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; patients should be counseled regarding this correlation so that their expectations can be managed more effectively.

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.

Impact reduction

Means of decreasing the effects of impacts include the following:

• 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 (consultation with a nutritionist, if available, should be considered)
• Use of soft cushions or insoles and soft-heeled footwear (see the first and second images below) ^[28]
• Taping, ^[29] arch supports, and custom-molded orthotics (see the third image below) ^{[30, 31]}

Anti-inflammatory measures

Application of ice, iontophoresis, or both may be helpful. ^[32]  Anti-inflammatory medication is useful in the early stages, especially if the patient has begun stretching exercises, which initially can worsen the pain (see Medication).

Stretching and strengthening

A variety of exercises can help the patient 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. ^[10] 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 the images below). ^[33]

Plantar fascia–specific stretching exercises

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 the image below).

A randomized, prospective study with 2-year follow up compared Achilles tendon stretching with plantar fascia–specific exercises. ^[34] The authors found plantar fascia–specific stretching exercises to be superior.

Rompe et al, ^[35]  randomly assigned 102 patients with acute plantar fasciopathy to perform an 8-week plantar fascia–specific stretching program (n = 54) or to receive repetitive low-energy radial shock-wave therapy without local anesthesia, administered weekly for 3 weeks (n = 48). ^[35] The primary outcome measures were a mean change in the Foot Function Index (FFI) sum score at 2 months after baseline, a mean change in item 2 on the FFI (pain during the first few steps of walking in the morning), and satisfaction with treatment. The stretching program was superior to repetitive shockwave therapy for treating acute symptoms of proximal plantar fasciopathy.

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 plantarflexion 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. ^[36] 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, need not be taken off before the patient gets out of bed (see images below).

Attard et al compared the effectiveness of the posterior night splint, which dorsiflexes the foot, with that of the anterior night splint, which maintains the foot in a plantigrade position. ^[37] In this study, two thirds of all participants confirmed that morning pain and stiffness was less after wearing the night splints; both types were relatively easy to don and doff, but the posterior orthosis was more uncomfortable and disrupted sleep. On average, the anterior night splint reduced heel pain more significantly than the posterior orthosis did.

Treatment of recalcitrant pain

If the pain persists persists for longer than 2 months despite the above treatment, then the following modalities can be offered.

Casting

A short leg walking cast for 6 weeks is generally effective in relieving pain, but the pain can recur after the cast is removed. ^[38] 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 two or three times per week. This therapy can provide short-term relief but 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 flatfoot deformity—especially if the injection is not administered deep into the fascia. ^[39]

Extracorporeal shockwave therapy

Extracorporeal shockwave therapy (ESWT) ^{[4, 40, 41, 39, 42]} was approved by the US Food and Drug Administration (FDA) in 2005; it had been used in Europe for more than a decade previously. Animal study data suggest that this modality creates microdisruption and stimulates new bone and tissue formation. Shockwaves may be delivered in three ways: (1) electrohydraulically (high power), (2) electromagnetically, or (3) 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.

Platelet-rich plasma injections

Platelets-rich plasma (PRP) is derived from autologous blood and contains high concentrations of growth factors necessary for tissue healing. The use of PRP in the treatment of plantar fasciitis is an evolving approach that is not yet widely accepted or practiced. ^[43]

A prospective study by Ragab et al evaluated 25 patients with chronic plantar fasciitis (mean age, 44 years) who were treated by means of PRP injection. ^[44] All patients were assessed for pain on the Visual Analogue Scale (VAS) before and after injection. The thickness of the plantar fascia was measured ultrasonographically before injection and at each postinjection follow-up visit (mean follow-up, 10.3 months). Average preinjection pain was 9.1 on the VAS (range, 8-10). Before injection, 72% of patients had severe limitation of activities, and 28% of patients had moderate limitation of activities.

Average postinjection pain in this study was 1.6 on the VAS. ^[44] Twenty-two patients (88%) were completely satisfied, two (8%) were satisfied with reservations, and one (4%) was unsatisfied. Fifteen patients (60%) had no functional limitations post injection, and eight (32%) had minimal functional limitations. Two patients (8%) had moderate functional limitations post injection. Ultrasonography showed significant changes not only in thickness but also in the signal intensity of the plantar fascia after injection. None of these patients experienced any complications from PRP injection at the end of the follow-up period.

