A Guide To Conservative Care For Plantar Fasciitis

Given that conservative care is effective for plantar fasciitis most of the time, this author explores the efficacy of conservative modalities such as stretching, extracorporeal shockwave and corticosteroids, and notes differential diagnoses to consider if conservative treatment fails.

There are more than 3 million doctor visits per year by people with heel pain. The majority of these cases are plantar fasciitis and the medical literature typically reveals that up to 90 percent of the time, heel pain resolves with conservative treatment.¹

The classic symptoms of plantar fasciitis include more pain with first steps in the morning and first steps after sitting. This is also known as post-static dyskinesia. The onset is typically insidious and the majority of the time, the symptoms will progress unless treatment begins. It is very important to ascertain the nature of the pain and symptoms in order to make the proper diagnosis. If the patient is an athlete or very active, and he or she continues to work out in the presence of plantar fasciitis, then compensatory injuries and pain may also be present when the patient presents to your office. One must be able to distinguish the injuries that compensation causes and decide if the other injured areas will resolve with successful treatment of the plantar fasciitis or if treatment is necessary of the other affected areas.

One should consider the anatomy of the plantar fascia when planning treatment. The plantar fascia is essentially a ligament with no elastic properties. Stretching has always been a mainstay of treatment but what exactly are we trying to stretch? Keep in mind that since the fascia does not have any elastic fibers, it does not make a lot of sense to try to feel too much of a stretch at the fascial attachment. In fact, I would argue that trying to stretch the fascial attachment directly can aggravate the symptoms.

Radiographs are an important part of the initial treatment plan to rule out other possible causes of heel pain. The presence of a plantar calcaneal spur should not change the treatment plan at all and even in recalcitrant cases that require surgery, one should leave the spur alone the majority of the time as it has either little or nothing to do with causing plantar fasciitis or most heel pain. Diagnostic ultrasound, if available, is an excellent tool to try to rule out a tear of the fascia. One can also use diagnostic ultrasound to visualize the thickness of the fascia as the plantar fascia will thicken beyond its normal 2 mm when fasciitis is present.

Key Insights On The Efficacy Of Stretching, Taping And Proper Shoes

DiGiovanni and colleagues published two studies that propose non-weightbearing stretching of the fascia along with massage of the area as effective parts of the treatment plan.^2,3 This method is preferable to applying body weight and force on the fascia when one attempts to stretch the fascia by hanging off a step or putting his or her toes up against the wall.

I will typically advise my patients to perform calf stretching by leaning against the wall and holding the stretch for 30 seconds, and have them repeat this five times at three different times during the day. If patients have a lot of pain during the first steps, I recommend they do the DiGiovanni type stretch prior to getting out of bed in the morning.³

On the initial visit, I prefer to see the most common shoe gear that patients use daily and the shoes they might be using for working out. It is important to note any changes in activity level and any changes in shoe gear. If the person works at a job that requires a lot of standing, this adds another layer of difficulty in resolving the pain. These patients should have an insert in their shoes and a good, supportive work shoe. If they are runners and they have put more than 300 to 400 miles on a pair of running shoes, then they should consider purchasing new running shoes. Find out if they have switched from a traditional 12 mm ramp angle into a zero drop or a more minimal shoe as that can trigger calf soreness and tightness, and lead to plantar fasciitis.

If I am confident in my diagnosis, then typically during the initial visit, I will advise the patient to stretch as stated above. We also discuss the proper shoe gear and I often recommend a visit to a local running specialty store to get new running shoes. I advise icing daily by rolling a frozen water bottle over the heel and I almost always tape the foot. I recall listening to a lecture by Richard Blake, DPM, at an American Academy of Podiatric Sports Medicine annual meeting in the 1990s, in which he stated that “plantar fasciitis almost always feels better taped.” I have found that taping the foot not only provides pain relief to patients but also serves as a good diagnostic indicator. If patients do not feel better with taping and the symptoms are not improving, then we may need to reconsider our diagnosis of plantar fasciitis. I have found that Kinesio Tape (Kinesio Holding Corp.) works well, adheres longer than cloth tape and is easier for the patients to use.

What About NSAIDs And Corticosteroids?

I will rarely prescribe non-steroidal anti-inflammatory drugs (NSAIDs) for any problem and NSAIDs are not very effective for plantar fasciitis. Lemont and colleagues have published studies showing there are no inflammatory cells in chronic cases of plantar fasciitis treated surgically.⁴ The authors propose that there is more of a degeneration present. The magnetic resonance imaging (MRI) findings of plantar fasciitis are mainly thickening, which is consistent with a fasciosis or a degenerative process as opposed to inflammation. The side effects of NSAIDs far outweigh any benefit that their use might achieve and it is certainly far from prudent to have someone on these drugs for longer than a few days. Treat the cause of the injury and not just the symptoms.

