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Keys To Treating Plantar Fasciitis In Runners

Treating plantar fasciitis in this patient population can be particularly challenging. Accordingly, this author offers insights on initial conservative care, weighs in on the merits of orthotics, and reviews pertinent issues in addressing recalcitrant plantar fasciitis.

   Treating plantar fasciitis is challenging for any patient but it is much more difficult in the running population due mainly to the runner not wanting to take any time off from running. A retrospective study of 2,002 running injuries found that 157 (7.8 percent) of the injuries were plantar fasciitis.1 Another study found there are more than 1 million patient visits per year to medical professionals for heel pain.2

   When it comes to treating heel pain, the patient history is extremely important in making a proper diagnosis. The vast majority of the time plantar fasciitis presents with post-static dyskinesia. In the early stages of this injury, a runner will be able to continue normal running as the pain will subside after the initial steps in the morning and at the start of a run. As the disease process progresses, the pain will increase as will the length of time it takes to subside. Gait compensation will begin to lead to pain in other areas of the foot and legs.

   The injury typically occurs from overuse with an insidious onset. Patients often do not seek treatment until the injury becomes more chronic in nature. The majority of the time, plantar fasciitis resolves with conservative treatment with studies showing relief of symptoms between 46 and 100 percent.3-6 Plantar fasciitis definitely responds better to early intervention.

   Typically, athletes do not have to completely refrain from training if treatment starts early enough in the disease process. In general, if there is no limping, a runner can continue to train while treatment occurs.

   A hallmark of plantar fasciitis is pain at the plantar medial calcaneal tubercle. The plantar fascia begins in the sulcus of the foot and runs along the plantar surface of the foot with three insertions in the plantar calcaneus: medially, centrally and laterally. Bøjsen-Möllerf and Flagstadke described the structure as being triangular with the base proximal.7

   Always look at the running shoes the patients are currently using. Make sure patients are training in the proper shoes as running shoes are divided into neutral or cushioned. Also check for stability and motion control. It is rare that a competitive runner would need a motion control shoe. Most stability shoes will provide enough pronation control.

   For excellent running shoe recommendations, refer to the American Academy of Podiatric Sports Medicine (AAPSM) Web site at http://www.aapsm.org/runshoe.html

Pertinent Insights On Initial Treatment Measures

   Amol Saxena, DPM, treats a high volume of runners including Olympic medalists at his practice in Palo Alto, Calif.

    “The most important aspect of treatment is that people, patients and providers all have to realize plantar fasciitis is a condition that often cannot be cured but controlled,” explains Dr. Saxena. He adds that many patients are controlling their plantar fasciitis with orthoses.

    “Some runners are controlling it by running less, getting massages or injections. Even the runners I operate on still usually do something (other than nothing) to control it,” notes Dr. Saxena.

   If one initiates treatment within weeks of the onset of symptoms, then the simple conservative measures have a greater impact. There are no exact protocols of conservative treatment that universally eliminate all the symptoms.

   Initial treatment should focus on stretching the gastroc-soleus complex for five minutes three times a day by performing a simple wall stretch. The fascia does not have any elastic fibers and attempting to stretch the fascia by hanging off a step or putting one’s toes up against the wall may actually prolong the duration of the injury. However, DiGiovanni and colleagues presented an alternative method of non-weightbearing specific stretching of the fascia using the hand to stretch the foot.8 They found that this worked better than the wall stretching.

   Ice is the best anti-inflammatory and patients can best use it by freezing water in a round smooth plastic bottle and rolling the foot over the bottle for at least 20 minutes a day. Physicians should counsel patients to avoid going barefoot and emphasize that they wear shoes with good arch support. These measures are important in the initial treatment phase.

   Taping can be very effective at reducing symptoms and also may aid in the diagnosis. When it comes to plantar fasciitis pain, patients achieve symptom relief the majority of the time through taping consisting of a low-Dye with a Campbell’s rest strap over the top of the low-Dye. Instruct patients on how to perform the taping themselves before activity.

   Taping may also serve to reinforce the diagnosis of plantar fasciitis. Richard Blake, DPM, a Past President of the AAPSM, used to state in his plantar fascia lectures that patients with plantar fasciitis almost always feel better taped. Successful treatment with taping can also be a good indicator of future success with orthotic devices.

   Night splints are another treatment that one can use during the initial treatment phase. Typically, they help to alleviate some of the morning pain. The Strassburg sock is an excellent choice for a splint since it is less bulky than plastic splints and patients can easily adjust it for more or less tension. Instruct patients that they do not need to feel a stretch in their calf muscles or else they will not tolerate the splint.

   Corticosteroid injection can be very effective at reducing symptoms but it is not without risks. Plantar fascia ruptures have been associated with injections and multiple injections in the same area can lead to fat pad atrophy.9-11 The associated ruptures could possibly be related to the dose and type of steroid. Higher doses of insoluble steroids may have a more deleterious effect.

