Overview
Plantar fasciitis is typically evaluated and treated without surgery, responding well to physical medicine and rehabilitation approaches such as stretching, splints (or other orthotic devices), modalities, and local injections.
One issue regarding physical medicine and rehabilitation for 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.
For further information on this topic, see the Medscape Reference article Plantar Fasciitis.
Physical Therapy
A retrospective study by Fraser et al, using a large patient record database, determined that between 2007 and 2011, among unique patients with plantar fasciitis who made an ambulatory care visit, only about 7% underwent evaluation by a physical therapist. Of those who were evaluated, the majority were treated with manual therapy and a course of supervised rehabilitation. [1]
The mainstay physical therapy for plantar fasciitis is stretching. [2] Many authors advise against considering surgical referral and intervention until a minimum of 6-9 months of comprehensive nonsurgical treatment has been completed.
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. Upon awakening, the patient 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). [3]
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. [4] Another study suggests that static progressive stretch bracing may be an effective alternative to static stretching exercises. The study showed no significant difference between static stretching exercises and static progressive stretch braces in terms of pain relief or functional improvement. [5]
According to a recent study investigating plantar fasciitis treatment options, no evidence supports gastrocnemius/soleus stretching as a stand-alone treatment to be as effective as plantar fascia-specific stretching. Gastrocnemius/soleus stretching may be beneficial as a supplement to the more isolated plantar fascia–specific stretching. [6]
In addition to stretching regimens, improving gait patterns can be helpful in patients with plantar fasciitis. By using arch-building gait patterns, patients with plantar fasciitis can help to modulate the pressure distribution in their feet and mimic biomechanics of patients without plantar fasciitis. Arch-building gait patterns can be achieved by practicing short-foot exercises. Short-foot exercises involve pulling the big toe towards the heel in a way that flexes the toe and effectively shortens the foot. [7]
Orthotics devices are a viable treatment option for patients with plantar fasciitis and are relatively inexpensive compared with other options. Orthotics devices are thought to reduce symptoms by diminishing and absorbing shock that is normally absorbed by the plantar fascia. Another theory proposed is the orthotics attempt to correct postural deviations or muscle deficiencies that may predispose an individual to developing plantar fasciitis. [8]
Commonly prescribed silicone inserts are effective in reducing pain and increasing functions in the short term. Both affordable and readily available, popular recommendation includes first-line treatment with silicone orthotics for patients with plantar fasciitis. [9]
Combined use of foot orthoses and night splits may provide better outcomes than either modality alone. [10]
Dorsiflexing both the ankle and metatarsophalangeal joints can reduce the tension of the posterior calf along with the plantar fascia, thereby reducing pain. These modalities can be applied both during the day, while being active, and at night, increasing the chance of pain reduction. [10]
While evidence has been somewhat inconsistent regarding the effectiveness of night splints and orthoses used separately for reducing pain caused by plantar fasciitis, recent studies suggest that the treatment protocol combining the 2 modalities is more effective than orthotics alone in relieving foot pain in patients with 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 perform this technique during 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 ultrasound, phonophoresis, or iontophoresis, to assist further with pain relief and reduction of inflammation.
A single-blinded study by Heigh et al indicated that intense therapeutic ultrasound is effective against chronic plantar fasciitis musculoskeletal pain. In addition to conservative standard of care, the study’s 33 patients underwent two ultrasound treatments 4 weeks apart. At 4-, 8-, 12-, and 26-week follow-up, 72%, 81%, 86%, and 79% of patients, respectively, met pain reduction criteria. Mean pain scores at these intervals varied from baseline by -39%, -49%, -51%, and -44%, respectively. [11]
In some cases, taping of the plantar fascia by an athletic trainer or physical therapist can help 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 activity level because of 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.
Corticosteroid injections
Local corticosteroid injections (CSIs) are a popular choice in the treatment of plantar fasciitis, but evidence supports their use for a short-term benefit only. [12] This conclusion was evidenced by a literature review by Li et al. Using a meta-analysis of four studies (289 patients total), the investigators found that although patients with plantar fasciitis who underwent CSIs experienced better pain relief after one month than did patients receiving placebo injections, no such difference was found between the two groups after two months. [13]
When comparing the use of CSI versus foot orthoses for long-term treatment, a study by Whittaker et al comparing the efficacy of both therapies at weeks 4 and 12 found orthoses to be more effective. [14]
The patient should be instructed to contact the physician before the scheduled follow-up appointment if there is significant progression of the symptoms or if there are any local signs of infection at the injection site.
