Approach Considerations
Understanding the etiology of the problem and directing treatment accordingly is the key to successful treatment of plantar fasciitis. Close attention must be paid during the history and physical examination to ensure that other potential causes of heel pain are not missed. An organized, evidence-based, stepwise approach to treatment will help achieve good outcomes. Also essential is educating the patient about the expected time of recovery.
Plantar fasciitis is typically a self-limited condition, and studies have reported a resolution incidence of up to 90% with nonsurgical measures. [26, 39, 36, 40, 41, 42] 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.
The major component contributing to discomfort is the irritation occurring secondary to the disease process, rather than a spur or other mechanical factor. Traditional therapeutic efforts have been directed at decreasing the presumed inflammation. These treatments include icing, nonsteroidal anti-inflammatory drugs (NSAIDs), rest and activity modification, corticosteroids, botulinum toxin type A, splinting, shoe modifications, and orthoses.
Other treatment techniques have been directed at resolving the degeneration caused by the disease process. In general, these techniques are designed to create an acute inflammatory reaction with the goal of restarting the healing process. These techniques include autologous blood injection, platelet-rich plasma (PRP) injection, nitroglycerin patches, extracorporeal shock-wave therapy (ESWT), and surgical procedures. Formal physical therapy can include components that target both goals.
It is important to note that these treatment modalities are to be used in combination, as components of a multimodal therapeutic approach. Such an approach can be challenging, in that it places high expectations on the patient with respect to responsibility, consistency, and compliance. If these expectations are met, the chances of success are good.
Traditional treatment algorithms usually begin with 6 weeks of consistent and daily icing, stretching, NSAID therapy, strapping and taping, and over-the-counter (OTC) 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, an injection, along with the initial regimen for another 6 weeks.
If pain persists, 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. For severe recalcitrant cases, surgical intervention may ultimately be required.
A study looked to determine whether initial clinical findings could help predict patient response to conservative treatment primarily consisting of supportive footwear and stretching. The study reported that patients with severe ankle equinus were nearly four times more likely to experience a favorable response to treatment centered on home Achilles tendon stretching and supportive therapy. [43]
Icing
Ice is a first-line anti-inflammatory treatment for plantar fasciitis, especially for athletes. Icing should be performed after completing exercise, stretching, and strengthening, and this treatment can be applied via ice massage, ice bath, or ice pack, as follows:
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For ice massage, the patient freezes water in a small paper or polystyrene cup and then rubs the ice over the painful heel, using a circular motion and moderate pressure for 5-10 minutes.
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For an ice bath, a shallow pad is filled with water and ice, and the patient soaks the heel for 10-15 minutes; to prevent cold injuries, neoprene toe covers should be used, or the toes should be kept out of the ice water
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For an ice pack, crushed ice is placed in a plastic bag wrapped in a towel, then applied for 15-20 minutes; the use of crushed ice allows the pack to be molded to the foot, thereby increasing the contact area (a bag of prepackaged frozen corn kernels wrapped in a towel is a good alternative)
Rest and Activity Modification
Rest is critical to the treatment of plantar fasciitis. This includes activity modification or a level of relative rest; 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. [26]
Athletes with plantar fasciitis may return to activities as limited by their symptoms. However, they must modify activities that can aggravate plantar fasciitis (eg, walking, running, and jumping); such modifications may be as simple as decreasing the amount, frequency, or intensity of the inciting activity or activities. Athletes are more compliant with a decreased level of activity if they are allowed to increase other nonaggravating activities. [44]
The physician might need to plan a strict activities regimen because many athletes tend to ignore pain during activity. Generally, athletes should start at 50% of their usual distance or time with a gradual increase of activity by approximately 10% per week.
The following recommendations are appropriate for runners:
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Replacing worn-out shoes and selecting appropriate shoes are also important; runners should replace shoes every 250-500 miles (400-800 km) to maintain optimum shoe cushioning [20]
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Runners who overpronate and who have pes planus should select motion-control shoes, which typically feature a straight-lasted, board-lasted, or combination-lasted construction; an external heel counter; a wider flare; and extra medial support. [20]
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Runners who have pes cavus should select shoes that have greater cushioning properties
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All distance runners should practice in training flats that are better cushioned, reserving the lighter and less well-cushioned racing flats for competition.
