Sharing practical pearls as well as insights from the literature and studies from their own institution, these authors offer new perspectives on first-line therapies for plantar fasciitis, and discuss emerging findings on the impact of osseous pathology, nerve pathology and obesity.
"Doc, I’m here today for pain in my heel. It’s so weird. It is worst in the morning when I first get out of bed. It gets a little better on my way to the bathroom. I Googled it. I think I have plantar fasciitis. So I did what the Internet said. I rest. I roll my foot on a water bottle. I purchased some inserts at the local drug store. I wear “good shoes.” I try the stretching but I do not like the stretching that much because it hurts. Essential oils are not working. I was thinking about acupuncture but the needles freak me out. I do not get it. It has been like this for six months and it is not getting any better.”
We hear this story multiple times per day at all of our offices. Fifteen years ago, the story might have been different as Google likely would not have been part of the patient’s history. The Internet has given everyone a voice.
Unfortunately, not all of those voices contain solid medical advice. Most patients Google something about their foot and/or ankle condition prior to coming to the office. In our practice, patients with plantar fasciitis typically use treatment protocols that they found on the Internet before making an initial appointment. Treatments in these “protocols” range from over-the-counter orthotics, icing, stretching and changing shoes to essential oils and meditation. When patients are in the office, it is our job to correct anything that is not working and provide care above and beyond what they can find on Google.
Plantar fascia heel pain is one of the most common chief complaints of patients presenting to foot and ankle specialists. Patient visits for this problem account for over one million patient visits each year and account for 192 to 376 million health-care dollars.1-3 With Medicare implementing a bundled payment structure for total hip and total knee arthroplasty, it is only a matter of time before this change occurs for foot and ankle problems.
Therefore, it is important that we start to rethink some of our current treatment algorithms in light of current research and to account for cost-effectiveness.
Reassessing The Timing Of First-Line Therapies
Non-surgical treatment for plantar fasciitis tends to be successful for the majority of patients. The 2010 American College of Foot and Ankle Surgeons (ACFAS) Clinical Practice Guidelines (CPG) suggest that a ‘treatment ladder’ may be less appropriate and customizing treatments to patients’ activity, lifestyle, job requirements and chronicity of symptoms may be more appropriate.4
To do this, the physician must have a conversation with the patient about his or her symptoms as well as his or her day-to-day life. Prescribing custom orthotics, for example, may not be appropriate if the patient’s daily shoe gear will not accommodate a custom device. Similarly, prescribing physical therapy three days a week for a patient who does not have adequate means of transportation would be similarly problematic.
It is interesting that the consensus panel for the 2018 ACFAS Heel Pain Clinical Consensus Statement chose chronicity as a way to help identify appropriate treatment plans.5 The document states that acute plantar fasciitis is heel pain that has been present for four to six weeks. Subacute plantar fasciitis is present for six to 12 weeks. Chronic plantar fasciitis is present for greater than three months with refractory/recalcitrant plantar fasciitis being a subdivision of the chronic category. Plantar fasciitis that is refractory/recalcitrant is plantar fasciitis that has not improved with appropriate intervention for more than six months and is thought to be more difficult to successfully treat.5
Today, patients have higher deductibles and higher in-office copayments and coinsurances. Due to this increased awareness of expense, patients are typically looking for care that will get them better in a cost-effective manner. This has led the Weil Foot and Ankle Institute, a referral center for recalcitrant heel pain, to offer more advanced treatments sooner.
For example, clinicians traditionally offered extracorporeal shock wave therapy (ESWT) when a patient had failed multiple modalities of treatment but did not want a more invasive procedure. We are now offering ESWT to patients who have subacute plantar fasciitis instead of waiting until they have chronic plantar fasciitis. If a patient has a significant deformity (i.e. cavus or planus) or is an active individual with considerable mechanical load issues (i.e. running), it may be more appropriate to get him or her into a custom orthotic rather than waiting for failure of an over-the-counter or off-the-shelf device.
