Why Orthotics Are Not The Answer For Plantar Fasciitis

There are approximately 2 million documented cases of plantar fasciitis per year in the United States. For most podiatrists, this is the most common foot pathology we see in our practices.1 The “sacred cow” in the podiatric community for plantar fasciitis has always been custom orthoses.

However, I have a slightly different opinion on the role of custom orthoses for the treatment of plantar fasciitis. I do not think custom orthoses are a treatment at all for acute plantar fasciitis. This is coming from someone who prescribed an average of 31 pair of custom orthotics per month over the past 12 months. So what gives?

I have come to believe that treatment in plantar fasciitis cases is a two-stage process, which involves an acute inflammatory stage treatment and a long-term stage treatment. I firmly believe that one must treat patients “acutely” and must reduce their level of pain to a 1 or 2 on a Visual Analog Scale (VAS) before you can proceed with long-term stage treatment. The long-term treatment is consistent from patient to patient for me but the acute-term treatment is variable and driven by patient response.

A Closer Look At Treating Acute Pain

The acute term treatment starts with three very easy steps. The first is supporting the plantar fascia with taping. I love taping and did it an average of 45 times per month over the past 12 months. I used to have the patients leave the taping on for a full week. Recently though, I have started to have them come in about three to four days after the initial taping to be re-taped. I will usually tape someone two to four times before moving on to the next step.

The second thing I do on the initial visit is dispense a night splint to treat equinus. A recent study showed that 83 percent of the cases of plantar fasciitis are associated with equinus.2 I typically have patients use the night splints for two to three months or until symptoms have completely resolved. One dilemma for me has always been those cases of unilateral plantar fasciitis. It makes no sense to me to only stretch one side. In my mind, this is creating a functional limb length discrepancy. Therefore, I usually use night splints on both limbs.

The final part of the initial visit treatment is doing something to get the symptoms of inflammation under control. I like to start with a Medrol Dosepak. I know some prefer an injection to the oral medication but let us face it: injections hurt. If I can avoid them, the patient is much happier.

If the patient is responding positively, the next step of the acute term treatment is to switch from the taping to a plantar fascia brace to continue to support the plantar fascia. I will typically have patients use this for two more weeks and continue stretching with the night splints. If the patient is not progressing in a positive direction, I will use an injection at this point and see him or her back in two weeks. If patients are still not progressing as expected, I will emphasize cast boot immobilization for two to four weeks to calm the symptoms down.

Then I will start back at where we left off in the treatment plan. If things are still not progressing as expected, I often will get a magnetic resonance image (MRI) to evaluate the condition, especially when it comes to looking for changes consistent with entrapment of Baxter’s nerve. If these changes are present on the MRI, I will confirm this with a diagnostic nerve injection. If this diagnosis is confirmed, this becomes much more of a surgical problem.

What You Should Know About Preventative Long-Term Treatment

Once the patient is at a pain level of 1 or 2 on the VAS, then I proceed to long-term treatment and this consists of orthoses. I think the purpose of the orthotic is not to treat the condition but to prevent the condition from recurring once the patient is asymptomatic and the equinus deformity has resolved. Patients with an inflamed heel do not tolerate a rigid or semi-rigid orthotic well. Additionally, and most importantly, equinus will cause a dorsiflexion moment of the forefoot and plantarflexion moment of the rearfoot. These motions with a rigid or semi-rigid orthotic pushing up into the arch will often result in poor tolerance of the device by the patient.

Final Notes

I recommend treating the patient in two stages with acute term and long-term treatment. Once patients are asymptomatic, you can subsequently offer them long-term preventative treatment with custom orthoses if you have resolved any equinus deformity. I think you will find this approach produces consistent results and will additionally result in better practice profitability.

References

1. Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for plantar fasciitis: a matched case-control study. J Bone Joint Surg Am. 2003; 85-A(5):872-877.

2. Patel A, DiGiovanni B. Association between plantar fasciitis and isolated contracture of the gastrocnemius. Foot Ankle Int. 2011; 32(1):5-8.



Dieter J Fellnersays: May 23, 2011 at 10:53 am

Sage and pertinent advice without a doubt. I have no issue with the treatment plan as outlined for the acute case. My only concern here, is the assertion that FFO are deployed as a mainstay treatment of acute plantar fasciitis. Is this really true? In many cases, the patient will present with chronic inferior heel pain. There is good evidence from the literature that an orthotic insert, OTC or other, is a useful adjunct in managing this cohort of patients.

