An Evidence-Based Medicine Approach To Plantar Fasciitis

Allen Jacobs, DPM, FACFAS

   While clinicians commonly employ iontophoresis for the treatment of plantar fasciitis, one study found no difference at one month between placebo and iontophoresis utilizing 0.4% dexamethasone.29 Another study demonstrated strapping of the foot to be superior to iontophoresis.30

   Studies supporting the utilization of orthotics for the treatment of plantar fasciitis are not overly convincing. Pfeffer and colleagues demonstrated the superiority of stretching exercises only, rubber inserts, felt inserts and silicone inserts in comparison to custom orthotics for the treatment of plantar fasciitis.31 Landorf and coworkers demonstrated that a prefabricated orthotic was superior to customized orthotics for the reduction of plantar fascia pain.32 Turlik and coworkers, however, demonstrated that orthotics were superior in the treatment of plantar fasciitis versus heel pads although both groups demonstrated a reduced duration and severity of heel pain.33

   Landorf and colleagues noted that while orthotics play a role in the treatment of plantar fasciitis, no randomized, controlled trials or other good evidence existed to recommend orthotics over prefabricated supports.34 The authors recommended the initial use of prefabricated supports prior to the initiation of formalized orthotic management.

   Studies have demonstrated the utilization of rocker soles with orthotics to be superior to the use of orthotics alone, or the use of orthotics without rocker shoes.35,36

   In the treatment of recalcitrant plantar fasciitis, authors have demonstrated below-the-knee casts to be associated with a 25 percent complete resolution of pain and improvement in pain in 61 percent of patients.37

How Effective Is Injection Therapy For Plantar Fasciitis?

Authors have advocated a variety of injection therapies for the treatment of plantar fasciitis.38 These include dry needle techniques, the injection of local anesthesia, corticosteroids and autologous substances such as platelet-rich plasma (PRP) or other blood-derived products, sclerosants, mesenchymal and stem cell injection as well as prolotherapy with hyperosmolar dextrose.

   Physicians have frequently used corticosteroid injection to treat plantar fasciitis. One study documented rupture of the plantar fascia after an average of 2.67 injections in 2.4 percent of patients in one study while Acevedo and coworkers reported 44 plantar fascial ruptures in 765 patients receiving corticosteroid injections and Sellman reported 37 plantar fascial ruptures following corticosteroid injection.39-41

   Research has demonstrated corticosteroid injection for the treatment of plantar fasciitis as more cost effective and superior to extracorporeal shockwave therapy at three months and 12 months.42 Although advocated by many who cite greater accuracy of injection placement, studies have demonstrated no difference in response to ultrasound guided injection for plantar fasciitis versus palpation guided injection of corticosteroid injection for plantar fasciitis.43 Research has not demonstrated the use of a posterior tibial nerve block in conjunction with plantar fascia injection therapy, including ultrasound guided posterior tibial nerve block, to offer any clinical advantage.44,45

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