   Acevedo and Beskin reported a rupture of the fascia in 10 percent of their patients who received injections for plantar fasciitis with 40 mg/mL of triamcinalone acetate.9 I prefer a mixture of 1.0 cc of 0.25% marcaine, 4 mg of dexamethasone phosphate and 5 mg of triamcinalone acetate, and have had fewer than 10 post-injection fascial ruptures in 18 years of practice.

How Effective Are Arch Supports And Orthoses?

   Also consider over-the-counter arch supports for the initial treatment phase. There are many different types of OTC inserts that are typically made of a flexible or semi-flexible material. Many physicians use OTC inserts as a first-line treatment and this may also be a future predictor of successful implementation of custom orthotic devices.

   Using the proper prescription is of utmost importance when one adds custom orthotic devices to the treatment plan. Factors to consider include the activity level, the shoes the patient will be wearing, the previous custom device experience of the patient and the patient’s foot type.

   There are no absolute right or wrong devices but a good general rule of thumb is that cavus feet get a more flexible device while pes planus foot types require a more semi-rigid device. It is often necessary to add forefoot posting for a runner with EVA to the sulcus in order to provide proper support throughout the entire propulsive phase of gait.

   If patients have a sedentary occupation, then it is not necessary to have them wear the devices during normal daily activities. Wearing custom orthotic devices all day in every pair of shoes is only necessary if daily activities are aggravating the heel pain. Once the pain has subsided, it is better for the patient to not always have the devices in their shoes because they may serve to weaken the intrinsic musculature.

When Patients Have Recalcitrant Plantar Fasciitis

   One should utilize extracorporeal shockwave therapy (ESWT) as a last resort before considering surgical management if not beforehand. Shockwave therapy is ultimately purported to work by improving the vascularization to the injured area. The treatment induces trauma to the area and during the repair process, new blood vessels develop to deliver nutrients to the area and heal the tissue. There are virtually no long lasting negative effects from the treatment with cost being the main deterrent.

   There are both high-energy and low-energy machines. High-energy machines use a protocol of one treatment but this requires local anesthesia. The low-energy devices do not require local anesthesia and the protocol requires three treatments that are usually spaced one week apart. The medical literature mainly finds long-term success rates of over 70 percent but some studies have found that the treatment is no more effective than placebo.12-17

   Cryotherapy and Topaz (Arthrocare) are two other relatively new treatments for plantar fasciitis that require more long-term study before they become part of the typical protocol. One may consider these modalities for patients with recalcitrant cases of plantar fasciitis.

   The real challenge of plantar fasciitis treatment begins if all the initial conservative treatment fails. It is critical at this juncture to reassess the patient’s symptoms. Is post-static dyskinesia still present? Is the pain localized to the plantar medial calcaneal tubercle? Does the pain subside at all with activity?

How To Detect And Treat Plantar Fascia Ruptures

   If the symptoms begin with an acute onset of pain, then the patient may have ruptured the fascia. Rupture of the fascia may follow chronic long-term plantar fasciitis or be a sequella of treatment.18

   Most often, the patient will relate feeling a pop or sharp pain at the insertion of the medial or middle band. Patients often have bruising in the arch associated with the rupture. A correlation of patient symptoms with the bruising is more than enough evidence of rupture but magnetic resonance imaging (MRI) provides more conclusive evidence.

   The treatment of a rupture differs greatly from the treatment of plantar fasciitis. Initial treatment should aim at reducing pain and inflammation through the use of non-weightbearing, a CAM walker, ice and NSAIDs/narcotics as needed.

   Within one to three weeks, the patient should be able to progress to full weightbearing in a boot. After another one to three weeks, the patient may progress out of the boot to full weightbearing.

   Physical therapy can start very early in the process. This should initially focus on helping to relieve symptoms through the use of electrical stimulation, pulsed ultrasound, gentle massage and gentle stretching. Physical therapy can then progress to strengthening of the foot and leg to help the patient transition out of the boot and back to full activity.

   Saxena and co-workers found an average return to activity of nine weeks for athletes following plantar fascia rupture.18

Key Considerations With Surgical Treatment

   If all conservative care has failed and treatment has been ongoing for at least six months, then one can consider surgery. Richard Bouché, DPM, a Past President of AAPSM, states “we recommend surgery as a ‘last resort’ when conservative care has been exhausted ad nauseam. The athlete needs to realize that with the surgery, (he or she) still may not be able to perform and return to their sport.”

   Dr. Bouché acknowledges the topic of surgery for plantar fasciitis is controversial and it is difficult to select an optimal procedure. When it comes to performing surgery for this specific entity, he prefers a plantar medial oblique incision just anterior to the medial tubercle and consistent with the skin tension lines.

   Initially, Dr. Bouché releases the medial fascia and a portion of the abductor fascia, which is usually bowstrung. He believes this decompresses the first branch of the lateral plantar nerve. He then isolates and performs a plantar fascial “lengthening” and removes a spur if one is present.

   The critical part is keeping the patient non-weightbearing for six weeks after the surgery, according to Dr. Bouché. Subsequently, he says the patient should spend an additional four weeks in a walking boot, adding that this allows the released plantar fascia to heal back together in a lengthened position.

