Plantar Heel Pain Treatment & Management

Proximal plantar fasciitis is successfully managed with conservative care in approximately 90% of cases. In general, the longer the duration of symptoms, the longer it takes for the patient to obtain complete pain relief. Various modalities of treatment are available, and patient education is important to improve the understanding of the condition and to obtain compliance with various treatment regimens. The important aims of the treatment are to limit impact stresses on the heel, to alleviate inflammation, and to stretch the triceps surae muscle.

• Reducing impact

  • Activity modification: Avoiding impact activities is especially important in athletes, who can cross-train with nonimpact sports such as cycling or swimming.
  • Reduction of body weight
  • Use of soft cushions or insoles and soft-heeled footwear (see images below)^[16] Soft heel cushion to absorb shock. Soft heel cushion and a cup.
  • Taping, arch supports, and custom-molded orthotics (see image below)^{[17, 18]} Custom-molded orthotic.
• Reducing inflammation

  • Application of ice and/or iontophoresis
  • Anti-inflammatory medication: Medication is useful in the early stages, especially if the patient has begun stretching exercises because, initially, these can worsen the pain (see Medication).
• Stretching and strengthening

  • Exercises: A variety of exercises can help the patient to achieve active and passive ankle dorsiflexion with the knee kept straight and the subtalar joint in inversion, which helps achieve maximum stretch of the triceps surae muscle. The foot can be rolled over a tennis ball or a can to massage and stretch the plantar fascia. The exercises can be performed at home or can be guided by a physical therapist (see images below).^[19]
  • In a recent study, 102 patients with acute plantar fasciopathy were randomly assigned to perform an 8-week plantar fascia-specific stretching program (Group I, n=54) or to receive repetitive low-energy radial shock-wave therapy without local anesthesia, administered weekly for 3 weeks (Group II, n=48). The primary outcome measures were a mean change in the Foot Function Index sum score at 2 months after baseline, a mean change in item 2 on this index (pain during the first few steps of walking in the morning), and satisfaction with treatment. Manual stretching exercises specific to the plantar fascia were found to be superior to repetitive low-energy radial shock-wave therapy for the treatment of acute symptoms of proximal plantar fasciopathy.^[20] Stretching exercise. Lean against the wall with the knee kept straight and the heel touching the floor. Stretching the back of the leg at the edge of a stair. Massaging and stretching the plantar fascia using a can.
  • Plantar fascia–specific stretching exercises
    • A randomized, prospective study with 2-year follow up compared Achilles tendon stretching with plantar fascia tissue—specific exercises.^[21] The authors found a plantar fascia–specific stretching exercises was better.
    • To perform the exercise, the patient crosses the affected leg over the contralateral leg. While placing the fingers across the base of the toes, the patient pulls the toes back toward the shin until he or she feels a stretch in the arch or plantar fascia. The patient confirms that the stretch was correct by palpating tension in the plantar fascia (see image below). Plantar fascia tissue-specific stretching exercise
  • Intrinsic muscle strengthening: Exercises include toe curls or other activities, such as picking up marbles with the toes.
  • Resting splints: During the night, the relaxed posture of plantar flexion at the ankle tends to favor contracture of the triceps surae. To prevent this, night splints that hold the ankle in dorsiflexion can be worn.^[22] Patients who wear a posterior night splint should be warned to take it off before getting out of bed. As an anecdotal example, one patient walked to the toilet while wearing the splint, slipped, and sustained a humeral fracture. However, a dorsally applied splint, as opposed to a posterior splint, does not need to be taken off before getting out of bed (see images below). A night splint applied on back of the leg and foot. A night splint applied on the front of the leg.
• Treating recalcitrant pain: If the pain persists for longer than 2 months despite the above treatment, then the following modalities can be offered:

  • Cast: A short leg walking cast for 6 weeks is generally effective in relieving pain, but the pain can recur after the cast is removed.^[23] To prevent this, the patient should use the previously mentioned treatment modalities, such as activity modification, stretching exercises, and insoles, until recovery is complete.
  • Corticosteroids: Iontophoresis is administered by a physical therapist and uses low-voltage galvanic current stimulation to distribute topical corticosteroids. It is performed 2-3 times a week. This therapy can provide short-term relief, but it is usually reserved for patients in whom other therapies are unsuccessful or who have occupations that involve spending most of their time on their feet. Depot injections can provide good short-term relief, but multiple injections can cause plantar fascia rupture and fat pad atrophy—and, later, a flat-foot deformity—especially if the injection is not administered deep into the fascia.^[24]
  • Extracorporeal shockwave therapy (ESWT)^{[5, 25, 26, 24, 27]} : This therapy was approved by the US Food and Drug Administration (FDA) in 2005 (see New Device Approval: Orthospec Extracorporeal Shock Wave Therapy – P040026), although the treatment has been used in Europe for more than a decade. Animal study data suggest that this modality creates microdisruption and stimulates new bone and tissue formation. Shockwaves may be delivered in 3 ways: electrohydraulically (high power), electromagnetically, or piezoelectrically. The FDA approved electrohydraulic and electromagnetic devices for the treatment of chronic plantar heel pain that has persisted for longer than 6 months despite other treatment.

Fat pad atrophy is managed conservatively with the use of heel cups, soft insoles, and soft-soled footwear. The heel cup helps to centralize and increase the bulk of the soft tissue under the calcaneus.

In patients with planovalgus deformity, if the valgus hindfoot is thought to be the cause of tarsal tunnel syndrome due to traction on the tibial nerve, the initial treatment can be placement of a medial longitudinal arch support and a medial lift.

Stress fractures of the calcaneus and traumatic rupture of the plantar fascia are managed with conservative measures. Avoiding the offending activity and a 6- to 8-week period in a cast may be required to alleviate the symptoms.

The guidelines developed by the American Orthopaedic Foot and Ankle Society on the use of endoscopic and open heel surgery to treat plantar heel pain are widely accepted.

Because 90% of patients with plantar fasciitis respond favorably to conservative care, conservative methods should be tried for at least 6, or, preferably 12, months before surgery is considered. Furthermore, full counseling regarding the risks and benefits must be administered because complete satisfaction after surgery is observed in only 50% of patients.

The surgery can be performed by open or endoscopic methods. However, if plantar fasciitis is suspected to coexist with compression of the first branch of the lateral plantar nerve, then the endoscopic method is not recommended. (Electromyography and nerve conduction studies are not necessary to diagnose compressive neuropathy of the first branch of the lateral plantar nerve; rather, the diagnosis of entrapment of the first branch of the lateral plantar nerve is made on a clinical basis. Testing nerve conduction across the site of entrapment in the heel is technically demanding. Motor weakness in the abductor digiti quinti may not be detected because of the dynamic nature of the compression.)

• By either the open or endoscopic method, only 50% of the plantar fascia is released because a complete release can lead to collapse of the medial and lateral longitudinal arches.
• Excision of a plantar heel spur is performed only if it is significantly large and it is compressing the first branch of the lateral plantar nerve.
• Surgery for tarsal tunnel syndrome or for decompression of the first branch of lateral plantar nerve requires release of the tibial nerve and its branches and overlying fascia, including the deep fascia of the abductor hallucis.