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Runners whom are considering starting barefoot running style programs should be cautioned to start these runs at lengths and intensities as if they are beginning runners.
Pharmacologic Therapy
NSAIDs
Anti-inflammatory medications are frequently used to treat plantar fasciitis. Although there is controversy as to whether NSAIDs actually assist in the physiologic healing process, these agents can be useful as an adjunct for controlling pain while the individual’s plantar fasciitis is being treated with stretching, strengthening, and relative rest. [26, 45]
In one study, 79% of patients were successfully treated with NSAIDs. [26] The key to NSAID therapy is consistent, daily dosing throughout the acute phase of treatment. Risks such as gastrointestinal (GI) sequelae, gastric pain, and renal damage have been well documented. [46] Use NSAIDs with caution in elderly patients, monitoring for the most common adverse effects and for any drug interactions. Oral NSAIDs should be avoided during pregnancy.
Corticosteroids
Corticosteroids can be administered either orally or via injections. Oral preparations, such as a methylprednisolone dose pack, are distributed systemically and can be used in the acute phase in conjunction with, or in place of, NSAIDs.
Corticosteroid injections, on the other hand, involve local, concentrated administration and are generally reserved as a tertiary level of treatment after failure of other primary conservative measures (eg, stretching, shoe inserts, or orthoses) in severe recalcitrant cases. [47, 48, 49] Whether or not injected corticosteroids alter the long-term pathology of chronic inflammation, many patients experience acute symptomatic improvement. [45, 50, 51] One study found that ultrasound (US)-guided steroid injection provided short-term relief from pain in plantar fasciitis for up to 4 weeks and improvement in plantar fascia swelling for up to 12 weeks. [52, 53] Whether or not the use of ultrasound guidance improves outcome of corticosteroid injections is unknown at this time. [54, 55, 56] A single-blinded, randomized, controlled trial of 90 patients found that at 2-year follow-up a combination of injected corticosteroid and physical therapy was superior to either of the treatments alone. [53]
Before steroids are injected, potential causes of heel pain other than plantar fasciitis should also be considered, and a plain radiograph of the foot or calcaneus should always be obtained.
A corticosteroid injection may be given through a plantar or a medial approach, with or without ultrasound guidance, typically in conjunction with a local anesthetic. The basic technique may be briefly summarized as follows:
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Use a 22-gauge, 1.5-in. (3.8-cm) needle containing a mixture of 4 mL of local anesthetic (eg, lidocaine) and 1 mL (40 mg) of corticosteroid (eg, methylprednisolone)
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Palpate the most anterior aspect of the medial plantar calcaneal tubercle, and insert the needle at this site
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Advance the needle until it reaches the most anterior (distal) aspect of the plantar medial calcaneal tuberosity
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When the proximal (anterior) edge of the heel spur has been identified, advance the needle immediately anterior to this spot
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Avoid injecting within the superficial layers of the subcutaneous tissue, because corticosteroid injection into the superficial fat pad can cause fat necrosis and atrophy, which reduce the shock-absorbing capacity of the plantar heel
Studies have reported success rates of 70% or better. [39, 57] Corticosteroid injections have been shown to improve symptoms at 1 month but not at 6 months. It is recommended not to give more than 3 steroid injections within a year.
A randomized, controlled study demonstrated that intralesional corticosteroid injection is more efficacious and more cost-effective than low-energy ESWT in the treatment of plantar fasciitis that has persisted for more than 6 weeks. [58]
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. [59]
Trials of ultrasound-guided steroid injection have shown its potential efficacy. This approach has been shown to produce a good clinical response when palpation-guided injection is unsuccessful. [57] Accurate injection under ultrasonographic guidance may also minimize adverse effects from the injection. [60]
A study of 25 patients who received corticosteroid injections for plantar fasciitis showed that patients received symptomatic relief as measured by tenderness threshold and a visual analog scale (VAS). [60] Although this benefit was obtained whether the injection was performed with imaging (ultrasound) guidance or with palpation alone, patients receiving image-guided injections had a lower rate of recurrence of heel pain. Thus, although injection is helpful with or without imaging guidance, the use of imaging may provide additional benefit.
