How to stop chronic plantar fasciitis. Surprisingly, it may not require surgery.

You’ve tried all the things to stop your plantar fasciitis: orthotics, stretching, physical therapy, cortisone injections, splints and it has not gotten better long term or keeps coming back. Life is too hard to be suffering from chronic heel pain.

***Discuss any treatments with your doctor before implementing. This blog post is not medical advice. Please read full medical disclaimer.

First what constitutes chronic plantar fasciitis?:

• plantar fasciitis failing to respond to 6 months ( some studies cite 12 months) of consistent conservative treatment. Insurances companies usually have this stipulation of 6 months of failed conservative treatment before they consider paying for advanced treatments.
• The plantar fascia being 6mm thick at the insertion site at the heel bone seen on ultrasound. This indicates that the chronic injury- reparative process has been extensive and the plantar fascia is now very fibrotic . This type of tissue is very tough with decreased blood flow. This makes it resistant to treatment.

Before exploring advanced treatment for plantar fasciitis, know why the conservative treatment has failed :

Be honest with yourself. Did you faithfully adhere to your doctor’s treatment plan? All too often, the daily night splint use ,stretches and constant use of orthotics are not done and this could be the reason for treatment failure. Remember conservative treatment works for 80-90% of patients with plantar fasciitis so it is worth the consistent effort. Check out my previous posts on this: Will my heel pain ever go away ? (Part1) Short answer: Yes (if treated early) ! Follow what worked for thousands of my patients below: and Will My Heel Pain Ever Go Away? (Part II plantar fasciitis that’s becoming chronic ) Short Answer: most likely ! See what worked for thousands of my patients!

If one has NOT faithfully adhered to the treatment plan, I typically encourage my patients to do so continually for at least another 1-3 months. If after a month or two there is no progress then we explore other options.

Conservative treatment failure needs to be analyzed by the patient and the doctor together before moving onto more expensive treatment options that require recovery and may have complications.

Advanced treatment options proven to stop chronic plantar fasciitis in over 80% of patients:

1. Extracorpeal Pulse Activation Technology or EPAT

EPAT is a form of ESWT or ( extracorporeal shockwave therapy). Fun Fact: ESWT was developed from the same technology used to break apart kidney stones or lithotripsy. ESWT was developed in the late 90’s as a treatment for orthopedic conditions.

How does EPAT work?

EPAT uses sound pressure waves to stimulate healing in a chronically injured area such as chronic plantar fasciitis. The sound wave pulses into the injured area. The shockwaves alter pain receptors. These pulses cause controlled micro-trauma to the area. Unlike what caused the plantar fasciitis which was uncontrolled microtrauma. This stimulates healing by the body with improved circulation to the plantar fascia insertion site.

Essentially EPAT technology takes a chronic non-responsive injured tissue with very little blood flow and turns it back into a mildly acute injury. Acute injuries cause an influx of blood flow and growth factors that can break up tough thick fibrotic tissue by repair and regeneration. Basically jumpstarting your body’s own healing processes that have been stagnant.

Key features of EPAT:

• FDA approved
• No anesthesia required
• It is NON-INVASIVE!!
• Uses body’s own processes to regenerate injured tissue
• Used world-wide to treat various orthopedic conditions
• Once a week treatment lasts 10- 15 minutes
• 3 treatment sessions in the office but up to 4-5 treatments may be needed
• In some patients, pain relief can be experienced immediately after a session
• Most see improvement 4 weeks after last treatment with significant improvement 8-12 weeks after last treatment
• Full benefits can take up to 3 months as new tissue has regenerated
• Treatment sessions can be uncomfortable for some painless for others.
• up to 80% improvement of plantar fasciitis cited in the scientific literature. ¹.²³⁴⁵
• Treatments can cause discomfort, bruising , redness but generally well tolerated.

Contraindications to EPAT include:

• patients on blood thinners
• patients with peripheral arterial disease or decreased blood flow in extremities
• patients with deep vein thrombosis (DVT ) or blood clot in vein
• cancer patients
• those who are pregnant

Post – procedure patient recommendations:

• Continue orthotics, stretching, and night splint use . This allows continue support of the plantar fascia as it heals . The night splint will help it to heal stretched out instead of contracted.
• Do physical therapy exercises to strengthen the foot muscles supporting the arch. Strong foot muscles will take stress off the plantar fascia. If done correctly, you can work with your doctor to wean out of the orthotics.
• Continue working on the root cause of plantar fasciitis such as being overweight or obese, bad shoes, weak muscles in feet, inflammatory diet and lifestyle. Health coaches are a great help in this regard. This is so important so you don’t have suffer with this again.

