eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions

Plantar Fasciitis: Treatment & Medication

Author: Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service, University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Coauthor(s): Todd P Stitik, MD, Professor, Department of Physical Medicine and Rehabilitation, Acting Director of Sports Medicine, UMDNJ-New Jersey School of Medicine; Lead Physician, Practice Medical Director of University Hospital PM & R Clinic
Contributor Information and Disclosures

Updated: Mar 31, 2008

Treatment

Rehabilitation Program

Physical Therapy

The mainstay physical therapy treatment for plantar fasciitis is stretching.⁹ There are a number of ways to stretch the plantar fascia and the Achilles tendon.

• For patients who report that the most severe symptoms occur with the first steps after awakening, stretches should be performed before the patient even gets out of bed. This can be accomplished by keeping a long towel at the bedside. When the patient wakes up, he/she can stretch the plantar fascia by using the towel to cause passive dorsiflexion of the ankle, with each hand pulling one end of the towel, using the midportion of the towel to pull on the plantar aspect of the forefoot region.
• Other techniques for stretching the Achilles tendon include passive stretch while standing and nighttime ankle foot orthoses to keep the feet in neutral at night (thus stretching the Achilles tendon).
• The plantar fascia also can be stretched by having the patient, while seated, roll a soda can between the sole and the floor. Using a cold can of soda may give further symptomatic relief through local cooling.
• Passive stretching of the plantar fascia also can be achieved by using one hand at the plantar aspect of the forefoot region, then dorsiflexing the foot.
• A study found non – weight-bearing stretching exercises specific to the plantar fascia to be superior to the standard program of weight-bearing, Achilles tendon – stretching exercises in patients with chronic plantar fasciitis.¹⁰

Massage of the plantar fascia, accomplished by running the thumb or fingers lengthwise along the fascia, can be beneficial for patients with plantar fasciitis. The physical therapist may complete this technique within therapy sessions and may instruct the patient or family members on how to continue the massage independently at home.

Application of ice is an important part of the treatment process to reduce pain and inflammation. Ice should be applied after exercise and may be performed either as an ice massage for 5 minutes or by applying an ice pack for 15-20 minutes. The physical therapist also may recommend other modalities, such as ultrasonography, phonophoresis, or iontophoresis, to assist further with pain relief and reduction of inflammation.

Sometimes, taping of the plantar fascia by an athletic trainer or physical therapist can help to decrease stress on the fascia, enabling the patient to better tolerate activity. Taping techniques are used to distribute force away from the stressed and irritated fascia and to provide some relief from discomfort caused by weight-bearing activities.

If the patient needs to decrease his/her activity level due to this condition, remember to suggest alternative means of maintaining strength and cardiovascular fitness (eg, swimming, water aerobics, other aquatic exercises). Generally, in patients with plantar fasciitis due to work-related causes, the physical therapist can perform work-hardening activities with physician supervision.

Medical Issues/Complications

• The main rehabilitation medicine issue in plantar fasciitis is that chronic plantar pain leads to increased limping; this can produce an antalgic gait pattern that may hinder and possibly decrease mobility to levels that are unacceptable for the performance of activities of daily living (ADLs), including work and recreation.
• Medical complications of plantar fasciitis are limited to aggressive medical interventions when conventional therapy, nonsteroidal medications, and modalities (eg, heat, cold, ultrasonography) have failed to achieve resolution of the symptoms. Corticosteroid injection into the superficial fat pad may cause fat pad necrosis, due to loss of the shock absorption normally provided by the superficial fat pad, with subsequent pain during the early part of stance phase with ambulation. This development could create a significant disability in the event of a worker's compensation case.

Surgical Intervention

• Surgical intervention, which rarely is required, involves a resection to release the plantar fascia from its bony attachment at the calcaneus.
• A study by Bazaz and Ferkel found that endoscopic plantar fascia release provided significantly improved outcomes for patients, specifically those with less severe symptoms.¹¹

Consultations

• Many authors advise against considering surgical referral/intervention until a minimum of 6-9 months of comprehensive nonsurgical treatment has been completed.