Overall, it would appear that while cortisone is effective in providing short term pain relief, ultimately there is no significant difference in outcome from other treatments. [61, 62]
The general risks involved with the use of corticosteroids include skin atrophy, skin hypopigmentation, soft-tissue atrophy, infection, bleeding, and failure to work. A steroid flare-up, which consists of increased pain for up to several days, may occur in up to 2% of individuals who use corticosteroids. [50]
Potential risks of corticosteroid injection include plantar fascia rupture, which was found in almost 10% of patients after plantar fascia injection in one case series, [28] and fat pad atrophy. [28, 29] Long-term sequelae were found in approximately 50% of patients with plantar fascia rupture. [28]
Improper placement of a corticosteroid injection for plantar fasciitis can result in necrosis and atrophy of the plantar fat pad at the heel. This complication may result in significant pain and a decreased activity level for the patient.
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. Allergic reactions to the injected medications are rare, but possible.
Intravascular injection could potentially cause cardiac dysfunction as a consequence of 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.
In diabetic patients, transient elevation of blood glucose levels may occur after corticosteroid injection. Corticosteroid injection can be performed during pregnancy, although safety for use during pregnancy has not been established. With pediatric patients, obtain informed consent from the parent or legal guardian before proceeding with examination or any injection.
Patients should be informed that the symptomatic improvement from the corticosteroid usually does not begin to take effect until a few days after the injection. They may experience a transient, mild increase in symptoms when the effect of the short-term local anesthetic has ended, but the long-term corticosteroid effect has not yet begun.
Finally, they should be educated to watch for any signs or symptoms of local infection at the injection site, while maintaining good skin hygiene.
Botulinum toxin type A
Several short-term, randomized, controlled, double-blind studies found that botulinum toxin type A injection appeared to yield significant improvements in pain relief and overall foot function. [63, 64, 65, 66] One of these studies found that ultrasound-guided injection of botulinum toxin type A did not induce the complication of fat pad atrophy and was successful at improving the maximal center of pressure loading in the foot. [64] A double-blind, randomized, controlled study of 50 patients with plantar fasciitis compared the injection of botulinum toxin type A to saline injection and found that there was significant improvement in VAS pain scores and plantar fascia thickness at both the 3-week and the 3-month follow-up visits. [64] A 6-month, randomized, controlled, double-blind study that compared botulinum toxin type A injection to corticosteroid injection in 36 patients found a more rapid and sustained response in the botulinum toxin–injected group. [65]
Autologous blood and plasma
Injection of autologous blood into the plantar fascia origin is thought to stimulate an acute inflammatory reaction, providing factors that stimulate fibroblast activity and vascular growth and thereby lead to reinitiation of the healing process. This treatment has been shown to be effective in limited studies of chronic inflammatory musculotendinous conditions. [67, 68, 69]
There is some evidence to suggest that platelet-rich plasma (PRP) may be beneficial in the treatment of chronic plantar fasciitis. [70, 71, 72, 73, 61] Most of the studies that compared corticosteroid injection with either autologous blood or PRP injections appear to show that while corticosteroids may provide better short-term relief, autologous blood and PRP injections have better long-term results. [52, 74, 75, 76, 77, 78, 79, 52, 80, 81] On the other hand, studies concluded that the results of PRP were only equivalent to corticosteroid injection [82] or placebo. [83]
Cryopreserved human amniotic membrane
One newer, experimental treatment involves the injection of cryopreserved human amniotic membrane. This fetal tissue is believed to contain growth factors, cytokines, and matrix components, which promote soft tissue healing. A randomized, controlled, double-blind, pilot study of 23 patients found equivalent results to the control group, which had been injected with corticosteroid, at the 12-week follow-up. [84]
Prolotherapy
Although the technique of prolotherapy injection has been used for many decades, research is scant. A more recent double-blinded, randomized, controlled study of 65 patients showed good relief at 7- and 15-week follow-up visits. [85]
Extracorporeal Shock-Wave Therapy
ESWT has been proposed as a treatment option for plantar fasciitis. The therapy bombards the tissue with high-pressure sound waves with its mechanism of action being to (1) stimulate blood flow for a beneficial immune response, (2) reinjure tissue to stimulate healing, and (3) shut down the neuronal pain pathways through the pulses hitting the affected nerves.
Although ESWT has not been definitively shown to be effective, it has been approved by the US Food and Drug Administration (FDA) for the treatment of plantar fasciitis and tennis elbow. ESWT is noninvasive, has few adverse effects, and is associated with a good recovery time in patients with chronic plantar fasciitis; however, it is not covered by most insurance plans.
