eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Plantar Fasciitis: Treatment & Medication

Author: Matthew D Sorensen, DPM, Foot and Ankle Surgeon, Summit Orthopedics
Coauthor(s): Christopher F Hyer, DPM, FACFAS, Foot and Ankle Surgeon, Director, Advanced Foot and Ankle Surgery Fellowship, Orthopedic Foot and Ankle Center; Gregory C Berlet, MD, FRCS(C), Clinical Assistant Professor of Orthopedics, Chief of Foot and Ankle Surgery, Department of Orthopedic Surgery, Ohio State University College of Medicine and Public Health
Contributor Information and Disclosures

Updated: Jun 9, 2009

Treatment

Medical Care

Nonsurgical intervention should begin with a multimodal approach of treatment, although this approach does take a significant amount of patient responsibility and consistency in following the regimen. This can be a challenging point in the treatment cycle, as patient expectation must be set and compliance placed at a premium. However, with compliance, success rates of 70-89.5% are achieved.16,17,18,19  

Plantar fasciitis is classically a self-limiting condition, and studies have reported a resolution incidence of up to 90% through nonsurgical measures.15 -20   However, patients have differing degrees of pathology and varying types of body habitus and lifestyle and will therefore respond differently to various treatments. Even with individualized care, some patients respond quickly and others exhaust all conservative measures before relief is achieved. 

Nonsurgical measures include, but are not limited to, rest, icing, stretching, nonsteroidal anti-inflammatory drugs (NSAIDs), shoe modification, taping/strapping, orthoses (over the counter or custom-made), physical therapy, weight loss, corticosteroid injection, night splinting, and heel pads.  

Rest 

Rest includes activity modification or a level of relative rest, as complete rest may not be practical, particularly for more active individuals and for those whose jobs require standing.  Alternative exercises or avoidance of inciting activities will increase the success rate of pain relief and of patient compliance. In patients with severe pain, a period of casting or immobilization in a walker boot may be necessary. In one study, 25% of patients considered rest to be the most effective form of treatment.20

Icing
Ice is an age-old remedy for problems of inflammation and should be used as adjunctive therapy in acute plantar fasciitis. Treatment with ice is best utilized directly after periods of activity, such as immediately after work and just before going to bed. Consistent, daily patient compliance is paramount regarding successful pain relief.

Stretching
 
In a study by Wolgin et al, 83% of patients treated with stretching exercises experienced successful relief20 ; therefore, stretching of the Achilles tendon has become a key component in the resolution of heel pain. Wall stretching or the runner’s stretch, stair stretching, and towel stretching are commonly employed. 

A level 2 clinical trial led by DiGiovanni et al studied the effect of passive dorsiflexion on the toes with simultaneous stretching of the Achilles tendon.21 Recruiting the extension of the toes and subsequently engaging the windlass mechanism increased the effectiveness of the traditional stretching regimen, as well as subsequent symptom relief. To assist with compliance, formal physical therapy may also be used. Along with stretching, strengthening of the intrinsic muscles of the foot has also proven beneficial.22 Exercises to strengthen the intrinsic muscles consist of towel curls and picking up objects (eg, marbles, coins) with the toes.

NSAIDs
It has been documented that the major component contributing to the discomfort associated with acute plantar fasciitis is the inflammation occurring secondary to the disease process, rather than a spur or other mechanical factor. Thus, treatment arms have been directed at decreasing inflammation. In one study, 79% of patients using NSAIDs were successfully treated.20  The important component to NSAID therapy is consistent, daily dosing throughout the acute phase of treatment. Risks such as gastrointestinal sequelae and renal damage have been well documented.23  

Shoe modification
 
A supportive heel counter and stiff midsole are important components of any shoe for those experiencing heel pain. Fashionable shoewear often does not provide sufficient support for the arch and further exacerbates the problem. In general, lace-up shoe gear is recommended to maximize support.  In the Wolgin study,20 14% of patients credited change in shoe gear as the best treatment. 

Orthotics
 
Orthoses are used to provide support to the arch and control dynamic biomechanical function of the foot. The orthosis helps to connect the hindfoot to the forefoot during the gait cycle as well as in static stance. Most commonly, excessive pronation is a contributor to the pathology, and the orthosis harnesses this dysfunction. Orthoses can be purchased over the counter or can be custom made.  One study showed that over-the-counter and custom-made orthoses had equitable effectiveness in the treatment of plantar fasciitis.24,25,26,27,28,29

Low-dye strapping with athletic tape has been purported to be a reliable adjunct to orthotic use in the acute phase of treatment, particularly in combination with over-the-counter orthoses, and may be a good indicator of eventual custom orthotic effectiveness. Heel pads are widely used, but they are generally useful only for shock absorption and do not provide support or structural control.

