Current Concepts In The Algorithm For Plantar Fasciitis

Patrick DeHeer, DPM, FACFAS, and Kellie Higgins, DPM

   One study by Donley and colleagues looked at the efficacy of NSAIDs.2 The researchers evaluated 29 patients with plantar fasciitis. Twelve patients received 200 mg of an NSAID (celecoxib) once a day for 30 days and 17 patients received a placebo. All 29 patients got a heel cup with an at-home stretching program and night splint.

   Twenty-three patients were available for a six-month follow-up. The NSAID group’s final pain score was 1.43 (on a 0 to 10 scale with 10 being the worst) in comparison to 1.86 for the placebo group and their disability score was 1.16 in comparison to 1.49 in the placebo group.2 The study showed that NSAIDs do help reduce the pain of plantar fasciitis.

   Another important modality is stretching. Research has shown manual stretching to be ineffective, primarily due to patients not stretching correctly, not stretching long enough and not stretching consistently.6 Since equinus is often one of the etiologies of plantar fasciitis, it is important to address this issue for pain reduction and prevention of recurrence.7 The best current method of stretching is a night splint but adherence with sleeping in night splints is often quite poor. A meta-analysis by Radford and co-workers showed that stretching for at least 15 to 30 minutes daily is effective.6 The senior author recommends doubling this and has patients stretch with a night splint for one hour daily.

   The other initial step in treatment is strapping of the foot to control biomechanical abnormalities and relieve strain on the plantar fascia. It may take multiple rounds of taping to reduce the symptoms of plantar fasciitis to that 80 to 90 percent pain reduction level.8,9

Gauging Patient Response To Treatment

If patients are improving at any step in the treatment process, continued strapping and stretching are encouraged as well as the use of a plantar fascia brace until symptoms resolve. The plantar fascia brace is essentially a removable taping that is easier for the patient to manage but does not provide the same type of support as taping.10 In a study by Ogdem and colleagues, 237 patients received treatment entailing NSAIDs, stretching, night splints and heel cups or orthotics.11 At six months of this continued treatment, 51 percent of patients were completely pain-free and 81.8 percent of patients were satisfied with their pain level.

   If patients’ symptoms are not improving, the senior author’s next step would be an injection. Steroid injections are well documented for the treatment of heel pain but are relatively painful.12-14 Clinicians may provide up to three injections in the same area in a six-month time period. If available, ultrasound guided injections into the plantar fascia are recommended.12 Typically, if a patient receives an injection, he or she receives a strap to protect the plantar fascia.15 It must be emphasized that injections are solely for inflammation reduction and one must concurrently address the etiologies as well.

   If there is minimal improvement after this, one may consider immobilization of the patient with a below knee walking boot and have him or her initiate physical therapy. If the patient is still having pain and is actively following treatment plans, more invasive treatment becomes necessary. Before proceeding with a more invasive intervention, one can use MRI to evaluate the plantar fascia and specifically look for tears and any inflammation or irritation of the nerves.

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