A Guide To Conservative Care For Plantar Heel Pain
Given that heel pain is one of the most common maladies that podiatrists treat, this author offers a pertinent overview of conservative therapies ranging from corticosteroid injections and night splints to low-Dye taping and platelet-rich plasma.
Current estimates suggest there may be over one million visits to physician offices per year for plantar fasciitis.1 Given that it may be the most common condition podiatrists see, the podiatric community should have a firm handle on the different etiologies of plantar fasciitis, differential diagnosis and treatment options as well as treatment algorithms or protocols they follow because variations exist in the management of plantar fasciitis. Indeed, one systematic review identified 26 methods of treating plantar heel pain.2
We see plantar fasciitis in adults on a regular basis and almost 11 percent of all foot complaints are attributed to plantar fasciitis.3 Heel pain can be very disabling for some patients and at times, patients can become frustrated with the lack of progress with treatment. If conservative treatment has failed, one should look for other possible etiologies that may be the source of pain prior to proceeding to surgery. Other conditions like tarsal tunnel syndrome, inflammatory arthropathies, nerve entrapments and calcaneal stress fractures are just a small sample of other etiologies of heel pain in adults.4 The literature is replete with both conservative and surgical treatment options for plantar fasciitis but the scope of this article will focus on conservative treatment for plantar fasciitis.
Anatomically, the plantar fascia is a thick aponeurosis that attaches to the inferior calcaneus and courses distally to attach to the base of the proximal phalanges of all five digits. The plantar fascia is comprised of three bands: medial, central and lateral. The primary functions of the plantar fascia are to plantarflex the metatarsals and support the medial longitudinal arch. Computer models have shown that disruption of this structure can lead to flattening of the medial longitudinal arch and increase pressure under the metatarsal heads.5,6 By definition, plantar fasciitis is inflammation of the plantar fascia and the thickness reportedly increases with age.7
Pertinent Diagnostic Insights
Other names for plantar fasciitis that clinicians use interchangeably include heel spurs, heel pain syndrome and heel spur syndrome.8 The prevailing thinking on plantar fasciitis is that it is an overuse injury. Researchers have identified abnormal biomechanics, obesity and improper footwear as possible etiologies.9-12 One recent study even found an association longitudinally between plantar fascia thickness and diabetic retinopathy and renal dysfunction.13
The history of a patient with plantar heel pain is critical in the diagnosis and treatment. Patients may complain of first step pain after a period of rest that generally eases after several minutes of ambulation and may worsen with continued activity. It is not unusual for patients to complain of continuous pain throughout the day that does not subside until they go to bed. Other information that one should obtain includes the type of footwear, the level of activity at work (standing/sitting), the surface the patient works on and any previous history of trauma.
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.
What About Low-Dye Taping And Stretching?
Low-Dye taping has been a mainstay in treating plantar fasciitis. Clinicians use it to relieve the tension of the plantar fascia and stabilize the foot. Low-Dye taping serves as a short-term test to see if an orthotic will or won’t work, and should be high on the list of conservative treatments. The literature on low-Dye taping is mixed. While Landorf and coworkers found that low-Dye taping significantly reduced pain associated with plantar fasciitis, van de Water and Speksnijder found limited evidence that low-Dye taping provided any benefit.19,20 Radford and colleagues found small improvement in first step pain with low-Dye taping.21
Stretching is one of the hallmark treatments in treating plantar fasciitis. By stretching the plantar fascia and/or gastrocsoleus complex, the goal is to relieve the stress on the plantar fascia. It is difficult to determine the effectiveness of stretching alone since most studies used other interventions along with stretching.
In one of the most recent studies, Bolivar and coworkers found that not only was the triceps surae tight in patients with plantar fasciitis but the hamstrings were tight as well.22 Both areas should be in a stretching protocol but there are currently no long-term studies to determine the effectiveness of this approach. Patients with hamstring tightness are also reportedly 8.7 times more likely to have plantar fasciitis.23
DiGiovanni and colleagues compared a program of non-weightbearing plantar fascia stretches to Achilles tendon stretching.24 While both groups reported significant improvements at eight weeks, there was greater pain relief in the patients who performed the plantar fascia stretches. In their study of sustained Achilles tendon stretching versus intermittent stretching, Porter and his co-authors concluded that it was more critical that patients were stretching daily and that the type of stretching was not important.25 There are currently no randomized control trials that compare the effectiveness of two different gastrocsoleus methods of stretching.
Can Night Splints Have An Impact?
Night splints are another treatment option that can be effective depending on patient adherence. The goal is to prevent plantarflexion of the ankle during sleep, allowing the plantar fascia to heal near or at its functional configuration. Batt and colleagues performed a randomized, controlled trial in which one group used night splints, heel pads, ibuprofen and gastrocsoleus stretching, and the other group received the same treatments without the night splint.26 The control group patients who were not responding after eight to 12 weeks subsequently crossed over to the night splint group, in which 72.7 percent were cured in 13 weeks.
