Current Concepts In The Algorithm For Plantar Fasciitis

Author(s): 
Patrick DeHeer, DPM, FACFAS, and Kellie Higgins, DPM

Given the common presentation of heel pain, these authors discuss their stepwise approach to treating plantar fasciitis, focusing on pain reduction and controlling biomechanical abnormalities.

Plantar fasciitis has become a commonplace medical condition. In America, close to 11 percent of all foot complaints are attributed to plantar fasciitis and it causes over 2 million Americans to seek medical attention annually.1,2 Plantar fasciitis can be a self-limiting condition with patients usually having resolution of their symptoms within 10 months in most cases.3 However, this is a frustrating period of time to have discomfort, especially in active patients. Accordingly, let us take a closer look at key considerations in approaching and treating a patient with a chief complaint of heel pain.

   The plantar fascia is a thick, fibrous aponeurosis composed of dense connective tissue. It originates from the medial and lateral tubercle of the calcaneus and inserts into the plantar plate. The plantar fascia provides static support and stabilizes the arch of the foot by plantarflexing the metatarsals during the gait cycle.

   Plantar fasciitis is the inflammation and degeneration of the aponeurosis.4 Chronic overuse due to excessive standing, running or abnormal anatomy or biomechanics leads to an inflammatory process. Plantar fasciitis commonly occurs in patients with equinus, patients who are overweight or older, and those who are on their feet for much of the day. It also arises in active patients who have abnormal foot loading. Some structural deformities that lead to plantar fasciitis include pes planus, overpronation, pes cavus and limb length discrepancies. Some functional deformities causing overuse of the plantar aponeurosis include gastroc and/or soleus tightness or weakness and intrinsic foot muscle weakness.5

   The diagnosis of plantar fasciitis often is based on a good history and physical. Patients will usually have a chief complaint of severe heel pain with the first few steps in the morning or after prolonged sitting or resting (post-static dyskinesia). Many will have a dull ache at the end of the day and pain with excessive walking or standing.

   During the physical exam, palpation over the medial calcaneal tubercle will elicit pain. Palpating the medial band of the plantar fascia while passively dorsiflexing the toes (and thereby activating the windlass mechanism) can also cause discomfort. It is important to note the patient’s foot type as well as the quality of shoe gear. During the physical exam, it is also important to assess for any neurological changes and check for a Tinel or Valleix sign.

   While we often do not use imaging in the diagnosis of plantar fasciitis, one may utilize it to evaluate for a plantar calcaneal spur. Radiographs can be valuable to rule out differential diagnoses including a calcaneal stress fracture, neoplasm and arthritis. However, they are not needed solely to diagnose fasciitis. Magnetic resonance imaging (MRI) can rule out nerve entrapments as well as assess the thickening and changes in consistency in the fascia. One may employ ultrasound to assess the fascia as well but this can be more technically difficult.

Keys To Initial Treatment

After diagnosing a patient with plantar fasciitis, the senior author believes the treatment is a two-step process. The first step is to decrease the patient’s pain level by at least 90 percent. Medrol packs and non-steroidal anti-inflammatory drugs (NSAIDs) can help to achieve this by treating the inflammatory component of the condition.

   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.

   It is important to assess for Baxter’s neuropathy.16 Baxter’s nerve is the first branch of the lateral plantar nerve and can become entrapped and compressed with altered foot biomechanics, such as plantar fasciitis. If this is the case, one will need to address this along with any further treatment of the plantar fasciitis to resolve the patient’s pain.

Pertinent Pointers On ESWT And Platelet Rich Plasma

Some more invasive treatment options include shockwave therapy or platelet rich plasma (PRP) injections.

   Extracorporeal shockwave therapy (ESWT) is a procedure that one can perform in the office, using focused shockwaves to incite microtrauma in the plantar fascia to initiate the body’s healing process. In a meta-analysis of shockwave therapy by Ogdem and co-workers, 113 patients received high-energy shockwaves and 79 received low energy shockwaves.11 After one treatment session, 24.8 percent of the high-energy treatment patients were pain-free in comparison to 11.4 percent of low-energy patients.

   Odgem and colleagues also looked at 322 patients with plantar fasciitis for six to 18 months.11 These patients received extracorporeal shockwave therapy. At three months post-treatment, 56 percent of patients had reduced pain. At one year, 94 percent of patients were pain-free.

   In another study from 2010, 50 patients with unilateral plantar fasciitis were randomly placed into a control group of 25 patients and a treatment group of 25 patients.17 The treatment group received radial extracorporeal shockwave therapy set at 2,000 impulses per second at 8 Hz delivered in two sessions, each one week apart. The placebo group of radial ESWT was at 0 impulses. Ninety-two percent of radial ESWT patients had over 60 percent improvement in pain and quality of life in comparison to just 4 percent of the placebo group at four weeks after the first treatment. One hundred percent of treatment patients had 60 percent improvement of pain and quality of life at 24 weeks. Shockwave therapy has been well documented as a minimally invasive, in office procedure that works well for plantar fasciitis.

   In a randomized, double-blinded study, researchers distributed small, wearable pulsed radiofrequency devices in patients with plantar fasciitis.18 Forty-two patients received an active device and 28 had a non-active device, which they wore nightly for seven straight nights. Over the seven days, researchers found the morning pain level was reduced 40 percent in the active pulsed radiofrequency device group in comparison to a 7.9 percent reduction in the control group. Evening pain levels decreased 30 percent in the active group and 19 percent in the placebo group.