Many physicians including myself will inject the plantar fascia with corticosteroids. Landorf reviewed the medical literature for plantar fasciitis treatments and only found two articles in the recent medical literature that support the use of corticosteroids as an effective short-term treatment.⁵ I will typically only offer an injection if the patient has had symptoms for less than two months and if one injection does not resolve the symptoms for longer than two to four weeks, then I will typically not offer another injection.

While the foot is symptomatic, I encourage good support and often prescribe an off-the-shelf arch support to wear during any activity. I often have a custom orthotic device as part of the treatment plan but I have found in many cases that it is worthwhile to try an OTC-type insert initially. I discourage going barefoot or wearing flip flops while the symptoms are present.  

Pertinent Pointers On ESWT For Heel Pain

By far, the most effective treatment according to the medical evidence is extracorporeal shockwave therapy (ESWT). The new radial ESWT units are portable and one can and should initiate treatment on the initial visit in chronic cases of plantar fasciitis. Shockwave works by inhibiting substance P, which governs pain impulses. The main benefit that helps the tissue is neovascularization of the symptomatic area, which theoretically leads to better perfusion of the area. However, one should not wait until the pain becomes chronic. In fact, shockwave may possibly work better the earlier in the treatment plan that ESWT begins. I would never consider surgery for plantar fasciitis unless the patient has had a course of shockwave therapy.

An excellent review article on ESWT for heel pain by Schmitz and colleagues highlights many of the following important points about ESWT.⁶

1. The terminology is no longer high energy versus low energy. Most clinicians utilize radial ESWT, which used to be known as low energy while focused ESWT used to be termed high energy.⁶
2. There is no difference in the effectiveness of radial versus focused treatments.  
3. Radial shockwave has the maximum impact closer to the treatment applicator head whereas focused shockwave has the maximum impact deeper in the tissue. This allows focused units to be effective for delayed unions of fractures and I believe, despite the literature, they could possibly work better on the plantar fascia.  
4. The literature shows that the most effective protocol is three treatments of 2,000 shocks, without anesthesia, spaced a week apart at the highest energy flux density that one can apply.

It is important to advise patients that the treatment will not reduce the pain as quickly as a corticosteroid injection. I typically advise my patients that they will not feel any improvement until at least six weeks after the treatments are finished. If the patient has improvement during the treatment phase with ESWT, then I anticipate a full resolution of symptoms in the near future. I recommend that patients continue to stretch, ice, tape and keep the foot supported. If patients are not limping or compensating, then they may continue their workouts.

Once the symptoms begin to resolve, I encourage the patient to work to improve the strength of the intrinsic muscles of the foot and proprioception. I advise my patients to balance on one foot while brushing their teeth twice a day, progressing to balancing with the eyes closed. I also recommend patients pick up a towel with their toes and lay a towel flat with a book at the other end and pull the book toward them with their toes.

A Closer Look At Other Causes Of Heel Pain

Nerve pain. In 2001, Weldon Johnson, an elite runner and co-founder of the popular running website LetsRun.com, had a huge career breakthrough, finishing fourth at the USA Track and Field National Championships in the 10,000 meter race and running 28:10 for the distance.⁸ Later that year, however, he developed heel pain and had treatment by several physicians and therapists with no success.
When Weldon first presented for treatment, he said his symptoms didn’t include more pain with his first steps in the morning and that the pain was localized to the inside of his heel. The presentation was more similar to medial calcaneal neuritis.

I injected Weldon’s medial calcaneal nerve area with 1 cc of Marcaine, 4 mg of dexamethasone phosphate and 3 mg of Celestone Soluspan (Merck), and he improved significantly. Several weeks later, a second injection in the same spot resolved all his pain there permanently. In 2003, Weldon improved his 10K personal record to 28:06 while finishing fourth in the national championships and beating four-time U.S. Olympian Abdi Abdirahman, among others.

The medial calcaneal nerve will cause heel pain that mimics plantar fasciitis in some ways, but it definitely will not feel better taped and first steps are usually not any more painful. Rest, ice and keeping pressure off the area should all be parts of the treatment plan. Sometimes a firm or hard orthotic device can exacerbate the symptoms so an insert is not always the best option for this injury.