In 2013, two meta-analyses concluded that ESWT could be a safe and effective nonsurgical treatment for plantar fasciitis. [86, 87] Some studies show favorable results with ESWT but recommend that it be used only after other noninvasive, proven measures have failed. [88] Although multiple studies have shown success rates of 50-90%, [89, 90, 91, 92, 93, 61, 94] overall, study results have been mixed. [95, 96, 88, 97, 98, 47, 48, 99, 100, 101, 102]
One study used low-frequency electrical stimulation to safely treat pain and increase functional activity levels in patients with plantar fasciitis. [103, 104]
Another study showed that ESWT induces an immediate analgesic and anti-inflammatory effect, as well as long-term tissue regeneration. ESWT has been observed to increase blood flow in the treated area, and preliminary data indicate increased endothelial nitric oxide levels as the mechanism. After 4-8 weeks of treatment, ESWT was also found to increase neoangiogenesis in the tendons of dogs; further research in this area is needed. [105]
Focused ESWT seems to be superior to radial ESWT. [106] However, a study that compared shockwave treatment with conventional physiotherapy for treating plantar fasciitis showed that whereas shockwave treatment yielded earlier pain reduction and functional improvement, it was no more effective than conventional physiotherapy 3 months after the end of treatment. [107]
In 2013, three different meta-analysis studies concluded that ESWT was effective compared to placebo. [108, 109, 110]
A pilot study suggests that intracorporeal pneumatic shock treatment (IPST) may be used in patients with chronic plantar fasciitis that does not respond to conservative management. IPST may be considered before surgery when ESWT devices are not available. A randomized, double-blind, prospective clinical pilot study showed that IPST is safe and effective; however, the exact mechanism is unknown and thus warrants further research. [111]
Laser Therapy
Laser therapy is a newer technique that has not been well studied. Theoretically, low-level lasers are supposed to stimulate metabolism via the inflammatory pathways. A meta-analysis of 6 randomized controlled trials suggests that low-level laser therapy might provide short-term pain relief. [112]
Splints and Orthoses
Night splints
Most people naturally sleep with their feet in a plantar-flexed position, which causes the plantar fascia to be shortened. Night splints maintain a neutral 90° foot-leg angle and provide constant passive stretching of the Achilles tendon and plantar fascia. [113] Their effectiveness is believed to derive from the rest and healing provided by the constant stretching. In addition, the passive stretching helps prevent microtrauma at the plantar fascia–bone interface with the first steps out of bed in the morning.
A night splint can be molded from either plaster or fiberglass casting material, or a prefabricated and commercially produced plastic brace can be used (see the image below).
Night splint, designed to prevent shortening of Achilles tendon and plantar fascia at night.
A number of studies have shown that a high percentage of patients using night splints had improvement of their plantar fasciitis. [114, 115, 116, 117, 118, 119, 120] Regarding the difficulty of patient compliance with night splints, a prospective trial showed that the comfort afforded by the night splint resulted in 95% patient compliance. [118] Some studies suggest that the splints are especially useful in individuals who have had symptoms of plantar fasciitis for longer than 12 months. [114, 115, 116, 117]
Casts or splints holding the ankle in neutral to slight dorsiflexion have been investigated, although their efficacy remains to be determined.
Shoe modifications and orthotics
A supportive heel counter and stiff midsole are important components of any shoe for those experiencing heel pain. Fashionable shoe wear often does not provide sufficient support for the arch and further exacerbates the problem. Better cushioned footwear may also decrease symptoms of plantar fasciitis. [121] A randomized, double-blind study comparing patients' sandals with and without arch support found significant improvement in pain and function in the group with the arch supports. [122] In general, lace-up shoe gear is recommended to maximize support. In one study, [26] 14% of patients credited change in shoe gear as the best treatment.
