Good News! Conservative treatment helps in 80-90% of patients ! Yahoo !!
Before I start, I have to say that I am shocked how many non-credible/ unqualified businesses are taking advantage of people with chronic heel pain . I have seen it on social media with different paid programs promising to resolve plantar fascia and retail shoe stores on TV promising the same . This all disturbs me on many levels . First, that non-medical retailers and non-foot specialists are taking advantage of hurting people. Secondly that my profession is not educating patients properly or taking care of this problem. Lastly, that healthcare is so expensive that patients can’t afford proper care .
I will focus this blog on patients who have established plantar fasciitis diagnosed by a medical professional preferably a podiatrist for greater than 3 months and have tried professional treatment. Ideally, one has tried all the treatments I elaborated in part I of my plantar fasciitis series : https://wordpress.com/post/drgaffneybestfoot.wordpress.com/167 , All of these treatments should be continued as one moves into another phase of care.
Proper diagnosis is important :
So, you’re getting frustrated, you are stretching, wearing insoles, using voltaren gel for a month or longer and the heel pain keeps hanging around interfering with life. At this point, definitely consult with a podiatrist. Plantar fasciitis treatment is a podiatrist’s bread and butter not the Good Feet Store, not the chiropractor, not your PCP, not even the foot and ankle orthopedic (remember orthopedics is surgical sub-specialty) . Your diagnosis should be verified because all heel pain is not plantar fasciitis. Usually a podiatrist will check an X-Ray to rule out stress fracture, boney abnormalities suggestive of possible gout or autoimmune arthritis or even infection. Surprisingly, it is not to check for a heel spur . Heel spurs DO NOT cause plantar (bottom of heel ) heel pain unless they are very large and pointing down in someone with atrophied fat pad.
Most heel spurs do not cause pain.
Heel spurs are a result of tight soft tissue over a long period of time either from the muscle pulling on the bone or the plantar fascia pulling on the bone. Podiatrists over 30 years ago used to resect plantar heel spurs to resolve chronic plantar heel pain but it has been found that this is no longer necessary in fact it causes undue pain and longer recovery after surgery .
Plus MOST plantar heel pain resolves WITHOUT Surgery!
A podiatrist should do a thorough exam to rule out other causes of heel pain and diagnose structural and biomechanical problems contributing to the problem.
Heel pain can be referred pain from back pathology:
Heel pain can be referred to the heel from back pathology such as a slipped disc . Also a pinched nerve in the ankle can cause heel pain as well ( tarsal tunnel syndrome). This all can be very nuanced and the shoe and insole salesman at the Good Feet store have NO training in any medical conditions.
TREATMENT:
1. I have my patients continue all preliminary treatment plus consider adding a cortisone injection:
Once all other causes have been ruled out, treatment options will be discussed . Everything in the Part I blog post should be continued. Typically for chronic plantar fasciitis, I recommend a series of 2-3 cortisone injections spaced 4-6 weeks apart . Cortisone weakens and thins out tissue if given too much so there is a limit. I will not give more than 3 injections within 6 months. Even when given correctly, cortisone can weaken the fascia where a tear can occur in the plantar fascia requiring offloading in a cam boot for 4 weeks. I don’t like to give athletes active in their sport running or jumping a cortisone injection because of this.
If the patient is faithfully doing the stretches, wearing the night splint , wearing the over the counter orthotics, not going in barefeet , stocking feet , slippers, avoiding excessive weightbearing exercise such as running and jumping and has had 2-3 cortisone injections and still struggling with heel pain, the next phase of treatment is offered.
I’d just like to add that in my 29 years as a podiatrist, I’d have to say that 80% of patients are partially adherent to treatment plans or non- compliant . I’d say only 20% of patients are compliant to the treatment plan. This causes the plantar fasciitis to become chronic and treatment resistant. You’d be surprised how quickly it resolves when the treatment plan is followed.
If there has been no relief of heel pain or it’s changed in some way, the condition should be re-evaluated . The problem may be mis-diagnosed or there could be a compensatory problem like pain in other parts of foot from limping too long or something else contributing to the heel pain such as referred pain from the back of a pinched ankle nerve ( tarsal tunnel syndrome) .
2. Rest in Cam boot and physical therapy:
Many times heel pain persists due to a patient’s occupation and inability to do light duty . Also, if there is significant inflammation still and the patient is developing compensatory problems from limping such as tendonitis in the ankle then I will rest the patient. At this point, I typically recommend to my patients a brief leave from work and we fill out FMLA (family medical leave act) papers for about 4 weeks . During this time, I try to rest my patients in a cam boot, which is like a cast for 2 weeks. However, immobilization weakens foot and leg muscles so it’s a trade off and I try to get formal physical therapy started during this time as well.
