47 heels. After performing ultrasonic guided intrasubstance injection of corticosteroid, the authors found a significant reduction in the thickness of the fascia and a corresponding decrease in pain.14 The authors noted these effects six months after the corticosteroid injection and there were not any plantar fascia ruptures in the study. Of course, clinicians should emphasize that patients modify their activity level for seven to 10 days after a corticosteroid injection in order to help protect against a possible rupture (see “Plantar Fascia Ruptures: What You Should Know” below). Plantar Fascia Ruptures: What You Should Know A sudden increase or onset of pain (or what the patient might describe as a “pop” in his or her heel) may be associated with a rupture of the fascia. The insertion will typically occur at the attachment of the fascia. In a retrospective analysis of 18 athletic patients with plantar fascia ruptures, the authors reported a highly effective treatment plan for these ruptures.15 (Incidentally, only one of the patients had a prior corticosteroid injection in the fascial area.) The treatment for a rupture should involve two to three weeks of non-weightbearing in a removable cast boot. One would follow this with two to three weeks of weightbearing in the boot until the patient is pain-free. Clinicians may initiate physical therapy (including electrical stimulation of the fascia) by week three. The average return to activity was nine weeks for all the participants. All participants in the study were able to return to pre-injury exercise levels and continued to perform their activity at the two-year, follow-up point.15 Can Custom Orthoses And Modifications Have An Impact? Clinically, most practitioners know that using a well-designed custom foot orthotic device is highly effective in treating plantar fasciitis. Unfortunately, there is very little scientific evidence to back up the use of the devices. However, Humble, Nigg and co-authors have done some excellent scientific research showing that custom foot orthoses do affect muscle activity and are functional devices.16 Orthotic therapy has been examined in depth in previous issues of Podiatry Today (see the November 2005 issue). When it comes to orthotic therapy for plantar fasciitis, one should keep in mind there may be more than one right device for a patient and that several devices or modification may be necessary to achieve suitable results. Kogler, et. al., reported that a forefoot valgus wedge relaxed the tension on the plantar fascia while a varus wedge increased tension.17 I often use different orthotic materials ranging from graphite composite to cork depending on the patient’s foot type, the patient’s prior experience with custom devices and my own evaluation. A Primer On Shockwave Therapy In regard to the use of extracorporeal shockwave therapy for plantar fasciitis, there are three different types of machines that all send ultrasound in two different types of dosing into the plantar fascia area. Low intensity units do not require any local anesthesia but require multiple uses. High intensity machines are single dose but necessitate the use of anesthesia and accurate placement of the therapeutic electrode. The theory behind extracorporeal shockwave therapy is that it works by creating new blood vessels in the area and instigating a pain response which, in turn, helps to heal the damaged tissue. However, this process may take up to 12 weeks to occur. Accordingly, clinicians should discourage patients from activity beyond their normal activities of daily living in order to assess treatment properly. The literature is divided on the efficacy of extracorporeal shockwave therapy and there is not any consensus on which protocol works the best at the current time.18-20 One major drawback is the cost of the treatment and the fact that insurance does not typically provide coverage. The obvious advantage of ESWT is the lack of apparent negative sequelae following treatment. Why One Should Emphasize Foot Strengthening One area of treatment that is rarely mentioned is strengthening of the foot. Weakness of the intrinsic musculature accompanies plantar fasciitis. Early introduction of restrictive shoe gear in Westernized cultures may contribute to atrophy of these muscles. As part of the rehabilitation from this injury, it is important to add a strengthening and proprioception protocol to the treatment plan following the reduction of pain. Grabbing a towel with the toes, balancing on one foot and progressing to the use of a BAPS board can facilitate foot strengthening. After performing these exercises, then athletes can progress to barefoot running in the grass. The Nike Free line of shoes is a nice adjunct to the treatment plan when the shoes are used in moderation. In Conclusion When traditional conservative therapy fails and initial pain upon weightbearing is no longer the chief complaint, clinicians should consider the differential diagnoses including: stress fracture, tarsal tunnel syndrome, nerve entrapment (often the first branch of the lateral plantar nerve) and plantar fascia rupture. One may pursue further diagnostic testing to help make the correct diagnosis. When it comes to treating plantar fasciitis, clinicians should always reserve surgery as a last resort. Dr. Fullem is a Fellow of the American College of Foot and Ankle Surgeons, and the American Academy of Podiatric Sports Medicine. He is board-certified in foot and ankle surgery by the American Board of Podiatric Surgery. Dr. Fullem is in private practice in Newtown, Ct.
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