Shoe inserts (see the images below) can be used with existing shoes. Orthoses may be purchased over the counter or can be custom made. In general, over-the-counter (OTC) and custom-made orthoses appear to be equally effective in treating plantar fasciitis. [123, 124, 125, 126, 113, 127, 120] However, one randomized, controlled trial found that ethylene vinyl acetate (EVA) prefabricated inserts may be more beneficial than custom-made ones in uncomplicated plantar fasciitis. [128] One randomized, prospective study found that more supportive orthotics resulted in better pain relief when compared with softer, non-supportive orthotics [129] ; on the other hand, another found both hard and soft orthotics provided equal relief. [130]
A systematic review and meta-analysis by Whittaker et al that included 19 trials (1660 participants) reported that in the medium term (7 to 12 weeks), there was moderate-quality evidence that foot orthoses are effective at reducing plantar heel pain in adults. In the short and longer term (0 to 6 weeks and 13 to 52 weeks), there was low-quality evidence that foot orthoses reduce pain or improve function. [131]
Example of arch support with cushioned heel. These are available in three-quarter or full lengths to fit in shoe.
Patients with low arches experience increased stress on the plantar fascia with foot strike and have a decreased ability to absorb the forces that are generated by foot strike. [20] Mechanical corrections for pes planus include taping of the arches, OTC arch supports, and custom orthotic devices. Studies have found significant benefit to these conservative treatments when they are used in appropriate patients. [26, 132, 127, 133, 120, 130]
Low-dye strapping with athletic tape (see the image below) can be used as a definitive treatment or as a trial to determine whether the expense of arch supports or orthotics is worthwhile. Taping may be more cost-effective for the acute onset of plantar fasciitis, whereas OTC arch supports and orthotics may be more cost-effective for chronic or recurrent cases of plantar fasciitis and for the prevention of injuries. Heel pads are widely used, but they are generally useful only for shock absorption and do not provide support or structural control. [134] A meta-analysis concluded that kinesiotaping was no more effective than standard taping techniques. [135]
Low-dye taping method. This technique provides support for plantar fascia and helps reduce excessive pronation.
OTC arch supports usually last a full athletic season; custom orthotic devices should last many seasons. OTC arch supports are especially useful in athletes with acute plantar fasciitis and mild pes planus, particularly adolescents whose rapid foot growth may necessitate the purchase of 1 or more new pairs of arch supports per season.
Custom orthotic devices are designed to control biomechanical risk factors such as pes planus, valgus heel alignment, and leg-length discrepancies. Athletes treated with orthotic devices usually require semirigid, three-quarter to full-length orthotic devices with longitudinal arch support to control overpronation and metatarsal head motion, especially of the first metatarsal head. [136] The main disadvantage to the use of orthotic devices is the cost, which ranges from $75 to $300 or more; frequently, these devices are not covered by insurance. Studies have suggested that over-the-counter insoles are often as effective as these custom orthotics [137] or are not needed at all. [138]
Physical Therapy
As a second level of treatment, formal physical therapy can help get the patient obtain long-term pain relief if he or she is unable to do so on his or her own. Contrast baths, ultrasonography, and iontophoresis may be used as adjuncts. In one study, iontophoresis was found to increase the speed of resolution of plantar fasciitis, though it had no effect on long-term outcome. [139]
For convenience, physical therapy programs may be divided into stretching, strengthening, and maintenance phases.
Stretching
The initial physical therapy program for plantar fasciitis emphasizes stretching of the calf and foot. Although the exact benefits are unknown, [140] one study found that 83% of patients treated with stretching exercises experienced successful relief. [26] Accordingly, stretching of the Achilles tendon has become a key component in the resolution of heel pain.
Wall stretching (the runner’s stretch) with the knee in both the extended and flexed positions, stair stretching, and towel stretching are all commonly employed. To perform a wall stretch, the patient stands 3 feet from a wall, placing the hands on the wall. Keeping the toes pointed straight and the heel on the ground, the patient leans the hips toward the wall, then holds this position for 30-40 seconds (see the image below). [8]
Stretches targeted at the plantar fascia (see the image below) are particularly important. 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. [141] 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.
Strengthening
A strengthening program that emphasizes intrinsic foot muscle strengthening has also proved beneficial. [27] . Exercises to strengthen the intrinsic muscles include towel curls, marble (or coin) pickups, and toe taps. [8]
For a towel curl, the patient sits with the affected foot lying flat on the end of a towel that is placed on a smooth surface, then pulls the towel toward the body by using the toes to curl up the towel while keeping the heel on the floor (see the image below). As the patient’s ability to perform this exercise improves, weight may be added to the far end of the towel to increase the difficulty.