At our institute, chronic heel pain is frequently multifactorial or there is other pathology present. This pathology can be related to bone, nerve or soft tissue. During our initial visit with the patient, we ask questions related to a broader spectrum of pathology to ensure that we are not missing the “something else” that is preventing the patient from healing.
A Closer Look At Osseous Pathology Associated With Heel Pain And The Role Of Subchondral Stabilization
The plantar fascia attaches to the calcaneus proximally. With this in mind, there has been an evolution of opinions regarding the ‘heel spur’ and the presence or absence of association with plantar fascia symptoms and response to treatment.
Over time, there have been some scattered reports of magnetic resonance imaging (MRI)-identified bone marrow edema in the calcaneus associated with plantar fasciitis and/or Achilles tendonitis.6 This finding has been amorphous and a bit of an enigma as the calcaneus does not necessarily have a discrete fracture line with decreased signal on the T1 imaging but there is, unquestionably, an increased signal on the T2 and/or STIR image. The long-standing observational finding at our institution is that this patient will likely take longer to respond to care. More recently, however, several members of our institution are more assertively managing bone marrow edema in patients with plantar fasciitis by adding a subchondral stabilization of the calcaneus to operative care.
Subchondral stabilization of the calcaneus is an adjunctive procedure to plantar fascia release or tarsal tunnel release. During this procedure, one draws bone marrow edema from the lateral aspect of the calcaneus and mixes it with a calcium phosphate mineral compound (AccuFill® Bone Substitute Material, Zimmer Biomet or AlloSync™ gel, Arthrex). The surgeon then uses fluoroscopy for triangulation before introducing a trochar into the region of bone marrow edema already identified by MRI. The surgeon subsequently injects the bone marrow aspirate and calcium phosphate mineral compound into the bone. One would leave the system closed for eight minutes while continuing with the rest of the surgical procedures. The postoperative course for subchondral stabilization is largely dictated by concomitant procedures.
A recent review of patients in a yet unpublished study at our institution utilized a validated patient reported outcome measure (Foot and Ankle Outcome Score (FAOS)) to measure improvement in patients who had subchondral stabilization of the calcaneus as part of their operative care. The patients, who were all female with an average age of 52, experienced statistically significant improvements in foot-specific quality of life (average/mean change of 32.9). This data further suggested trends for increased performance in activities of daily living (ADLs) with an average/mean change of 12.3 as well as sports and recreation with an average/mean change of 15.0. All patients had less pain post-operatively, returned to their desired level of physical activity and, by the final follow up visit, stated that they would undergo this procedure again as they were very satisfied with their care and recovery.
Patients with bone marrow edema may also benefit from a preliminary bone health workup. Our practice is located in a region where vitamin D deficiency is exceptionally common as we are in the northern part of the United States. Although bone health is most optimally managed by a primary care doctor or a rheumatologist, starting that process by drawing a vitamin D level is assertive, solid medical care that may benefit the patient in more ways than just bone health as vitamin D deficiency is also related to tendon health, fibromyalgia, depression and cancer.7-10
Addressing Nerve Pathology And Its Impact On Heel Pain
Tarsal tunnel syndrome is frequently associated with plantar fascia, heel pain. Podiatrists typically suspect this diagnosis after multiple treatment modalities have failed. Commonly cited causes of neurogenic heel pain include space-occupying masses (i.e. varicose veins), accessory muscles, masses and tumors.1, 2-16 Other considerations in this differential diagnosis would include entrapment neuropathies of the tibial nerve, the medial and/or lateral plantar nerves, the medial calcaneal nerve or Baxter’s nerve. The presence of a more proximal cause of the pain in the foot is rarely discussed but may be part of foot-related nerve pathology. Possible etiologies may include radiculopathy, spinal stenosis, diffuse idiopathic skeletal hyperostosis (DISH), facet arthrosis, scoliosis, ankylosing spondylitis or degenerative disc disease.