When clinicians use night splints in combination with other treatment modalities like prefabricated orthotics, stretching and NSAIDs, they can be effective adjunctive treatment options.27,28
What You Should Know About Corticosteroid Injections
Corticosteroid injections are a common choice for treating plantar fasciitis. Like many of the other plantar fasciitis studies, most studies using corticosteroid injections used them in conjunction with other modalities. Despite the common use of corticosteroid injections, very few randomized, controlled trials exist to support their use versus placebo.
One trial compared prednisolone 25 mg and lidocaine to lidocaine (placebo) and found significant pain reduction after one month with the prednisolone group.29 Another study found no statistical difference between 25 mg of hydrocortisone and normal saline two months after treatment.30
Perhaps the most important study performed to date was by Ball and colleagues, who compared corticosteroid injection to placebo and ultrasound-guided injection to unguided injection.31 Researchers performed injections on 65 patients and used the visual analogue scale (VAS) to assess pain with follow-up assessments at six and 12 weeks. Twenty-two patients were randomized into the ultrasound-guided steroid injection group, 21 in the palpation guided placebo group and 22 were in the ultrasound-guided placebo injection group. There was statistical difference in VAS scores between the ultrasound-guided steroid group versus placebo and between the unguided steroid group versus placebo. There was no difference in VAS scores at six or 12 weeks between the ultrasound-guided and palpation-guided groups. Ball and co-authors did note decreased plantar fascia thickness in both steroid groups following injection.31
While Yucel and coworkers found significant improvement with corticosteroid injection, they found no statistical difference between ultrasound-guided, scintigraphy-guided or palpation-guided injections.32
Adverse effects of corticosteroids are well documented. Adverse effects of corticosteroid injections for plantar fasciitis include fat pad atrophy, plantar fascia rupture, local skin effects and steroid flare. Each clinician should also be well versed in dealing with any adverse event secondary to a corticosteroid injection.
Assessing The Use Of Orthotics
There may not be any greater source of controversy in podiatry and other health professions than the use of orthotics to treat foot pathology. Despite the controversy, podiatrists continue to use orthotics as a main component in the treatment of plantar fasciitis. Orthotic devices come in all shapes and sizes. Unfortunately, the “one size fits all” device is abundant on the market. Shoe stores, sporting goods stores, pharmacies and online stores carry an overwhelming supply of prefabricated inserts so the consumer doesn’t even begin to know where to start if he or she is advised to get an over-the-counter orthotic.
Even today, custom foot orthotics don’t have a uniform standard from profession to profession and lab to lab. Given the multiple devices and differences in manufacturing, it becomes difficult to perform studies that demonstrate the effectiveness of orthotics. Several studies demonstrate the effectiveness of custom foot orthotics for plantar fasciitis when clinicians use them in conjunction with other modalities and other studies show custom foot orthotics are no more effective than a prefabricated orthotic.12,33-36
The use of custom foot orthotics comes down to each clinician’s preference and skills in deciding to use these as treatment options. Some clinicians prefer a different treatment regimen in which they exclude the use of orthotics while others will cast or scan several patients a day for orthotics to address various pathologies. There is no high-level evidence to support the use of orthotics but as a profession, we know there are successful outcomes with custom foot orthotics.
Does PRP Offer Promise For Plantar Fasciitis?
Platelet-rich plasma (PRP) has gained notoriety over the past several years. It is not only one of the newer options available for treating plantar fasciitis but clinicians may also use PRP to treat tendinopathy, ulcers, and various osseous pathologies. Plasma taken from one’s own body contains numerous growth factors and recent reports on PRP have been favorable. In a prospective study, Kumar and colleagues found a 64 percent satisfaction rate with PRP injections for intractable plantar fasciitis while Aksahin and coworkers found similar relief when comparing corticosteroid injection to PRP.37,38 In another study of PRP for chronic plantar fasciitis, Ragab and his co-authors cited a decrease in pain from a 9.1 to 1.6 on the visual analogue scale and there was a 96 percent satisfaction rate. Post-injection ultrasonography identified a thinner plantar fascia with less signal intensity.
Currently, clinicians would just inject PRP once and not through a series of injections. While PRP offers a safe alternative to corticosteroid injections, the high cost and lack of insurance coverage are pitfalls for patients electing to have this procedure. While there is no high-level evidence on the efficacy of PRP for plantar fasciitis, the results of some of these recent studies appear promising.
While plantar fasciitis is likely one of the most treated conditions in our offices, there is no solid evidence of what is most effective and most treatment is based on how we were trained, or what has worked in our clinical practices. The realm of treatment is always expanding with several new methods available. While these modalities do seem promising, there are no concrete studies to support their effectiveness. The longer one is in practice, the likelier he or she is going to adhere to what he or she has always practiced, but it doesn’t hurt to step out of the box every once and a while and try something new.
Dr. Yakel is in private practice in Boulder, Colo. He is the Immediate Past President of the American Academy of Podiatric Sports Medicine, and is the team podiatrist for the Colorado Rapids of Major League Soccer.
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For further reading, see “Plantar Fasciitis: How To Maximize Outcomes With Conservative Therapy” in the May 2006 issue of Podiatry Today. For an enhanced online experience, check out Podiatry Today on your iPad or Android tablet.