A Closer Look At A New Algorithm For Treating Plantar Fasciitis
In the United States, at least 10 percent of the population experiences heel pain secondary to plantar fasciitis. Reportedly, 600,000 outpatient visits to medical professionals a year are due to plantar fasciitis.1 According to a 2003 study, plantar fasciitis frequently occurs in people who are on their feet most of the day, those who are obese and those who have limited ankle dorsiflexion.2
However, it is important to recognize that all heel pain symptoms do not stem from plantar fasciitis. There are many different etiologies for heel pain and making the correct diagnosis becomes crucial in determining the right treatment course for the patient.
Usually, when one obtains a proper history and conducts the physical exam, it is easy to distinguish a case of plantar fasciitis among patients with heel pain. The pain is mostly caused by acute or chronic injury to the origin of the plantar fascia from cumulative overload stress. The pain is usually medial and inferior to the heel, starts in the morning with the initial step and the patient experiences extreme tenderness with palpation. Patients may describe throbbing pain that occurs after periods of inactivity.
In the physical examination, one should assess dorsiflexory range of motion of the ankle, palpate the medial inferior of the heel and evaluate the angle and base of gait.
Since neurologic, soft tissue, skeletal and systemic conditions can cause heel pain, it is necessary to have high index of suspicion when seeing patients with heel pain. There are many different etiologies of heel pain. Accordingly, the differential diagnosis for heel pain includes:
• local inflammatory plantar heel
• pain/mechanical heel pain
• plantar fasciitis
• plantar heel pain
• nerve entrapment syndromes
• calcaneal branch neurodynia
• tarsal tunnel syndrome
• Baxter’s neuritis
• lumbar spine disorders
• calcaneal bone cyst
• aneurysmal bone cyst
• unicameral bone cyst
• interosseous lipoma
• calcaneal stress fractures
• systemic inflammatory plantar heel pain
• rheumatoid arthritis
• seronegative spondyloarthropathy
• ankylosing spondylitis
• psoriatic arthritis
• Reiter’s syndrome
What About Diagnostic Imaging?
Diagnostic imaging is very helpful in diagnosing plantar fasciitis. Imaging is also strongly recommended if one suspects other diagnoses. Ultrasound is a helpful modality in determining the thickness of the plantar fascia. According to one ultrasound study, the plantar fascia was significantly thicker in the heels of symptomatic patients with plantar fasciitis (3.2-6.8 mm with a mean of 5.2 mm) in comparison to their asymptomatic heels (2.0-4.0 mm with a mean of 2.9 mm), and in comparison to the heels of the patients in the control group (1.6-3.8 mm with a mean of 2.6 mm).3
On the lateral radiograph, calcifications in the soft tissue on the anterior calcaneus may be present. However, 50 percent of symptomatic patients and up to 19 percent of asymptomatic patients have heel spurs.4 The presence of a heel spur is not a definitive diagnosis of plantar fasciitis and this is a very important fact to emphasize to patients. A bone scan can show increased uptake in the body of the calcaneus in cases of stress fracture. Magnetic resonance imaging (MRI) can show thickening of the plantar fascia, soft tissue lesions within the body of the calcaneus or a space-occupying lesion in the medial ankle that may cause tarsal tunnel syndrome.
Other Pertinent Pointers
Treating patients with plantar fasciitis is rewarding because most patients’ symptoms improve with conservative treatment alone. In a recently published study, after four years, 80 percent of patients with plantar fasciitis had complete resolution of pain with conservative treatment alone.5 Usually when the plantar fasciitis symptoms have persisted for greater than six months to one year, conservative care is less successful due to the increase in scar tissue and a loss of blood flow to the fascia region. This results in a new diagnosis called plantar fasciosis.
Plantar fasciosis is a recent term that suggests a region of scar formation in the fascia that is chronic in nature and is not responsive to traditional conservative care due to the lack of circulation in the region. It is important to emphasize this fact when dealing with patients who have had pain for an extended period of time and have not responded to conservative measures.
We recommend following a stepwise treatment approach using a three-step algorithm that is easy to follow. We have seen a lot of success with this algorithm at our institutes.
