Developing A Comprehensive Plan To Treat Plantar Fasciitis

Bob Baravarian, DPM, FACFAS, and Lindsey Mae Chandler, DPM

Patients with chronic heel pain represent a significant percentage, up to 20 percent, of the population presenting to healthcare providers specializing in foot and ankle disorders.1 Patients frequently comment that their plantar heel pain is worse with the first few steps they take in the morning after arising from bed. The pain declines after a few minutes but returns through the day the longer the patient is on his or her feet. Significant findings associated with plantar heel pain include tightness of the Achilles tendon, high body mass index (BMI) and unsupportive shoe gear.2

   Many patients believe the pain will go away on its own or they will try self-remedies before going to the doctor. A thorough history and physical is essential in making the diagnosis of plantar fasciitis. The time of the day the pain occurs, the patient’s activity level both at work and play, current shoe gear, the presence of sensory disturbance such as radiating pain, and the history of trauma are all important information to gather in your history.

   The lower extremity physical examination must include: range of motion of the foot and ankle, with particular consideration of decreased ankle dorsiflexion with the knee extended and/or flexed; architectural alignment of the foot; the angle and base of gait; palpation of the heel and plantar fascia; observation of swelling or atrophy of the fat pad; and the presence of any dysesthesia or hypoesthesias.

   Obtain weightbearing lateral radiographs of bilateral feet following a comprehensive lower extremity history and physical. An infracalcaneal spur is often linked with plantar fasciitis symptoms. Plantar heel spurs commonly imply that the condition has been present for at least six to 12 months, whether it is symptomatic or asymptomatic. Theoretically, the longer the duration of heel pain symptoms, the more prolonged period there will be for final resolution of the condition.

   However, researchers have reported that more than 90 percent of patients respond to conservative measures.3 The most common cause of heel pain is plantar fasciitis yet the non-surgical treatment is not standardized.3 It is important to individualize treatment in order to resolve symptoms.

What The Authors Have Found With Conservative Care For Plantar Fasciitis

At the University Foot and Ankle Institute, we looked at approximately 2,500 cases of plantar fasciitis in one year and followed those patients for a duration of five years.

   Initial treatments included habitual Achilles and plantar fascia stretching with regular sessions of home therapy or (preferably) formal physical therapy when the patient has the means to go to therapy three to four times per week. It is also helpful for patients to avoid flat shoes and barefoot walking with transition to the use of stiff soled shoes with a 1 to 1.5 inch heel, wear over-the-counter arch supports and heel cups versus custom orthotics, and restrict high-impact physical activities.

   In our patient population, we find patients recover with stretching, physical therapy, change of shoe gear, arch supports or custom orthotics, and modification of activity levels. Within six weeks of the initiation of treatment, we found our patients tended to report a decrease in symptoms and almost complete resolution of pain. If progression had occurred, initial therapy continued until symptoms had completely resolved.

   If pain continues to be present for over six weeks without much resolution, we perform a cortisone injection under ultrasound guidance to try to resolve any residual swelling. We prefer not to perform multiple injections as they do not seem to make a significant difference if the first injection does not adequately resolve the swelling and pain.

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