An Evidence-Based Medicine Approach To Plantar Fasciitis

Allen Jacobs, DPM, FACFAS

A Look At Other Techniques For Heel Pain

Brook and coworkers reported on the successful use of radiofrequency electromagnetic field therapy for the treatment of plantar fasciitis.80 Gordon and colleagues reported recent success with the use of extracorporeal pulse activated therapy.81 Both of these techniques offered the advantage of noninvasive management of plantar fasciitis.

   Authors have described radiation therapy as successful for the treatment of plantar fasciitis in multiple recent publications and one may consider this as an additional noninvasive therapeutic alternative for the treatment of plantar fasciitis.82

   For some time now, experts have advocated extracorporeal shockwave therapy (ESWT), both low- and high-energy, with and without ultrasound guidance. Generally, reported results for the use of ESWT have been favorable but they do vary. Speed and colleagues reported that at three months, only 37 percent of active ESWT patients improved while 24 percent of sham patients had improved.83 In a randomized double-blind placebo controlled study, Buchbinder and colleagues demonstrated no difference between shockwave and a placebo in the treatment of plantar fasciitis.84

   Conversely, Ogden and coworkers demonstrated a 95 percent improvement at one year utilizing ESWT for the treatment of plantar fasciitis.85 A meta-analysis of shockwave for the treatment of plantar fasciitis revealed an overall success rate of 80 percent and recommended consideration of this technique prior to surgical intervention.86 Othman and coworkers found that endoscopic plantar fasciitis demonstrated a superior outcome in comparison to ESWT in the treatment of plantar fasciitis while Rompe and coworkers found that stretching exercises yielded superior results to the utilization of low energy radial shockwave therapy.87,88

In Summary

Chronic plantar heel pain encompasses a variety of potential diagnoses including fasciitis, fasciopathy, fasciosis, fibromatosis, nerve entrapments and bursitis among other diagnoses. Various authors have advocated an eclectic array of therapies for the management of plantar fasciitis. In the majority of studies, researchers noted improvement in both the active treatment group as well as the placebo group.

   A variety of existing conservative therapeutic options are generally reported as being successful in the treatment of plantar fasciitis. It would appear that non-operative management is typically indicated for the majority of patients with symptomatic plantar fasciitis. Bear in mind that most studies in the treatment of plantar fasciitis are characterized by small sample sizes and a failure to conceal active from sham treatment groups is also common. Accordingly, it is difficult to draw definitive conclusions as to the best non-surgical or surgical options for the treatment of plantar fasciitis. Overall, it does appear that a number of options are successful for the treatment of plantar fasciitis.

   One should consider weight loss when indicated and reduction of mid-ankle joint dorsiflexion when indicated. It does appear that the use of orthotics with rocker bottom shoes increases the efficacy of orthotics for the treatment of plantar fasciitis.

   There is no indication that ultrasound guidance for the treatment of plantar fasciitis provides any additional benefit to justify the increased costs. Corticosteroid injection for the treatment of plantar fasciitis has relevant literature support. The utilization of onabotulinum toxin injections is also well supported in the literature for the treatment of plantar fasciitis. The indications for the use of PRP remain unclear. Finally, the literature supports a number of surgical interventions but there is no indication of the superiority of one technique over another.

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