Refining The Treatment Algorithm For Plantar Fasciitis And Plantar Fasciosis

Bob Baravarian, DPM

The more I practice the care of foot and ankle ailments, the more I realize the importance of keeping an open mind and recognizing that no one treatment is perfect for all patients. As far as plantar fasciitis is concerned, I have come to realize that a treatment algorithm is important to set up for your practice.

   Over the past two years, our team of doctors has treated more than 2,000 patients with plantar fasciitis. This has allowed us to try multiple conservative and surgical options. We have concluded that certain conservative options seem to make significant improvements.

   If I have one conservative option to offer patients on a consistent basis that has the most impact in their recovery from heel pain, it would be Achilles and gastrocnemius stretching. We usually will ask patients to perform both calf and Achilles stretches for five minutes three times per day. We teach the patients these stretches on the initial visit.

   Second in line for conservative options is a close tie between physical therapy and orthotic use. We have found that the combination of stretching, physical therapy and orthotic use has helped over 80 percent of our patients recover without further need for care. The average time to recovery has been less than two months and no further treatment has been necessary in over 90 percent of this initial group.

   Then there are the remaining 20 percent of patients who have either severe initial pain with only a short history or chronic heel pain that has been present between six months and a year.

   The treatment algorithm differs for those with a short history of pain. Although there is some fluidity in the treatment options, patients with a brief history of heel pain who have not responded to orthotics and/or physical therapy and/or stretching often receive continued physical therapy in combination with steroid injection under ultrasound guidance.

   I give a total of two injections and these are spaced apart by two weeks to a month depending on what is necessary. What is amazing is the fact that many of the patients with a brief history of heel pain respond exceptionally well to a steroid injection and experience improvement after one to two injections. There is an inflammatory involvement. The steroid injection relieves the inflammation and allows the fascia to begin the healing process.

Distinguishing Between Plantar Fasciitis And Chronic Plantar Fasciosis

The second group of patients, those with chronic heel pain for more than six months, is by far the most difficult to treat. Often, they have had pain for over six months prior to presenting to us. I believe this results in chronic plantar fasciosis and not plantar fasciitis. The difference in the two terms is subtle but definite.

   In the aforementioned patients with plantar fasciitis, they have an inflammatory problem that responds well to anti-inflammation treatments. In the chronic plantar fasciosis group, there is a lack of inflammation and an exceptional amount of scar tissue and fibrosis. The body’s response to the chronic scar tissue and fibrosis is to give up and decrease the healing blood supply necessary for resolution.

   So how do we treat this last 10 percent of patients? We have found that some patients will feel better with steroid injection therapy but this is short-lived as there is no inflammatory problem.

   Therefore, when the steroid leaves the patient’s system, the problem returns with no improvement. In such patients, we have found that irritation of the tissue causes an increase in blood supply, breakup of the scar tissue and a fresh new micro-injury to the tissue.

   This allows us to take the chronic plantar fasciosis and transform the problem to acute plantar fasciitis. We can then begin to treat the transformed fasciosis as an acute plantar fasciitis.

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