For marble pickups, the patient places a few marbles on the floor near a cup, picks them up with the toes, and drops them in the cup while keeping the heel on the floor. To provide a greater challenge, coins may be substituted for the marbles.
For toe taps, the patient lifts all the toes off the floor and, while keeping the heel on the floor and the outside 4 toes in the air, repetitively taps just the big toe to the floor (see the image below). Next, the patient reverses the process and repetitively taps the outside 4 toes to the floor while keeping the big toe in the air.
Maintenance
To minimize the likelihood that plantar fasciitis will recur, athletes should continue on a maintenance program of daily stretching or strengthening at least 2-3 times per week.
Fasciotomy
In 5-10% of cases of plantar fasciitis, surgery may be required. [40, 39, 41, 142] 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. [143, 144] 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. [145]
Overall, surgical release has a 70-90% success rate in treating patients with this condition. [146, 147, 148, 149, 150, 151, 152] A study by Bazaz and Ferkel found that endoscopic plantar fascia release provided significantly improved outcomes for patients, specifically those with less severe symptoms. [153]
Potential complications of surgical intervention include flattening of the longitudinal arch and heel hypoesthesia, in additions to the complications associated with plantar fascia rupture and corticosteroid injections. Longitudinal arch strain appears to account for over 50% of the chronic complications. [28, 29]
Percutaneous Procedures
Percutaneous partial fasciotomy
In a series of 55 patients, percutaneous variation of medial fascial release appeared to have similar long-term pain outcomes to open fasciotomy with quicker return to activity. [154]
Cryosurgery
Cryosurgery is a relatively new technique in which a small cryoprobe is inserted percutaneously and used to destroy pathologic tissue or cells at temperatures reaching -70° C. A prospective study of 61 cases suggests that this modality is an effective treatment for plantar fasciitis after failed conservative management. [155] A larger study of study of 137 feet reported a 77% success rate with cryosurgery at 2-year follow-up. [156]
Bipolar radiofrequency microdebridement
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 equivalent 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 achieved an average American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score of 92 out of a possible 105 at an average of 11 months after operation. [157] In another small study of 31 feet, radiofrequency nerve ablation resulted in significant improvement in VAS scores at 1 week, 1 month, 3 month, and 6 months. [158] Long-term, randomized, double-blind studies are still needed. As with any surgical procedure, the risk-benefit ratio must be determined.
Radiation Therapy
A relatively new option for recalcitrant plantar fasciitis is radiation therapy. Studies of this treatment are relatively limited, but preliminary outcomes are positive. Long-term effects are still unknown. [159, 160]
Prevention
Education is the single most important means of preventing plantar fasciitis. Instruct athletes with plantar fasciitis to warm up sufficiently before initiating activity, continue stretching programs, and ice down after activity. Patients may need to decrease their running temporarily; later, they may resume their earlier level of activity at the discretion of the physician and physical therapist.
Make sure that sports-minded patients wear appropriate shoes and change to a new pair every 250-500 miles (400-800 km). [20] Alternating between 2 pairs of shoes seems to help some athletes by allowing the cushioning in the shoes to recover more completely between runs. Adequate padding, proper sole stiffness, and appropriate arch support all can help alleviate symptoms.
In cases of occupationally related plantar fasciitis, evaluation of the worker’s shoes and work environment is essential for preventing a recurrence of this musculoskeletal condition. [19]
Long-Term Monitoring
In general, patients should return for reevaluation no sooner than 2 months after the initial evaluation and implementation of a rehabilitation program since progress is typically slow. Occasionally, patients requiring more aggressive treatment because of severe disruption of their athletic, occupational, or recreational activities may need to be seen more frequently, mainly so that the caregiver can provide reassurance and chart the progress of therapeutic interventions.
At the time of follow-up, assess the therapeutic response to the corticosteroid injection, and evaluate for any complications.
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Weight-bearing windlass test.
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Calf stretch.
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Towel curl.
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Toe taps.
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Night splint.
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Low-dye taping method. This technique provides support for plantar fascia and helps reduce excessive pronation.
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Example of arch support with cushioned heel. These are available in three-quarter or full lengths to fit in shoe.
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Example of night splint. These are intended to prevent shortening of Achilles tendon and plantar fascia at night.
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Orthosis
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Night splint, designed to prevent shortening of Achilles tendon and plantar fascia at night.
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Plantar fascia stretching exercise.