Big downside to EPAT: It is not covered by insurance.

Each treatment costs $200-$250 so the series would cost $600-$750. In my opinion, this is worth it. With high deductible plans being the mainstay nowadays, this would take a big chuck out of the deductible. Plus , one can use Health Savings Plan or Flexible Spending Plan to pay for it. If I had chronic plantar fasciitis, I would be doing this treatment.

There is a upside to this downside . Since insurance is not covering it, one does not have to wait the 6 months of failed conservative surgery guideline set by the insurance company before trying this advanced treatment.

Another issue is that it may be difficult to find a doctor who has this EPAT device. It is expensive. Curamedix who provides EPAT to physicians, has a find a provider service on their website .

2. Surgeries: Endoscopic Plantar Fasciotomy (EPF) or Medial Gastrocnemius Recession Surgery

***A word about surgery. It is a big step and one not to be taken lightly. Be sure to discuss any foot surgeries completely with your foot surgeon. Foot surgery will change your foot but hopefully for the better. Recovery from foot surgery is more involved than other surgeries due to the decreased blood flow to this area and the fact that it has to be able to tolerate weightbearing . Surgery causes a big stress to the body from tolerating the strong medication for sedation to healing after the surgery. Most foot surgery can be done with IV sedation and local anesthesia and not under general sedation (totally knocked out with tube down the wind pipe for ventilation) which greatly reduces risk. However, your primary care physician should still verify that you are medically fit to handle surgery.

EPF basics:

• similar to arthroscopy where minimal incisions are made and a camera is used inside to visualize the surgery.

• EPF involves a small 1cm incision on both sides (medial and lateral) of the heel where a scope placed in the heel and tube for instruments to pass through
• About 1/3 of the medial (inside) plantar fascia band near the insertion site is sharply released.

It can be done with in a same day surgery center under IV sedation with the foot numbed.

Patients are partial weight bearing for three days post-operatively . They increase to full weight bearing as tolerated and usually achieved within 14 days. On average athletic activities can be resumed at 12 weeks.

EPF was seen in studies to have a very good satisfaction rate at close to 90% . ⁶⁷

Possible complications include but not limited to: nerve entrapment, delayed healing, hematoma (internal blood collection), painful scar, recurrence, failure of procedure, infection.

Medial Gastrocnemius Recession

This procedure has become more popular. It involves releasing part of the tendon and muscle tissue at back of leg to achieve lengthening and less stress on the heel. This also can be done with minimal incisions through a cannula and camera.

Your surgeon may consider this procedure if you have what is called gastrocnemius equinus or limitation of upward motion of ankle or dorsiflexion. This means this muscle group is tight and pulling on heel bone. The gastrocnemius muscle and the soleus muscle form a tendon that turns into the achilles tendon that inserts into the heel bone.

You may be wondering, ” Why would a surgery be done on the leg when the bottom of my heel hurts.?” It turns out that there is a connection of the achilles tendon with the plantar fascia at the heel. The achilles tendon insertion wraps around the heel bone and forms a connection with the plantar fascia around the heel bone. So if your heel pain symptoms involve pain at the back of the heel too or if there is a heel spur on the back of the heel indicating chronic achilles tension then your surgeon may consider this option. There was also a recent study by Pearce et al in 2021 showing correlation between gastrocnemius tightness and heel pain severity in plantar fasciitis.⁸

Key features of the Endoscopic Medial Gastrocnemius Recession:

• done through a scope through minimal incision which speeds healing
• Usually done at outpatient surgery center
• Requires at least a spinal block for anesthesia with IV sedation
• weightbearing as tolerated after surgery
• depending on the surgeon, a post-operative boot may be used
• Comfortable weightbearing as tolerated at 1 week with return to work on average was 3 weeks based on a systematic review of gastrocnemius recessions by Arshad et al, 2022 in Foot Ankle International. This systematic review reported excellent outcomes of all the studies review when treating chronic plantar fasiciitis ⁹

Complications included: Nerve entrapment , infection, blood collection (hematoma), swelling, delay in wound healing , painful scar, recurrence , failure of procedure.

In conclusion, there is hope for those of you that have been suffering with chronic plantar fasciitis . It might not even require surgery! Continue to work with your doctor for the best solution for you. Remember that the root cause of plantar fasciitis must be addressed so you do not have to go through this ordeal again!.

Thanks for reading !

Here’s to your Best Foot Forward!

Melissa Gaffney, DPM

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