Step One: Facilitating Initial Pain Alleviation
Step one of the algorithm includes conservative measures such as icing, stretching exercise, custom or over-the-counter (OTC) orthotics, nonsteroidal antiinflammatory drugs (NSAIDs), taping and/or physical therapy.
The stretching protocols of the tendo-Achilles and plantar fascia may help alleviate pain by increasing the movement of the Achilles. This allows the foot to dorsiflex without pronation and decreases the stress on the medial fascial band. Dorsiflexion of the toes to stretch the fascia is also helpful in increasing the stretch of the fascia and preventing micro-scar formation. Provide patients with written instructions so they can perform non-weightbearing and weightbearing stretching exercises at home. Researchers have seen superior outcomes with non-weightbearing stretching exercises specific to the plantar fascia versus weightbearing Achilles tendon stretching exercises for the treatment of symptoms of proximal plantar fasciitis.6
Prescribe custom-made orthoses or OTC arch supports. If the patient can afford custom devices, this is a more ideal course as one can write an orthotic prescription specific to the patient’s weight, angle of foot deformity and specific shoe needs. Low Dye taping or padding are also recommended during the initial visit while a patient is waiting for the orthotics to arrive from the lab. According to Donley, concomitant use of antiinflammatory medication with conservative treatments increases pain relief and decreases disability in patients with plantar fasciitis.7
Foot orthoses and anterior night splints are reportedly effective in both the short term and long term when it comes to treating pain from plantar fasciitis. When looking at the function of night splints versus orthoics, foot-related quality of life and improved compliance suggest that a foot orthosis is the best choice for initial treatment of plantar fasciitis in comparison to night splints.8 Be sure to instruct the patient to wear supportive shoes at home.
On the follow-up visit, if patients report 80 to 90 percent improvement in symptoms, continue the aforementioned treatments. We have found far better compliance with stretching and improved long-term outcomes when one begins physical therapy early in the treatment of plantar fasciitis. The proverb of teaching people how to fish versus catching them fish is true in cases of physical therapy use versus steroid injection for plantar fasciitis. During therapy, patients often observe an improvement in their pain level with stretching and manual therapy, and will continue this at home.
Steroid injections will decrease pain but patients will often not change their lifestyle in order to avoid the pain from recurring so they often have continued pain. Physical therapy also seems to stimulate an increase in blood to the fascia region through manual massage, resulting in hypervascularity that is helpful with healing.
If there is minimal improvement after two to three weeks of employing the first step of the algorithm, proceed to step two. If the patient is making progress, continue step one for two weeks and recheck the patient at that time.
Step Two: When You Should Consider Corticosteroids And Night Splints
Step two of the algorithm includes all first step treatment modalities, corticosteroid injection and/or night splint use.
In regard to runners or athletes, once one gives the injection, it is wise to recommend complete rest for the next few days prior to intensive athletic activities in order to prevent rupture of the plantar fascia. With recalcitrant plantar fascia symptoms, two to three injections with or without ultrasound guidance may be necessary.
Our institute emphasizes a minimum of three months with step two treatment modalities and, more commonly, up to six months of conservative care prior to progressing to step three. However, if a patient has received treatment from multiple doctors without improvement and conservative care has been exhausted, one may proceed to step three earlier in order to avoid further pain.
Step Three: Exploring Surgical Treatment Options
Step three treatment options include instep fasciotomy, endoscopic plantar fasciotomy, extracorporeal shockwave therapy or Topaz (ArthroCare) therapy.
If symptoms still persist, surgical intervention is recommended. The American College of Foot and Ankle Surgeons guidelines recommend utilizing a surgical option after four to six months of initial conservative therapy.9 Podiatrists currently use several surgical treatments for heel pain that is recalcitrant to conservative therapy.
