A Guide To Conservative Care For Plantar Heel Pain

Jamie Yakel, DPM

   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.

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