   Another option is PRP injections. Platelet rich plasma is concentrated platelets that are taken from the plasma of centrifuged autologous blood and injected in a peppering pattern into the fascia. Once injected, platelets activate and secrete proteins (including growth factors) as well as produce bioactive factors, promoting the healing process.19

   In a study from June 2012, 60 patients received either PRP injections or a steroid (methylprednisolone) injection.20 With a six-month follow up, there was no significant difference in the two treatment groups. The study found that both the steroid injection and PRP effectively treated plantar fasciitis with PRP having fewer potential side effects.

What The Literature Reveals About Surgical Treatment Options

If the aforementioned minimally invasive treatments of plantar fasciitis are not beneficial or available, a more invasive surgical procedure becomes necessary. Some common procedures include plantar fasciotomy with or without spur resection, gastroc recession and an instep plantar fasciotomy.

   Surgeons have routinely performed gastroc recessions to treat isolated contractures of the gastrocsoleus complex. However, literature has shown that a tight gastroc leads to excessive strain of the foot. This excessive strain can lead to plantar fasciitis. A gastroc recession specifically addresses the equinus deformity known to cause plantar fasciitis. A study by Maskill evaluated 29 patients (34 feet) who had undergone six months of conservative treatment with no relief.21 These patients had an isolated gastrocnemius rescession. Postoperatively, 93 percent were satisfied with the procedure and their pain reduction.

   The instep procedure is well documented as a successful surgical treatment for plantar fasciitis. In one study, researchers retrospectively evaluated 83 patients (94 feet) who had an instep plantar fasciotomy.22 All patients had received extensive conservative treatment without pain reduction. After the procedure, 93.6 percent of patients considered their surgery successful. The main complications were scarring in 9.6 percent of patients, medial arch pain in 7.5 percent of patients, cramping in the arch in 6.4 percent of patients and lateral column pain in 5.3 percent of the patients.

   In another study, Woelffer and co-workers conducted a five-year follow-up of the instep plantar fasciotomy.23 They looked at 33 surgical cases and found that 90.9 percent of patients had over 90 percent satisfaction and 81.8 percent of patients had over 90 percent pain relief. In a study by Brekke and Green on the plantar fascia release, they reported a 71.4 percent satisfaction rate with the main complication of the surgery being lateral foot pain.24 Overall, the instep procedure has a low complication rate and researchers have shown that it reduces patient pain significantly.

In Conclusion

Plantar fasciitis is becoming more prevalent in today’s population and patients want relief. Getting the patient’s pain reduced or resolved, using NSAIDs or oral corticosteroids, and addressing the equinus deformity with stretching and strapping are the first steps in successful treatment. When further invasive procedures are necessary, consider using injections, PRP, shockwave therapy and surgery to help patients quickly and painlessly return to their daily activities.

   Dr. DeHeer is a Fellow of the American College of Foot and Ankle Surgeons, and a Diplomate of the American Board of Podiatric Surgery. He is also a team podiatrist for the Indiana Pacers and the Indiana Fever. Dr. DeHeer is in private practice with various offices in Indianapolis.

   Dr. Higgins is a first-year resident at St. Vincent’s Hospital in Indianapolis.

References
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15. Yucel I, Yazici B, Degirmenci E, Erdogmus B, Dogan S. Comparison of ultrasound-, palpation, and scintigraphy-guided steroids injections in the treatment of plantar fasciitis. Arch Orthop Trauma Surg. 2009; 129(5):695-701.
16. Chundru U, Liebeskind A, Seidelmann F, Fogel J, Franklin P, Beltran J. Plantar fasciitis and calcaneal spur formation are associated with abductor digiti minimi atrophy on MRI of the foot. Skeletal Radiol. 2008; 37(6):505-10.
17. Ibrahim MI, Honatelli RA, Schmitz C, Hellman MA, Buxbaum F. Chronic plantar fasciitis treated with two sessions of radial extracorporeal shock wave therapy. Foot Ankle Int. 2010; 31(5):391-397.
18. Brook J, Dauphinee DM, Korpinen J, Rawe JM. Pulsed radiofrequency electromagnetic field therapy: a potential novel treatment of plantar fasciitis. J Foot Ankle Surg. 2012; 51(3):312-316.
19. Soomekh DJ. Current concepts for the use of platelet- rich plasma in the foot and ankle. Clin Podiatric Med Surg. 2011; 28(1):155–170.
20. Akşahin E, Doğruyol D, Yuksel HY, et al. The comparison of the effect of corticosteroids and platelet-rich plasma (PRP) for the treatment of plantar fasciitis. Arch Orthop Trauma Surg. 2012; 132(6):781-785.
21. Maskill JD, Bohay DR, Anderson JG. Gastrocnemius recession to treat isolated foot pain. Foot Ankle Int. 2010; 31(1):19-23.
22. Fishco WD, Goecker RM, Schwartz RI. The instep plantar fasciotomy for chronic plantar fasciitis: a retrospective review. J Am Podiatr Med Assoc. 2000; 90(2):66-9.
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   For further reading, see the Podiatry Today DPM Blog “Resistant Plantar Fasciitis: Why We Should Opt For A Gastrocnemius Recession Before Even Considering A Plantar Fasciotomy” at http://tinyurl.com/8wl5kuy , “Refining The Treatment Algorithm For Plantar Fasciitis And Plantar Fasciosis” in the May 2010 issue of Podiatry Today, or “Should You Change Your Approach To Plantar Fasciosis?” in the November 2006 issue.

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