Some physicians feel that entrapment neuropathies such as tarsal tunnel syndrome may not exist.18,19 Diagnosis of tarsal tunnel and other lower extremity nerve entrapments can be complicated as the nerve conduction velocity/electromyography (NCV/EMG) studies are reportedly highly subjective and difficult to reproduce between technicians.18,19
Treatment for tarsal tunnel syndrome may include medication, nerve mobilization, mechanical control of the foot and/or surgical release of the entrapped nerve (open or endoscopic).20-22 Outcomes after tarsal tunnel nerve release are variable with a high rate of dissatisfaction.22-24 The current literature on tarsal tunnel syndrome suggests that patients improve for up to a year after surgery but then have a regression of pain and associated symptoms.25 While there is currently little explanation of this phenomenon in the literature, some authors have postulated that patients treated earlier with surgery do better and that fibrosis of the nerve may be the cause of suboptimal results.25,26
In a currently unpublished study, our institution did an analysis of patients, with tarsal tunnel syndrome in order to better understand this pathology. Our goals were identifying common presenting symptoms and analyzing NCV/EMG findings (with a single examiner, bilateral lower extremity and bilateral paraspinal NCV/EMG studies).
The study involved 108 patients (30 men, 78 women) with an average age of 53 years old and an average body mass index (BMI) of 28.6. The vast majority of patients were non-smokers (84 percent) and non-drinkers (85 percent). Seventy-four percent of patients had a history of post-static dyskinesia, which is classically associated with plantar fasciitis. Less than half of the study patient population had documented pain that was worse at rest, pain at night while lying in bed, pain that would wake one out of a solid sleep and a previous history of lower back pain.
There was one universal history aspect among patients with tarsal tunnel syndrome. Their pain was worse while standing and walking (87.1 percent of patients). Patients with tarsal tunnel syndrome did not experience symptom relief with many common heel pain modalities (stretching, orthotics, corticosteroid injections, physical therapy and night splints).
The physical exam of patients with tarsal tunnel presented difficulty in diagnosis as 78.7 percent of patients had pain to palpation of the medical tubercle of the calcaneus and 71.3 percent of patients had equinus. In the study population, 83.8 percent of the patients had a rectus foot structure. However, 78.7 percent of patients had a positive Tinel’s sign on the symptomatic side. The Tinel’s sign finding provided an important piece of information for the patients with tarsal tunnel syndrome. Findings from the NCV/EMG study revealed that 106 out of 108 patients had an EMG positive for a tarsal tunnel on the symptomatic side and 88 out of 108 patients had an EMG consistent with a lumbosacral radiculopathy. This was primarily a unilateral or bilateral L5-S1 radiculopathy, but there were instances of multilevel spinal involvement.
These findings are inconsistent with previous literature, particularly in the sense that so many of our patients had lower back pathology and pain presenting as recalcitrant plantar fascia heel pain. More research is clearly required in the arena of nerve pain to enhance our current understanding.
What About The Role Of Obesity With Heel Pain?
Body weight, particularly obesity, is a factor that may change the course of treatment for certain patients with heel pain. A previous, currently unpublished study at our institution looked at medical records for all patients who presented to our clinic with a diagnosis of plantar fasciitis between 2002 and 2011. Researchers utilized an age-, gender- and year of visit-matched control group of patients who presented to the clinic for foot pain that was not plantar fasciitis (ankle sprains, metatarsal fractures, toe fractures, metatarsalgia and neuromas). The study authors calculated the body mass index (BMI) from height and weight data for all patients. Then the researchers compared the plantar fasciitis and control group patients for differences in age and BMI. The study authors also analyzed the plantar fasciitis group to assess patients who failed conservative therapy and progressed to advanced therapy/ESWT or surgical therapy.