Plantar fascia tear. A tear of the fascia is not always overt. Recently, a patient, who is a competitive runner, was training to qualify for the Boston Marathon. He stated he had heel pain for the last six weeks that was getting worse and he thought it was plantar fasciitis. Initial X-rays were negative and his pain was at the plantar medial calcaneal tubercle. His target marathon was less than 10 weeks away and he was in the middle of his hard training.

We opted to try a corticosteroid injection. He began icing and taping his foot every day. However, after a couple of days off from running, his pain recurred as soon as he started to run. We instituted radial shockwave therapy and after three treatments spaced a week apart, his foot was getting more painful. He had just done a speed workout of 8 x 800 meters before his last visit but I expected to see more improvement. An MRI revealed an almost complete tear of the fascia but the patient could not recall a specific instance of sharp pain, which usually accompanies a tear of the fascia.

Treatment of a fascia tear should begin with immobilization for a short time until the patient can walk pain free out of a controlled ankle motion (CAM) walker, which may take one to three weeks. One can add stretching, icing and physical therapy to the treatment plan after the initial immobilization and use of shockwave will serve as a good adjunct. In a paper I co-authored in the American Journal of Sports Medicine, we found that it takes athletes an average of nine weeks to return to activity after a tear and partial tears often take longer to heal than complete tears.⁸ One patient in our study with a complete tear, which included the distal portion rolling up a like a window shade, returned to running without any pain in three weeks. My patient was able to resume training six weeks after the initial immobilization in a boot.

Stress fracture. Stress fractures of the calcaneus are not uncommon. A four-year study of soldiers in basic training revealed that 1,050 soldiers out of 109,296 suffered stress fractures with the calcaneus accounting for 20 percent of the male fractures and 39 percent of the female fractures.¹⁰  

It is rare for the fracture to show up on a plain radiograph but if there is evidence of the fracture on X-ray, then the healing time may be three to four months as opposed to six to eight weeks.
The squeeze test is a good test to perform to rule out a stress fracture clinically. Interlock your fingers around the back of the patient’s heel and squeeze with your palms on the medial and lateral walls of the calcaneus.

Researchers have found that vitamin D is one of the most important factors in a stress fracture.¹¹ Normal lab values show that a D3 level above 30 ng/mL is normal but there have been several studies that propose that athletes should have D3 levels over 50 in order to have proper protection from stress fractures.¹²

Final Thoughts

The best practice for treating heel pain involves creating your own treatment plan algorithm that works and follow it. Re-evaluate your diagnosis if the patient is not responding to treatment. Listen to patients and let them speak as they will often be able to indirectly guide you to the right diagnosis. 

Dr. Fullem practices in Clearwater, Fla. He is a Fellow of the American Academy of Podiatric Sports Medicine. His new book is The Runner’s Guide to Healthy Feet and Ankles, and it is available at https://tinyurl.com/z5gygob .

References

1.     Rose JD, Malay DS, Sorrento DL. Neurosensory testing of the medial calcaneal and medial plantar nerves in patients with plantar heel pain. J Foot Ankle Surg. 2003; 42(4):173-177.
2.     Digiovanni BF, Nawoczenski DA, Malay DP, et al. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. J Bone Joint Surg Am. 2006;88(8):1775-81.
3.     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;85-A(7):1270-7.
4.     Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003;93(3):234-7.
5.     Landorf KB. Plantar heel pain and plantar fasciitis. BMJ Clin Evid. 2015 Nov 25;2015. pii: 1111.
6.     Schmitz C, Császár NB, Milz S, et al. Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database. Br Med Bull. 2015; epub Nov. 18.
7.     Gollwitzer H, Saxena A, DiDomenico LA, et al. Clinically relevant effectiveness of focused extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: a randomized, controlled multicenter study. J Bone Joint Surg Am. 2015 May 6;97(9):701-8.
8.     Fullem BW. The Runner’s Guide to Healthy Feet and Ankles. Skyhorse Publishing, New York, 2016.
9.     Saxena A, Fullem B. Plantar fascia ruptures in athletes. Am J Sports Med. 2004;32(3):662-5.
10.     Pester S, Smith PC. Stress fractures in the lower extremities of soldiers in basic training. Orthop Rev. 1992;21(3):297-303.
11.     Davey T, Lanham-New SA, Shaw AM, et al. Low serum 25-hydroxyvitamin D is associated with increased risk of stress fracture during Royal Marine recruit training. Osteoporos Int. 2016;27(1):171-9.
12.     Ogan D, Pritchett K. Vitamin D and the athlete: risks, recommendations and benefits. Nutrients. 2013; 5(6):1856–68.

For further reading, see “A Guide To Conservative Care For Recalcitrant Plantar Heel Pain” in the November 2014 issue of Podiatry Today.