Percutaneous radiofrequency nerve ablation

Percutaneous radiofrequency nerve ablation (RFNA) of the calcaneal branches of the inferior calcaneal nerve in patients with chronic heel pain associated with plantar fasciitis has also been used successfully in a few reports. However, there are no prospective randomized controlled studies comparing RFNA with other treatment modalities.

A prospective study by Erken et al reported their 2-year follow-up results of RFNA of the calcaneal branches of the inferior calcaneal nerve in 35 feet in 29 patients with chronic plantar heel pain associated with plantar fasciitis between 2008 and 2011. ^[45]  All of the patients who were treated had been complaining of heel pain for more than 6 months and had failed conservative treatment. The average VAS score of the feet was 9.2±1.9 before treatment, and the average American Orthopaedic Foot and Ankle Society (AOFAS) score was 66.9±8.1 (range, 44-80).

After treatment, the average VAS scores were 0.5 ± 1.3 at 1 month, 1.5 ± 2.1 at 1 year, and 1.3 ± 1.8 at 2 years. ^[45] The average AOFAS scores were 95.2 ± 6.1 (range, 77-100) at 1 month, 93 ± 7.5 (range, 71-100) at 1-year follow-up, and 93.3 ± 7.9 (range, 69-100) at 2-year follow-up. At the 1- and 2-year follow-up, 85.7% of the patients rated their treatment as very successful or successful.

Low-level laser therapy

Low-level laser therapy (LLLT) has demonstrated some early promising results for the treatment of acute and chronic pain. Jastifer et al reported on a study of 30 patients who received LLLT and completed 12 months of follow-up. ^[46] Patients were treated twice a week for 3 weeks for a total of six treatments. Patients demonstrated a mean improvement in heel pain VAS from 67.8 of 100 at baseline to 6.9 of 100 at the 12-month follow-up period. Total FFI score improved from a mean of 106.2 at baseline to 32.3 at 12 months post procedure.

Micronized dehydrated human amnion/chorion membrane injection

In a randomized controlled trial, Cazzell et al compared micronized dehydrated human amnion/chorion membrane (dHACM) injection (one injection in the affected area; n = 73) with 0.9% sodium chloride placebo (n = 72) for the treatment of plantar fasciitis. ^[47] They assessed safety and efficacy at 4 weeks, 8 weeks, 3 months, 6 months, and 12 months post injection, using the Visual Analogue Scale (VAS) for pain, the Foot Function Index–Revised (FFI-R) score, and the presence or absence of adverse events. The primary outcome was mean change in VAS score between baseline and 3 months; the secondary outcome was mean change in FFI-R score between baseline and 3 months.

Baseline VAS scores in this study were similar between groups. ^[47] At 3 months, VAS scores in the treatment group had a mean reduction of 76% versus baseline, whereas those in the control group had a mean reduction of 45%. FFI-R scores in the treatment group had a mean reduction of 60% versus baseline, whereas those in the control group had a mean reduction of 40%. Of the four serious adverse events noted, none were related to study procedures. The authors concluded that the pain reduction and functional improvement outcomes were statistically significant and clinically relevant, supporting the use of micronized dHACM injection as a safe and effective treatment for plantar fasciitis.

Other measures

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 through 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.

Multiple clinical recommendations, including the clinical consensus statement by the American Orthopaedic Foot and Ankle Society on the diagnosis and treatment of adult acquired infracalcaneal heel pain, ^[48] are available and are widely accepted. ^[10]

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 the 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 the lateral plantar nerve requires release of the tibial nerve and its branches and overlying fascia, including the deep fascia of the abductor hallucis.

Of patients with plantar fasciitis, 90% respond favorably to conservative care. Conservative methods should be tried for at least 6 months (preferably 12 months) before surgery is considered. Furthermore, patients should be fully counseled regarding the risks and benefits because complete satisfaction after surgery is observed in only 50% of patients.

For nonsurgical treatment, depot steroid injections can provide good short-term relief of symptoms; however, multiple injections can cause the plantar fascia to rupture and the fat pad to atrophy, especially if the injection is not administered deep into the fascia. ^{[49, 50, 51]}

Regardless of whether an open or endoscopic method is used for surgical correction, only 50% of the plantar fascia should be released, because a complete release can lead to collapse of the medial and lateral longitudinal arches.

Endoscopic plantar fascia release can be associated with a higher incidence of nerve damage and painful and hypersensitive neuroma. ^{[52, 53]}

Because overuse is the most common cause of plantar fasciitis in athletes, avoiding overuse can help prevent this problem. ^[54]