Physical therapy
 
As a second level of treatment, formal physical therapy with the employment of contrast baths, ultrasound, iontophoresis,30,31 range-of motion-exercises, and strengthening programs can help get the patient over the hump toward long-term pain relief.

Corticosteroids
 
Administration of steroids can be either oral or by injection. Oral forms, such as a Medrol (methylprednisolone) dose pack, are systemic and can be used in the acute phase in conjunction with, or in place of, NSAIDS. Steroid injections are a local, concentrated administration and are generally reserved as a tertiary level of treatment after failure of other primary conservative measures in severe recalcitrant cases.32  Steroid injections are successful in as many as 70% of cases.33,17 The risks associated with steroid injections include plantar fascial rupture and fat pad atrophy.34,35,36 It is recommended not to give more than 3 steroid injections within a year.

Night splints
 
Most people sleep with their toes pointed down in a plantar flexed position. Night splints maintain a neutral 90 º position of the foot to the leg and constant passive stretching of the Achilles tendon and plantar fascia.28  The theory regarding effectiveness is the rest and healing provided by the constant stretch. In addition, the passive stretching helps prevent microtrauma with the first steps out of bed at the plantar fascia – bone interface. Three randomized, clinical trials support the use of dorsiflexion night splints in plantar fasciitis.37,38,39   Regarding the difficulty of patient compliance with night splints, a recent prospective trial using the Dynasplint showed the comfort of the night splint resulted in 95% patient compliance.40  

Summary

It is important to note that the treatment modalities noted above are to be used in combination. Treatment algorithms usually begin with 6 weeks of consistent and daily icing, stretching, NSAID therapy, strapping/taping, and over-the-counter orthoses. Counseling as to activity modification, as well as choice of shoe gear, is important. After 6 weeks, recalcitrant cases should be treated additionally with a night splint and, possibly, a corticosteroid injection, along with the initial regimen for another 6 weeks. If pain persists, a referral to a foot and ankle specialist should be considered.  Injection therapy, immobilization in a cast or walker boot, physical therapy, and custom orthotics can be employed under more controlled supervision.  Severe recalcitrant cases may ultimately require surgical intervention.

Surgical Care

Extracorporeal shockwave therapy
 
Extracorporeal shockwave therapy (ESWT) is an alternative treatment for chronic heel pain using acoustic-energy shockwaves.41,42,43,44,45,46  This modality is a tertiary form of treatment and should be reserved for recalcitrant cases. Multiple studies have shown success rates of 50-90%.47,48 ESWT is noninvasive with few risks and good recovery time for chronic plantar fasciitis; however, it is not covered by most insurance plans.

Surgery 

In 5-10% of cases of plantar fasciitis, surgery may be required.16,17,18,49   It is reserved for those in whom a thorough 6-12 months of conservative treatment has failed.  Plantar fascia release—performed by sectioning part or all of the fascia via an open or endoscopic procedure—has been the mainstay of treatment.50,51  However, partial and, especially, total release of the plantar fascia results in instability of the medial column of the foot, along with lateral column overload and pain.52  

Cryosurgery 

Cryosurgery is a relatively new technique that uses a small cryoprobe to percutaneously destroy pathologic tissue or cells at temperatures reaching -70ºC. Some studies have shown relatively good success with the use of a cryoprobe.53  

Bipolar radiofrequency 

Another relatively new percutaneous technique is Topaz bipolar radiofrequency microdebridement, which applies a bipolar radiofrequency pulse to the plantar fascia.  In comparison to traditional surgical interventions, this new technology has been yielding very effective and even superior results, with the advantages of decreased morbidity, earlier pain relief, lack of wound infection, absence of lateral column pain, and earlier time to weight-bearing. In one study, patients related an average AOFAS (American Orthopaedic Foot and Ankle Society) hindfoot score of 92 out of a possible 105 at an average of 11 months post operation.54   Long-term, randomized, double-blind studies are still needed. As with any surgery, risk versus benefit must be measured. 

Activity

Walking, running, and jumping sports are associated with plantar fasciitis; restriction of these activities may be necessary.

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Nonsteroidal anti-inflammatory drugs

Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known but may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.