Other Treatment

• Shoe inserts and heel pads - A heel pad typically is considered part of the initial treatment. These prefabricated orthotic devices, which are available at most pharmacies and surgical supply stores, are relatively inexpensive. The heel insert can be made of silicone, rubber, gel, or felt.
• Orthotic arch supports - These have also been advocated to improve symptoms. The orthotic device can support the bony arch and decrease the stress on the plantar fascia.
• Corticosteroid injection - This can be considered for plantar fasciitis in the relatively small percentage of patients who do not respond to an appropriate plantar stretching program and/or appropriate shoe inserts or orthoses.^12,13
  • A randomized, controlled study demonstrated that intralesional corticosteroid injection is more efficacious and more cost-effective than low-energy extracorporeal shockwave therapy in the treatment of plantar fasciitis that has persisted for more than 6 weeks.¹⁴
  • Corticosteroid injection can be performed for plantar fasciitis, typically using a 22-gauge, 1.5-in (3.8-cm) needle to inject a mixture of 4 mL of local anesthetic (eg, lidocaine) and 1 mL (40 mg) of corticosteroid (eg, methylprednisolone [Depo-Medrol]).
  • Palpate the most anterior aspect of the medial plantar calcaneal tubercle and insert the needle at this site. Advance the needle until it reaches the most anterior (distal) aspect of the plantar medial calcaneal tuberosity. When the proximal (anterior) edge of the heel spur has been identified, advance the needle immediately anterior to this spot. Avoid injecting within the superficial layers of the subcutaneous tissue, because corticosteroid injection into the superficial fat pad can cause fat necrosis and atrophy, resulting in a loss in the shock absorption of the plantar heel.
  • In a preliminary report, a posterior tibial nerve block prior to steroid injection was shown to decrease the pain from injection and to improve compliance with treatment, without any complications.¹⁵
  • Bleeding or bruising generally is expected only in patients who have bleeding disorders or are taking anticoagulants.
  • Infection at the injection site is rare, but possible. In addition to the sterile technique for the procedure itself, patients need to maintain good foot hygiene after the injection.
  • In diabetic patients, transient elevation of blood glucose levels may occur after corticosteroid injection.
  • Allergic reactions to the injected medications are rare, but possible.
  • Intravascular injection could potentially cause cardiac dysfunction, due to the inherent toxicity of local anesthetic agents.
  • Peripheral nerve dysfunction is possible if the local anesthetic is injected either close to or within the medial plantar nerve or the calcaneal branch of the tibial nerve.
  • Trials of ultrasonographically-guided steroid injection have shown its potential efficacy. It has been shown to produce a good clinical response when palpation-guided injection is unsuccessful.¹⁶ Accurate injection under ultrasonographic guidance may also minimize adverse effects from the injection.¹⁷
  • A study of 25 patients who received corticosteroid injection for plantar fasciitis showed that patients received symptomatic relief as measured by tenderness threshold and a visual analog scale (VAS) (P <0.001).¹⁷ The study showed that this symptomatic benefit was obtained whether the injection was performed with image guidance (ultrasonography) or with palpation alone. However, patients injected using image guidance showed a lower rate of recurrence of heel pain. Thus, although injection with or without image guidance is helpful, image guidance does appear to provide additional benefit.
• Shockwave therapy - A meta-analysis seemed to show that shockwave therapy could be a safe and effective nonsurgical treatment for plantar fasciitis.¹⁸ Further research into this area seems warranted.
• Botulinum toxin type A injection - Botulinum toxin type A injection seems to produce significant improvements in pain relief and overall foot function according to a short-term, randomized, controlled, double-blinded study.¹⁹
• Cryosurgery - A prospective study suggests that cryosurgery is an effective treatment for plantar fasciitis after failed conservative management, without resorting to open, invasive surgery.²⁰

Medication

Medications are used primarily to decrease pain and inflammation. The most commonly used medications are oral nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections employed in conjunction with physical therapy.

Nonsteroidal anti-inflammatory drugs

These agents can help to decrease pain and inflammation. Various oral NSAIDs can be used, as there are no particular drugs of choice. Choice of NSAID is largely a matter of convenience (how frequently doses must be taken to achieve adequate analgesic and anti-inflammatory effects) and cost.

Ibuprofen (Motrin, Advil, Nuprin, Rufen)

DOC for mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. Many doses are available without a prescription.

Ketoprofen (Oruvail, Orudis, Actron)

For relief of mild to moderate pain and inflammation.
Small dosages are indicated initially in patients with small body size, elderly patients, and those with renal or liver disease.
Doses >75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.

Flurbiprofen (Ansaid)

May inhibit cyclo-oxygenase enzyme, which in turn inhibits prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.

Corticosteroids

In contrast to the widespread systemic distribution of an oral anti-inflammatory drug, a local corticosteroid injection can achieve focal placement of a potent anti-inflammatory agent at the site of maximal tenderness or inflammation. When corticosteroid injections are used, there are a variety of corticosteroid preparations to choose from. Commonly, the corticosteroid is mixed with a local anesthetic agent prior to injection. Again, there are various local anesthetic agents from which to choose.

Methylprednisolone (Depo-Medrol)

Corticosteroids such as methylprednisolone commonly are used for local injections of bursae or joints, to provide a local anti-inflammatory effect while minimizing some of the GI and other risks of systemic medications.

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