Thank you for sharing your treatment strategy.

Reply to this comment »
Patrick DeHeersays: May 24, 2011 at 11:12 pm

Hello Dieter,

Thank you for your comment. I need to make one concept clear about the acute and chronic treatment plans. By acute, I do not mean a time-related subjective complaint. For example, six days or six months, which would definitely be an acute condition vs. a chronic condition. By acute and chronic treatment, I mean solely based on pain. If the patient is in pain, then in my view, he or she would receive acute treatment. Once the pain is 80-100% improved, then you move on to chronic or a better term would be long-term treatment. I hope this clarifies what I was trying to say. Thanks again for your comment. Best wishes.

Patrick A. DeHeer, DPM

Reply to this comment »
gary evans dpmsays: May 27, 2011 at 8:57 am

What plantar fascia splint do you use once you stop taping?

Reply to this comment »
Patrick DeHeersays: May 30, 2011 at 9:51 pm

I have used the Bledsoe Plantar Fascia Brace for several years now and have been very happy with it. I think taping provides more support but the brace is much easier to deal with for the patient. Hope this helps. Best wishes.

Patrick A. DeHeer, DPM

Reply to this comment »
Robert Scott Steinberg, DPMsays: May 31, 2011 at 10:33 am

Not sure what 31pr/mo x 12mo has to do with things. Too short of a time span, to be sure.

I believe in addressing the cause of the patient's plantar fasciitis ASAP along with the immediate care for the pain. To my way of thinking (developed over my 35 years of orthotic work using only plaster of Paris impressions), it is more cost effective if I can get my patient into a Rx device within two weeks. For those "emergencies" (ie, elite runners with the race looming within a month), I FedEx casts and have the orthotics FedExed back with a 24hr lab turnaround time. I have lost track of the number of runners with the Rx orthotic in their shoes who, for no other reason (and no injections), were able to do their race and do very well.

If a patient is training for an important race and would rather not get an injection, then quick turnaround is very important. I do not advise patients to run for at least two weeks after an injection and saying a month's rest might be a safer bet.

I gave up on night splints a long time ago and instead demonstrate proper stretching of the calf.

Reply to this comment »
Patrick A. DeHeer, DPMsays: June 1, 2011 at 1:30 pm

I was just saying that I do believe in orthotics and that I use them often. I like to use them once the acute symptoms are under control. I have to disagree with you on manual stretching. There is a very good article by Saxena and Grady about how ineffective manual stretching is. Thank you for your input. Best wishes.

Patrick A. DeHeer, DPM

Reply to this comment »
Howard Dananberg, DPMsays: June 2, 2011 at 10:17 am

There is an additional treatment option which is often missed in the care of plantar fasciitis and this is manipulation of the ankle and cuboid.

In my Sept. 2000 article in JAPMA, we showed how ankle joint dorsiflexion can be improved immediately an average 5 degrees with manipulation. This can negate the use of cumbersome night splints which patients actually hate.

These videos are posted on youtube under Dananberg, Manipulation and can be safely performed with some practice. Results are immediate and can be outstanding.

Reply to this comment »
Robert Scott Steinberg, DPM, DABLESsays: December 27, 2011 at 8:59 pm

I have too many years (36) of experience treating plantar fasciitis and fasciosis to buy into Dr. DeHeer's theory. I just don't see it in my practice.

One needs to deeply probe some patients as to just how acute their problem really is. Most will admit the pain has being lingering for months but is tolerable with tolerance being quite individualized. Except for those who state they jumped off something and landed "back on their heels," causing hematoma, most truly acute cases claimed by patients are more a result of them now being in a state of panic after months of training that are seemingly going down the drain.

Prescribing Rx functional orthotics as a first line of treatment after a biomechanical exam indicates abnormalities is prudent and efficacious. I have also sensed that doctors who do not see the expected improvements after dispensing Rx functional orthotics may be doing something wrong or the lab is not handling the impression correctly.

Reply to this comment »
Jeff Kasssays: December 27, 2011 at 10:38 pm

Dr. DeHeer, what are your thoughts regarding fascitiis vs fasciosis?

Are you of the belief that what you are describing as an "acute phase" is indeed an inflammatory process and hence a fascitiis which at some point becomes degenerative and hence is a fasciosis? Is thisthe phase you are actually recommending orthotic therapy for?

Reply to this comment »

Post new comment

  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.

More information about formatting options

Image CAPTCHA
Enter the characters shown in the image.