3. ASTYM
If treatment is partially resolving the pain and there are no other contributing reasons, I recommend to my patients ASTYM which is done by a trained physical therapist and is like a deep massage done with a special instrument as seen below:
Image by physiownc.com
This breaks up the thick scar tissue within the plantar fascia insertion from the chronic injury – reparative process . It does this by activating the inflammatory process and brings in various growth factors and immune cells that will jump start healing as well as get blood flow to the area. Part of the problem with chronic musculoskeletal problems is that things get stagnate and scar tissue has less blood flow . So the ASTYM activates the repair process again . This is a painful treatment to have done but feels better after the therapist is done with the session which is 3 times a week for 4-5 weeks.
The reason why I like this ASTYM treatment is that it’s nonsurgical and and if done correctly, works 80% of the time!
Downside to ASTYM is that copays for PT 3x/week is costly and it is painful at first to have done.
4. Custom Orthotics
These are recommended when heel pain persists despite use of over the counter orthotics .
This is a mold of the foot used to create a custom arch support normally done digitally nowadays. I personally still prefer taking the mold the old fashion way with a plaster of Paris mold which I think gives the best impression and the foot can be manipulated better. The casting technique can decrease tension on the plantar fascia in the orthotic as well.
Image by mudgeeraba podiatry
A custom orthotic is designed to have the foot operate around a neutral position which typically is ideal for foot biomechanics and alignment.
Studies done comparing custom orthotics and over the counter orthotics have had poor methods with results showing no difference. More research needs to be done . In my experience, a custom orthotic in the proper patient with the proper casting technique and orthotic prescription is far superior to over the counter orthotics .
The other issue is that custom orthotics are very expensive. Also, due to the lack of good studies proving their effectiveness, custom orthotics typically are not covered by insurance. In my opinion , this is so tragic because custom orthotics have been vital in alleviating various foot conditions in my career. Custom orthotics cost $300-$500. However, in plantar fasciitis that’s becoming chronic, I highly recommend custom orthotics to my patients. There is risk , however, sometimes orthotics are not tolerated and one doesn’t know this until the orthotics are worn. But if over the counter orthotics and arch strapping are tolerated then it is highly likely that orthotics will be tolerated.
Custom orthotics should come from one’s podiatrist or an orthotist with a detailed orthotic prescription from the podiatrist. Mail order “custom orthotics “ are never recommended. I also never do foam box impressions.
This is a bad way to obtain a good impression of the foot. One needs a knowledgeable qualified practitioner who takes an appropriate impression and then guides a patient through the adjustment period , is available, and capable to do modifications. With mail order or store “ custom orthotics “ , one does not have the ability to get the orthotics modified , leaving the devices unusable in some cases. Modifications are frequently needed because impressions are taken of the foot at rest , then as one walks problems may arise. Also did you see the price in that ad above? As they say in the south, they are awfully proud of those box orthotics. That is a hefty price to have no knowledgeable practitioner write your prescription based on their exam and your problem and then no follow up and no one to modify.
Once one adjusts to the custom orthotics which can take up to a month , I recommend that my patients wear them all the time weightbearing until one has no heel pain then wear them at least 75% after that to prevent recurrence of heel pain. If, however, whatever problem is corrected that caused the plantar fasciitis such as poor shoe gear use or weight gain and the foot has been made stronger with exercise then one can work with their podiatrist to try to wean out of the orthotics. This is much easier for younger people (less than 45 years old). The older one gets the tighter and tougher the soft tissue gets and therefore less resilient.
5. Platelet Rich Plasma (PRP)
This is one’s own blood which is drawn and spun down in a centrifuge to separate the platelet rich plasma. Platelet rich plasma has many growth factors which help to heal the plantar fascia. There are studies showing that it can reduce the thickness of the plantar fascia at the insertion. Thick plantar fascia has been shown as a big culprit in plantar fasciitis being recalcitrant to treatment. Some studies have shown that PRP injections are more effective than cortisone injections in treating plantar fasciitis.
(Indian J Orthop. 2021 May; 55(Suppl 1): 142–148.
Published online 2020 Oct 6. doi: 10.1007/s43465-020-00261-w
Role of platelet rich plasma in chronic plantar fasciitis: a prospective study
R. B. Kalia,1 Vivek Singh,1 Nilotpal Chowdhury,2Ashish Jain,3 Sanny Kumar Singh,1 and Lakshmana Das1)
Unfortunately, medicare does not cover this treatment. A general rule of thumb is that if Medicare does not cover treatment most other insurances do not either . Cost runs from $500 to $2,500.
This appears to be a promising treatment but unavailable to most patients at this time. If I had chronic plantar fasciitis, I likely would NOT chance the $500 to $2,500 on a PRP injection .
Once pain-free, Focus is on Prevention:
So once my patients become pain-free with consistent treatments, which can take a few months, then I recommend at least use of custom orthotics, 75% of the time (unless there are favorable conditions to wean from them stated above), use of the night splint once a week, and at least once daily stretching to prevent recurrence. I recommend doing this for another 6 months. If at that point there is still no pain then these things can be stopped. I still think it is a good idea, though, to stretch daily.
A small minority of patients may fail conservative treatment, and at this point, we discuss advanced conservative treatment or surgical options. This will be outlined in my Part III blog .
Thanks so much for reading ! I hope this helps you.
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Melissa Gaffney, DPM
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