   Dr. Bouché does not recommend excising the fascia and does not like partial fascial releases in athletes as he does not feel they are effective. He has seen many patients develop lateral fascial symptoms after the medial/central fascia is released.

   There are many different approaches to surgical management for plantar fasciitis. I believe it is best to choose the procedure that works best in your hands.

Dr. Fullem is a Fellow of the American College of Foot and Ankle Surgeons, and the American Academy of Podiatric Sports Medicine. He is board-certified in foot and ankle surgery by the American Board of Podiatric Surgery. Dr. Fullem is also certified in foot orthopedics by the American Board of Podiatric Orthopedics and Primary Podiatric Medicine.

For further reading, see “How To Detect And Treat Running Injuries” in the May 2005 issue of Podiatry Today, “Recommending Athletic Footwear For Runners” in the June 2008 issue and “A Guide To Conservative Treatment For Heel Pain” in the November 2003 issue.

References:

1. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo B. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002; 36(2):95-101. 2. Riddle DL, Schappert SM. 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):303-10. 3. Wolgin M, Cook C, Graham C, et al. Conservative treatment of plantar heel pain: long-term follow-up. Foot Ankle Int 1994; 15(3):97-102. 4. O’Brien D, Martin WJ. A retrospective analysis of heel pain. JAPMA 1985; 75(8):416-18. 5. Scherer PR. Biomechanics Graduate Research Group for 1988: Heel spur syndrome: pathomechanics and nonsurgical treatment. JAPMA 1991; 81(2):68-72. 6. Lynch DM, Goforth WP, Martin JE, et al. Conservative treatment of plantar fasciitis: a prospective study. JAPMA 1998; 88(8):375-80. 7. Bøjsen-Möllerf F, Flagstadke KE. Plantar aponeurosis and internal architecture of the ball of the foot. J Anat 1976; 121(Pt 3):599-611. 8. DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain: a prospective, randomized study. J Bone Joint Surg Am 2003; 85A(7):1270-7. 9. Acevedo JI, Beskin JL. Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int 1998; Feb; 19(2):91-7. 10. Sellman JR. Plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int 1994; 15(7):376-81. 11. Leach R, Jones R, Silva T. Rupture of the plantar fascia in athletes. J Bone Joint Surg Am 1978; 60(4):537–539. 12. Chuckpaiwong B, Berkson EM, Theodore GH. Extracorporeal shock wave for chronic proximal plantar fasciitis: 225 patients with results and outcome predictors. J Foot Ankle Surg 2009 Mar-Apr; 48(2):148-55. 13. Marks W, Jackiewicz A, Witkowski Z, Kot J, Deja W, Lasek J. Extracorporeal shock-wave therapy (ESWT) with a new-generation pneumatic device in the treatment of heel pain. A double blind randomised controlled trial. Acta Orthop Belg 2008 Feb; 74(1):98-101. 14. Rompe JD, Meurer A, Nafe B, Hofmann A, Gerdesmeyer L. Repetitive low-energy shock wave application without local anesthesia is more efficient than repetitive low-energy shock wave application with local anesthesia in the treatment of chronic plantar fasciitis. J Orthop Res 2005 Jul; 23(4):931-41. 15. Gerdesmeyer L, Frey C, Vester J, et al. Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis: results of a confirmatory randomized placebo-controlled multicenter study. Am J Sports Med 2008 Nov; 36(11):2100-9. 16. Gollwitzer H, Diehl P, von Korff A, Rahlfs VW, Gerdesmeyer L.Extracorporeal shock wave therapy for chronic painful heel syndrome: a prospective, double blind, randomized trial assessing the efficacy of a new electromagnetic shock wave device. J Foot Ankle Surg 2007 Sep-Oct; 46(5):348-57. 17. Ho C. Extracorporeal shock wave treatment for chronic plantar fasciitis (heel pain). Issues Emerg Health Technol 2007 Jan; 96(1):1-4. 18. Saxena A, Fullem B. Plantar fascia ruptures in athletes. Am J Sports Med 2004 Apr-May; 32(3):662-5. Additional References 19. Pontious J, Flanigan KP, Hillstrom HJ. Role of the plantar fascia in digital stabilization. A case report. J Am Podiatr Med Assoc 1996; 86(1):43-47. 20. Vohra PK, Kincaid BR, Japour CJ, Sobel E. Ultrasonographic evaluation of plantar fascia bands: a retrospective study of 211 symptomatic feet. J Am Podiatr Med Assoc 2002; 92(8):444-449. 21. Berkowitz JF, Kier R, Rudicel S. Plantar fasciitis: MR imaging. Radiology 1991 Jun; 179(3):665-7.

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Brian Fullem, DPM, FACFAS

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Great Article! I love that you say that surgery is the last option. So many docs keep pushing more and more surgeries when they are not needed. I will be printing out this article and giving it to one of my runner friends. Nathan Tulsa Podiatrist
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