In the study, which included 4,954 patients, the average age was 49.6 in the plantar fasciitis group and 51.9 in the control group. The average BMI was 28.5 in the plantar fasciitis group and 24.9 in the control group. Employing odds ratios that used normal BMI as a reference category, the study authors found that patients who were overweight or obese were 2.2 to 3.7 times more likely to present with plantar fasciitis than with other pathology. They also noted that higher BMI increased the risk of requiring advanced or surgical therapy for plantar fasciitis.
Although obesity complicates an already complicated picture, there are many reasons this may be the case. Patients who are overweight or obese may be more likely to have decreased ankle joint range of motion. This could be secondary to glycosylation of tendons and ligaments, or accumulation of subcutaneous fat in the anterior ankle joint. Patients who are overweight or obese may also have more force and pressure being transmitted through the plantar fascia during walking. The increases in the force and pressure may stimulate the free and encapsulated nerve endings (i.e. Pacini and Ruffini corpuscles) at the junction of the plantar fascia, and the fascia of origin of the abductor digiti minimi muscle.11,12
What does all of this mean and how does it translate into clinical practice? Although the treatment guidelines for heel pain have been well established, it may be time to take a step back and reevaluate our approach to this pathology. There is a patient proximal to the ankle joint and the individual characteristics and/or requirements of this patient may be part of the problem. It may be time to take a minute or two to speak with patients about their life, their pain and more assertive care as you rethink your algorithm for treating plantar fascia heel pain.
Dr. Klein is an Associate and the Associate Director of Research of the Weil Foot and Ankle Institute. She is a Clinical Instructor at the William M. Scholl College of Podiatric Medicine at the Rosalind Franklin University of Medicine and Science. Dr. Klein is a Fellow of the American College of Foot and Ankle Surgeons, and a Diplomate of the American Board of Podiatric Medicine.
Dr. Weil is the CEO of the Weil Foot and Ankle Institute. He has previously served as Fellowship Director with the Weil Foot and Ankle Institute as well as the Editor of Foot and Ankle Specialist. He has lectured in five continents, 15 countries and 37 U.S. states. Dr. Weil has published over 70 articles, book chapters and peer-reviewed papers on the care of the foot and ankle. He is the Founder of Foot and Ankle Business Innovations, and a founding member of GLW Medical Innovations.
Dr. Fleischer is the Director of Research at the Weil Foot and Ankle Institute, and an Associate Professor at the William M Scholl College of Podiatric Medicine at the Rosalind Franklin University of Medicine and Science. He is a Fellow of the American College of Foot and Ankle Surgeons.
1. Riddle D, Schappert S. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int. 2004;25(5):303-310.
2. Thomas M, Roddy E, Zhang W, Menz H, Hanna M, Peat G. The population prevalence of foot and ankle pain in middle and old age: a systematic review. Pain. 2011;152(12):2870-2880.
3. Tong K, Funa J. Economic burden of plantar fasciitis treatment in the United States. Am J Orthop. 2010;39(5):227-231.
4. Thomas J, Christensen J, Kravitz S, et al. The diagnosis and treatment of heel pain: clinical practice guidelines - revision 2010. J Foot Ankle Surg. 2010;49(3 Suppl):S1-19.
5. Schneider H, Baca J, Carpenter B, Dayton P, Fleischer A, Sachs B. American College of Foot and Ankle Surgeons clinical consensus statement: diagnosis and treatment of adult acquired infracalcaneal heel pain. J Foot Ankle Surg. 2018;57(2);370-381.
6. Draghi F, Gitto S, Bortolotto C, Draghi A, Belometti GO. Imaging of plantar fascial disorders: findings on plain film radiolography, ultrasound and magnetic resonance imaging. Insights Imaging. 2017;8(1):69-78.
7. Min K, Lee J, Kim M, et al. Restoration of celluliar proliferation and characteristics of human tenocytes by Vitamin D. J Orthop Res. 2019;37(10):2241-2248.
