A Guide To Conservative Care For Plantar Heel Pain
- Volume 26 - Issue 11 - November 2013
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The physical examination can reveal pain with palpation of the plantar medial tubercle, the plantar central tubercle and less often, the plantar lateral tubercle of the calcaneus. Edema and erythema are uncommon. One may reproduce pain with ankle joint dorsiflexion and clinicians should evaluate for possible equinus. With the hallux dorsiflexed, the plantar fascia becomes taut and tenderness may or may not be present with palpation. Clinicians should also evaluate the calcaneus for fat pad atrophy. Any paresthesias/dysesthesias indicate a possible neurological cause.
Radiographs are usually not helpful in diagnosing plantar fasciitis but are necessary to rule out other etiologies. In their study, DiMarcangelo and Yu found that 50 percent of patients with plantar fasciitis had heel spurs and up to 19 percent of patients with heel spurs did not have plantar fasciitis.14 The most difficult part of treating plantar fasciitis is convincing patients that the spur is likely not their source of pain. Over the past several years, ultrasound has played a larger role in clinical practices in evaluating the plantar fascia. Increased thickness of the plantar fascia correlates with increased symptoms and clinicians have identified post-treatment thinning with ultrasound.15
After diagnosing plantar fasciitis, one must pursue a treatment regimen that addresses the cause of the problem and decreases the pain associated with the condition. There is very little evidence-based literature that identifies one treatment modality as being superior to another so any treatment protocol is based on anecdotal evidence.
Are NSAIDs Effective For Plantar Fasciitis?
One of the first treatment options implemented by podiatrists is the prescribing of non-steroidal anti-inflammatories (NSAIDs). Non-steroidal anti-inflammatories have analgesic, anti-inflammatory and antipyretic effects. The benefits of NSAIDs are the control of pain and acceleration of healing by decreasing inflammation, thus allowing an earlier return to an activity.
When prescribing an NSAID, one can choose from a multitude of NSAIDs, each with its corresponding selectivity for target enzymes and side effect profile. With the multiple classes of NSAIDs, when one fails, one may want to consider trying another class of NSAID. In a retrospective review, Gill found that 27 percent of patients reported improvement when using NSAIDs for plantar fasciitis.16 However, Donley and colleagues found no statistical difference between placebo and NSAID in patients with plantar fasciitis.17
Any discussion of plantar fasciitis would be incomplete without mentioning the work of Lemont and colleagues.18 They found a lack of inflammatory cells and concluded that plantar fasciitis was a degenerative process, and that fasciosis would be the appropriate term for this condition. With these findings in mind, are NSAIDs and corticosteroids really indicated and effective for a degenerative process when a true inflammatory process is absent? When deciding to use or not use NSAIDs in the treatment of plantar fasciitis/fasciosis, each clinician must weigh the overall benefit versus the potential side effects, and decide what is best for the patient.