A single-blinded, randomized, controlled superiority study by Johannsen et al indicated that CSIs combined with strength training and stretching are more effective in treating plantar fasciitis than is either therapy alone. Measuring pain at function using the Foot Function Index (FFI) and a 100-mm visual analogue scale (VAS) score, the investigators found mean FFI and VAS score differences of 40 points and 20 mm, respectively, between combined therapy and treatment with strength training and stretching alone. Mean FFI/VAS score differences of 29 points/17 mm were found between combined treatment and corticosteroid therapy alone. [15]
Platelet-rich plasma
Multiple studies have shown platelet-rich plasma (PRP) injections to be an effective treatment for plantar fasciitis. PRP is believed to benefit patients by promoting growth and repair of damaged tissue. A literature review by Alkhatib et al indicated that PRP injections are superior to CSIs in the treatment of plantar fasciitis. This was noted at 6-month follow-up, in the American Orthopaedic Foot and Ankle Society (AOFAS) Score (which measures functionality), and at 6- and 12-month follow-up, using the Visual Analog Scale (VAS) score (which measures pain). Despite this, no significant difference was seen between the PRP and CSI groups at 1 or 3 months with regard to the VAS score, indicating that PRP may be more beneficial for patients with chronic plantar fasciitis. [16]
In contrast, a literature view by Tseng et al showed no significant difference between patients with plantar fasciitis treated with autologous blood-derived products and those treated with CSI, with regard to the VAS or AOFAS scores at 3-6 weeks, 3 months, or 6 months. Nonetheless, the fact that these results differed from those of previous studies could be due to study design, in that this review included only randomized, controlled trials. [17]
Extracorporeal Shock Wave Therapy
Extracorporeal shock wave therapy (ESWT) is an effective treatment for reducing pain associated with plantar fasciitis. Shock waves are sound-wave vibrations that are generated and are transported through tissue by fluid and solid-particle interaction. This creates local tissue injury, causing new vessel growth, as well as increasing the amount of tissue growth factors within the localized area. Therefore, one of the proposed theories is that ESWT stimulates healing by creating a wound environment at the site of treatment.
Adverse effects include calcaneal pain, erythema on the calcaneal area, local edema, local paresthesia, and local bruising, all of which have generally been reported as short term and tolerable.
At moderate and high intensity, ESWT may reduce pain and improve function in patients with chronic plantar fasciitis and potentially reduce the need for invasive procedures (ie, surgery). The effectiveness of focused ESWT was demonstrated in a study by Gollwitzer et al on patients with chronic plantar fasciitis. The prospective, multicenter, double-blind, randomized, placebo-controlled study, which included 246 patients and a 12-week follow-up period, found that focused ESWT was successful in reducing heel pain in 50-65% of patients. [18]
Benefits to ESWT versus surgery include the risks associated with surgery such as swelling of heel pad, calcaneal fracture, injury to posterior tibial nerve or its branches, flattening of the longitudinal arch, and delayed recovery. ESWT can be administered in an outpatient setting, and patients are not required to avoid weight bearing to delay return to work.
ESWT is a cost-effective modality and one of the few treatments tested and supported with evidence-based medicine standards for approaching plantar fasciitis treatment. [19] However, ESWT may not be as effective as low-level laser therapy in producing pain relief in patients with plantar fasciitis. More specifically, low-level laser therapy may be capable of greater pain relief at short-term follow up of 3 months or less. [20]
A study by Bagcier et al involving 40 patients with plantar fasciitis indicated that the use of ESWT in combination with dry needling is more effective in reducing pain and improving functionality after 1 month than ESWT alone. Dry needling is believed to benefit the patient by decreasing the sensitivity of trigger points, which in turn may reduce the perceived pain the patient feels when stretching. This would permit more efficient stretching and increased physical activity. [21]
A prospective, randomized, 1-year follow-up study by Çağlar et al indicated that ESWT and foot orthoses have similar short- and medium-term benefits in plantar fasciitis. However, the use of foot orthoses produced better long-term benefits (>24 weeks). [22]
A study of 60 patients with plantar fasciitis concluded that a variation of ESWT, extracorporeal pulse-activated therapy (EPAT), should be recommended as a first-line treatment for the condition when compared with CSI. [23]
In a study involving 88 patients with plantar fasciitis, Dedes et al reported that although ESWT and ultrasound therapy are both effective treatments, ESWT showed superior results at 4-week follow-up. [24]
Endoscopic plantar fasciotomy (EPF) and ESWT are both effective for treating chronic plantar fasciitis, with EPF favored for outcome. However, ESWT treatment could be preferred since the athlete can remain active while undergoing treatment. Therefore, ESWT may be a viable first-line treatment with little disadvantages, especially when an athlete wishes to continue to be active. [19]
