Why Orthotics Are Not The Answer For Plantar Fasciitis

There are approximately 2 million documented cases of plantar fasciitis per year in the United States. For most podiatrists, this is the most common foot pathology we see in our practices.1 The “sacred cow” in the podiatric community for plantar fasciitis has always been custom orthoses.

However, I have a slightly different opinion on the role of custom orthoses for the treatment of plantar fasciitis. I do not think custom orthoses are a treatment at all for acute plantar fasciitis. This is coming from someone who prescribed an average of 31 pair of custom orthotics per month over the past 12 months. So what gives?

I have come to believe that treatment in plantar fasciitis cases is a two-stage process, which involves an acute inflammatory stage treatment and a long-term stage treatment. I firmly believe that one must treat patients “acutely” and must reduce their level of pain to a 1 or 2 on a Visual Analog Scale (VAS) before you can proceed with long-term stage treatment. The long-term treatment is consistent from patient to patient for me but the acute-term treatment is variable and driven by patient response.

A Closer Look At Treating Acute Pain

The acute term treatment starts with three very easy steps. The first is supporting the plantar fascia with taping. I love taping and did it an average of 45 times per month over the past 12 months. I used to have the patients leave the taping on for a full week. Recently though, I have started to have them come in about three to four days after the initial taping to be re-taped. I will usually tape someone two to four times before moving on to the next step.

The second thing I do on the initial visit is dispense a night splint to treat equinus. A recent study showed that 83 percent of the cases of plantar fasciitis are associated with equinus.2 I typically have patients use the night splints for two to three months or until symptoms have completely resolved. One dilemma for me has always been those cases of unilateral plantar fasciitis. It makes no sense to me to only stretch one side. In my mind, this is creating a functional limb length discrepancy. Therefore, I usually use night splints on both limbs.

The final part of the initial visit treatment is doing something to get the symptoms of inflammation under control. I like to start with a Medrol Dosepak. I know some prefer an injection to the oral medication but let us face it: injections hurt. If I can avoid them, the patient is much happier.

If the patient is responding positively, the next step of the acute term treatment is to switch from the taping to a plantar fascia brace to continue to support the plantar fascia. I will typically have patients use this for two more weeks and continue stretching with the night splints. If the patient is not progressing in a positive direction, I will use an injection at this point and see him or her back in two weeks. If patients are still not progressing as expected, I will emphasize cast boot immobilization for two to four weeks to calm the symptoms down.

Then I will start back at where we left off in the treatment plan. If things are still not progressing as expected, I often will get a magnetic resonance image (MRI) to evaluate the condition, especially when it comes to looking for changes consistent with entrapment of Baxter’s nerve. If these changes are present on the MRI, I will confirm this with a diagnostic nerve injection. If this diagnosis is confirmed, this becomes much more of a surgical problem.

What You Should Know About Preventative Long-Term Treatment

Once the patient is at a pain level of 1 or 2 on the VAS, then I proceed to long-term treatment and this consists of orthoses. I think the purpose of the orthotic is not to treat the condition but to prevent the condition from recurring once the patient is asymptomatic and the equinus deformity has resolved. Patients with an inflamed heel do not tolerate a rigid or semi-rigid orthotic well. Additionally, and most importantly, equinus will cause a dorsiflexion moment of the forefoot and plantarflexion moment of the rearfoot. These motions with a rigid or semi-rigid orthotic pushing up into the arch will often result in poor tolerance of the device by the patient.

Final Notes

I recommend treating the patient in two stages with acute term and long-term treatment. Once patients are asymptomatic, you can subsequently offer them long-term preventative treatment with custom orthoses if you have resolved any equinus deformity. I think you will find this approach produces consistent results and will additionally result in better practice profitability.

References

1. Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for plantar fasciitis: a matched case-control study. J Bone Joint Surg Am. 2003; 85-A(5):872-877.

2. Patel A, DiGiovanni B. Association between plantar fasciitis and isolated contracture of the gastrocnemius. Foot Ankle Int. 2011; 32(1):5-8.