8. Hightower J, Dalessandra K, Pope K, Hernandez G. Low 25-hydroxyvitamin D and myofascial pain: association of cancer, colon polyps and tendon rupture. J Am Coll Nut. 2017;36(6):455-461.
9. Karras S, Rapti E, Matsoukas S, Kotsa K. Vitamin D in fibromyalgia: a causative or confounding biological interplay? Nutrients. 2016;8(6):E343.
10. Schaad K, Bukhari A, Brooks D, Bocher J, Barringer N. The relationship between vitamin D status and depression in a tactical athlete population. J Int Soc Sports Nutr. 2019;16(1):40.
11. Atico M, Stevanato G, Ionta B, et al. Venous compression of the nerves in the lower limbs. Br J Neurosurg. 2012;26(3):386-391.
12. Pasku D, Karampekios S, Kontakis G, Katonis P. Varicosities as an etiology of tarsal tunnel syndrome and the significance of Tinel’s sign: report of two cases in young men and reivew of the literature. J Am Podiatr Med Assoc. 2009;99(2):144-147.
13. Lin D, Williams C, Zaw H. A rare case of accessory flexor hallucis longus causing tarsal tunnel syndrome. Foot Ankle Surg. 2014;20(3):e37-9.
14. Saar W, Bell J. Accessory flexor digitorum longus presenting as tarsal tunnel syndrome: a case report. Foot Ankle Spec. 2011;4(6):379-382.
15. Mirick A, Bornstein G, Bancroft L. Radiologic case study. neurofibroma causing tarsal tunnel syndrome. Orthopedics. 2013;36(2):154-157.
16. Hallahan K, Vinokur J, Demski S, Faulkner-Jones B, Giuini J. Tarsal tunnel syndrome secondary to schwannoma of the posterior tibial nerve. J Foot Ankle Surg. 2014;53(1):79-82.
17. Hamoui M, Largey A, Ali M, et al. Angioleiomyoma in the ankle mimicking tarsal tunnel syndrome: a case report and review of the literature. J Foot Ankle Surg. 2010;49(4):398.
18. Campbell W, Landau M. Controversial entrapment neuropathies. Neurosurg Clin N Am. 2008;19(4):597-608.
19. Alshami A, Souvlis T. Coppieters M. A review of plantar heel pain of neural origin: differential diagnosis and management. Man Ther. 2008;13(2):103-111.
20. Kaylak Y, Uygur F. Effects of nerve mobilizataion exercise as an adjunct to the conservative treatment for patients with tarsal tunnel syndrome. J Manipulative Physiol Ther. 2011;34(7):441-448.
21. Reichert P, Zimmer K, Wnukiewicz W, Kulinski S, Mazuerk P, Gosk J. Results of surgical treatment of tarsal tunnel syndorme. Foot Ankle Surg. 2015;21(1):26-29.
22. Gkotsoulias E, Simonson D, Roukis T. Outcomes and safety of endoscopic tarsal tunnel decompression: a systematic review. Foot Ankle Spec. 2014;7(1):57-60.
23. Singh G, Kumar VP. Neuroanatomical basis for the tarsal tunnel syndrome. Foot Ankle Int. 2012;33(6):513-518.
24. Yalcinkaya M, Ozer U, Yalcin M, Bagatur A. Neurolysis for failed tarsal tunnel surgery. J Foot Ankle Surg. 2014;53(6):794-798.
25. Ahmad M, Tsang K, Mackenney P, Adedapo A.Tarsal tunnel syndrome: a literature review. J Foot Ankle Surg. 2014;18(3);149-152.
26. Gould J. Recurrent tarsal tunnel syndrome. Foot Ankle Clin. 2014;19(3):451-467.
27. Benjamin M. The fascia of the limbs and back. J Anat. 2009;214(1):1-18.
28. Stecco C, Corradin M, Macchi V et al. Plantar fascia anatomy and its relationship with the achilles tendon and paratenon. J Anat. 2013;223(6):665-676.