One would perform instep plantar fasciotomy using a transverse incision on the plantar surface from medial to lateral directly plantar to the site of the heel spur. This incision facilitates full visualization of the plantar fascia, bursa and heel spur. However, one must emphasize partial or nonweightbearing status for an extended period of time, and there is the potential for post-op complications of irritation and scarring, which cause abnormal joint rotation and arch displacement. However, researchers have reported up to 90 percent of pain relief with this treatment.10
Endoscopic plantar fasciotomy (EPF) reportedly produces up to 81 percent satisfaction in recalcitrant plantar fascial patients.11 This has become a favorable procedure to perform due to its minimally invasive nature, the ease of the procedure itself, quick procedure time and the patient’s ability to bear weight immediately. Researchers have reported post-op complications such as lateral column instability, central arch pain and nerve entrapment.11
How Effective Is Shockwave Therapy?
Shockwave therapy, which was introduced initially in Germany in urology and gastroenterology, can help treat pathologies of the musculoskeletal system. These pathologies include epicondylitis of the elbow, plantar fasciitis and calcifying and noncalcifying tendinitis of the rotator cuff.
With the noninvasive nature of these waves and low complication rate, extracorporeal shockwave therapy (ESWT) seems to be a promising alternative to surgical options in the treatment of patients with chronically painful conditions. The ESWT treatments with 1,000 impulses of low-energy shockwaves appear to be an effective therapy for plantar fasciitis and may help the patient to avoid invasive procedure for recalcitrant heel pain.12 With the use of ESWT, there is an increase in blood supply to the heel, which results in fasciitis and fasciosis healing.
One study reported that 75.3 percent patients were complaint free, 18.8 percent were significantly better, 5.9 percent were slightly better and none reported that they had no change in pain or were worse. The recurrence rate was only 5 percent.13
However, we have not found shockwave therapy to be as successful as the aforementioned study indicates. Our rate of improvement has been 54 percent overall with those patients who improved having no recurrence at one year.
The thinking is that the waves may not penetrate deep enough and not cause enough damage to truly cause the fasciosis in the fascia to break apart and allow healing. The main complication we have noted is calcaneal bruising from high power machines, which results in calcaneal contusions that seem to improve with time.
Assessing The Merits Of Radiofrequency Coblation
The Topaz coblation technique utilizes radiofrequency-based technology. This technology causes microscopic damage to the fascia, increases blood supply to the region, increases healing factors to the area and breaks up the nocioceptor in the deep skin. This has resulted in improved healing and pain relief through a fairly noninvasive approach to heel pain.
The Topaz coblation procedure preserves the anatomical structure of the tissue while delivering a precisely controlled amount of radiofrequency energy that stimulates a healing response in the tissue. Surgeons often perform the procedure through a percutaneous approach and one can perform it in the office under local anesthesia. Often patients feel immediate minor relief due to nocioceptor cell ablation and this is followed by significant relief at two to three weeks.
At our institute, we will often place patients in a boot for one to two weeks and allow return to full activity in one month. We have performed over 100 of these cases through a percutaneous approach to date and have had over 94 percent success with no cases of increased pain and no complications.
All patients said they would undergo the procedure again as a conservative option prior to fasciotomy and surgical fascia release. It is essential not to use antiinflammatory medication or icing during the first two to three weeks after surgery as the inflammatory process is critical for tissue healing. Furthermore, the region to be treated should correlate with the area of pain and it is best to check this with ultrasound prior to treatment. This allows a more guided and appropriate treatment than a blind technique.
Topaz coblation is currently our most successful treatment for step three of heel pain and has truly been an ideal conservative surgical treatment for recalcitrant heel pain cases. It offers the option of surgical release should the procedure not work and maintains an intact fascia. This facilitates proper foot function and there are no cases of lateral column symptoms as has been reported with fasciotomy.
The first step in treating the plantar fasciitis involves correct diagnosis. Once you have established the diagnosis, using the aforementioned algorithm can guide you through alternatives that have worked well for us in our treatment of over 4,000 heel pain cases in the past two years.
We have a 90 percent conservative treatment rate and have found Topaz coblation therapy to be an excellent option for conservative treatment in step three cases that do not respond to traditional conservative care. Currently, we are studying the use of coblation earlier in our treatment algorithm as it seems to be simple to perform and has a very high rate of success. The idea of the body healing itself is finding more uses in the foot and ankle. We are also currently studying potential treatments such as platelet rich plasma injection therapy and deep tissue massage.
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