Ibuprofen (Motrin, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Adult

400-800 mg PO bid/tid

Pediatric

Not established

Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when anticoagulants are taken (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy


Sulindac (Clinoril)

Decreases activity of cyclooxygenase and, in turn, inhibits prostaglandin synthesis. Results in a decreased formation of inflammatory mediators.

Adult

200 mg PO bid with food

Pediatric

Not established

Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; hypersensitivity to aspirin, iodides, or other NSAIDS; GI bleeding; renal insufficiency

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely, and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if there is persistent leukopenia, granulocytopenia, or thrombocytopenia; caution in anticoagulation defects or are receiving anticoagulant therapy


Celecoxib (Celebrex)

Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited thus GI toxicity may be decreased. Seek lowest dose of celecoxib for each patient.

Adult

100-200 mg PO qd

Pediatric

Not established

Coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Category D in third trimester of pregnancy; may cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing to fluid retention; severe heart failure and hyponatremia, because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction, or in abnormal liver lab results


Meloxicam (Mobic)

Decreases activity of cyclo-oxygenase, which in turn inhibits prostaglandin synthesis. These effects decrease formation of inflammatory mediators.

Adult

7.5-15 mg PO qd

Pediatric

Not established

Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; active GI bleeding

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur (discontinue if there is persistent leukopenia, granulocytopenia, or thrombocytopenia)

More on Plantar Fasciitis

Overview: Plantar Fasciitis
Differential Diagnoses & Workup: Plantar Fasciitis
Treatment & Medication: Plantar Fasciitis
Follow-up: Plantar Fasciitis
References
Further Reading
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Further Reading

Related eMedicine topics

Plantar Heel Pain

Achilles Tendon Pathology

Stress Fractures

Acquired Flatfoot

Pes Planus

Clinical guidelines

ACR Appropriateness Criteria® chronic foot pain. American College of Radiology - Medical Specialty Society.  1998 (revised 2005).  7 pages.  NGC:004618

Diagnosis and treatment of adult flatfoot. American College of Foot and Ankle Surgeons - Medical Specialty Society.  2005 Mar/Apr.  36 pages.  NGC:004194

Diagnosis and treatment of pediatric flatfoot. American College of Foot and Ankle Surgeons - Medical Specialty Society.  2004 Nov/Dec.  33 pages.  NGC:004086

Clinical trials

Treatment of Plantar Fasciitis With Dorsiflexion Night Splints and Medial Arch Supports

PRP to Treat Plantar Fasciitis

Plantar Fasciitis Treated With Dynamic Splinting

Change and Clinical Significance of Plantar Fascia Thickness After ESWT

A Randomized Controlled Trial of Custom Foot Orthoses for the Treatment of Plantar Heel Pain

Foot and Ankle Range of Motion (Stretching) Apparatus

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Keywords

plantar fasciitis, heel pain, plantar heel pain, inflamed fascia, foot deformity, flat-foot, pes planus, stress fracture

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Contributor Information and Disclosures

Author

Matthew D Sorensen, DPM, Foot and Ankle Surgeon, Summit Orthopedics
Matthew D Sorensen, DPM is a member of the following medical societies: American College of Foot and Ankle Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher F Hyer, DPM, FACFAS, Foot and Ankle Surgeon, Director, Advanced Foot and Ankle Surgery Fellowship, Orthopedic Foot and Ankle Center
Christopher F Hyer, DPM, FACFAS is a member of the following medical societies: American College of Foot and Ankle Surgeons and American Podiatric Medical Association
Disclosure: Nothing to disclose.

Gregory C Berlet, MD, FRCS(C), Clinical Assistant Professor of Orthopedics, Chief of Foot and Ankle Surgery, Department of Orthopedic Surgery, Ohio State University College of Medicine and Public Health
Gregory C Berlet, MD, FRCS(C) is a member of the following medical societies: American Medical Association, American Orthopaedic Foot and Ankle Society, Canadian Medical Association, Canadian Orthopaedic Association, College of Physicians and Surgeons of Ontario, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Medical Editor

James K DeOrio, MD, Director of Foot and Ankle Fellowship Program, Assistant Professor of Orthopedic Surgery, Orthopedic Surgery, St Lukes Hospital, Jacksonville, Florida
James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Florida Medical Association, and German Society of Neurology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Shepard R Hurwitz, MD, Executive Director, American Board of Orthopaedic Surgery
Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FAAOS, Chairman, J Vernon Luck Distinguished Professor, Department of Orthopedic Surgery, University of Missouri
Jason H Calhoun, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, and American Orthopaedic Foot and Ankle Society
Disclosure: Nothing to disclose.

 
 
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