Rethinking The Treatment Options For Plantar Fasciitis

Plantar fasciitis is at epidemic levels with suggestions that one in six Americans may have the condition.¹ Patients often attempt to treat plantar fasciitis at home prior to seeing a doctor. In my experience, the majority of patients treat their heel pain poorly and tolerate it for an extensive period of time, from months to years, prior to seeking professional care. While some clinicians have stayed the course with the plantar fasciitis treatments they have offered and performed over the years, others have changed up their protocols along the way. After 20 years in practice, I wanted to share my current treatment regimen for plantar fasciitis and how I arrived at this protocol.

When I was in podiatry school, I remember early conversations about the treatment of plantar fasciitis. It was quite simply explained as a “strain” of the plantar fascia and “inflammation” of the heel attachment of the plantar fascia. This is not untrue but it is very simplistic. Treatments for plantar fasciitis consisted of taping and strapping of the foot to support the fascia, cortisone injections of the fascia once a week for three weeks and then, if necessary, an orthotic.

I always found this treatment approach a bit hard to comprehend but, as a good student would, I learned the rules and went on to residency. In my residency, I quickly realized that the cortisone injections only worked about 20 percent of the time and patients did not want tape on their foot for one week. The tape would smell and create a rash, and was not quite the best treatment for the three weeks that I was injecting cortisone. Orthotics were not covered in at my practice in Pittsburgh so we did not really offer them. If patients did not do well with the “conservative” care for about a month, we placed them in a cast for another month or two. If that did not work, we considered surgery.

We did a lot of endoscopic plantar fascia releases, maybe as many as 20 a week. I was so good at them by the time residency was over that I could do a release in about eight minutes start to finish without rushing. It was so simple and it should have worked so well, but only 80 percent of patients got better. Some stayed the same and a few got worse. Why was this happening? I released the fascia off the heel so it should not have pulled on the bone any longer but there was still pain.  

After joining UCLA for my initial job, I began to see how doctors at a world- class institution treated plantar fasciitis. I noticed physicians used orthotics much more commonly, both over-the-counter and custom orthotics. Patients had shoe modifications and extensive physical therapy. The physical therapy office was next door to our clinic and I spent some time there for about six weeks. It was the first time I noticed the patients with plantar fasciitis being treated with a metal object to “scrape” the bottom of their foot. After getting to know the technique, I realized that the instrument was for a Graston or Astym scar tissue break up in the fascia and Achilles.

I found this intriguing and followed my patients who were getting this technique. Again though, I saw mixed results. Over time, I realized the reason why everyone was getting the treatment and that it is not meant for everyone. Cortisone was still the mainstay of treatment for plantar fasciitis and it still was not very good.  
After opening my own location with my partner, Gary Briskin, DPM, we really started with a clean slate. We thought about every condition and its treatment, and began to incorporate algorithms that we still use today although we have adjusted and updated these along the way. We began to consult with our institute’s on-site physical therapist to see what he considered best practices. We also began to work with our orthotic and prosthetic specialists to consider their best practices, and come up with a team approach to the treatment of heel pain.

I hope the current treatment ideas I provide below let you think deeper about heel pain, what you do for it and why.

Differentiating Between Acute And Chronic Plantar Fasciitis

Plantar fasciitis is actually a multitude of conditions that affect the heel. The affected areas may include the plantar fascia insertion on the heel bone, the calcaneal bursa, the actual heel bone and the nerves on the medial side of the heel and the plantar heel.

One can divide plantar heel pain into an initial inflammatory problem we call plantar fasciitis, which is commonly present for the first three to six months, and a chronic non-inflammatory plantar fascia problem we call plantar fasciopathy. It is important to keep the six-month window in mind. Patients will have similar complaints of initial heel pain with first steps, which improves within a few minutes of walking, but often the chronic state involves residual pain that does not completely resolve. Central heel pain that increases with walking and activity can be the result of either an issue with the heel bone or the bursa. Finally, nerve pain in the heel region can result in a multitude of pain symptoms and is the most difficult to diagnose. There can be an issue with strain or damage to the tarsal tunnel, an inflammation or muscular strain of the calcaneal branch, or a neuropathic condition that may be causing the pain.

For now, we will leave out back pain as a source of nerve pain in the heel but this should also be a consideration. Often, patients will say they have more pain with sleep or sitting if the heel pain is resulting from pain in their back.

Of course, the main issue to consider is the actual plantar fascia pain. If the pain has only been present for a short time, it is mainly inflammatory and a strain of the fascia. If the patient has had the problem for over six months, it is rarely an inflammatory condition any longer and more commonly a chronic scar formation with microtears of the fascia causing the pain.  

Key Considerations For The Initial Patient Visit And Workup

The initial patient visit consists of an extensive history and a series of questions to consider the length of time the patient has had pain and what he or she has done to treat it. We will consider the shoe gear requirements and needs, the patient’s use of an orthotic or over-the-counter insole, his or her history of stretching and equinus issues, and whether there was an actual event that precipitated the problem or if it was just chronic damage over time.

We will obtain a lateral radiograph of the weightbearing foot in order to check foot alignment, see if there is a spur present and also to ensure there is no cyst or fracture present. However, a large part of our diagnostic testing centers on the use of ultrasound to image the heel region, the plantar fascia, the calcaneal bursa and the nerve branches leading to the foot in the tarsal tunnel. We do not use ultrasound to diagnose tarsal tunnel syndrome but can use ultrasound to see if there is a space-occupying lesion or any form of venous congestion in the tarsal tunnel. The plantar fascia is very easy to image and we check the consistency of the fascia, whether there is tearing present, scar tissue present and what the insertion on the heel is like. If you have access to a power Doppler with ultrasound, you may also be able to see the amount of blood in the area. This can help indicate the chronicity of the damage, which will result in less blood flow on power Doppler imaging.  

A Quick Overview Of The Treatment Algorithm For Plantar Fasciitis

Our treatment begins with shoe recommendations, mainly centering on a stiff-soled shoe with good structure and additional recommendations for orthotic or over-the-counter insoles. We will also try to have patients not go barefoot and will have them wear an arch-supportive shoe at home. We usually begin with physical therapy as a first-line treatment, both at home by the patient and with a physical therapist. We will adjust treatment based on the acute or chronic stage of diagnosis. If the problem is acute, we often use anti-inflammatory treatments, gentle stretching and support through continued taping.

However, a majority of the heel pain we see is more chronic in nature. In these cases, we add Graston scraping of the fascia and deep massage to break up the chronic scar tissue formed in the fascia due to chronic tears and fibrous changes. This process lasts about four to six weeks and more than 70 percent of our patients will recover fully with this treatment.

If a patient is still having problems and is early in the fasciitis history, we will then offer a single cortisone injection under ultrasound guidance. If the bursa is inflamed, we will inject the bursa and fascia, but most commonly, the injection is in the damaged and inflamed fascia region. This will take care of an additional 10 percent of patients who have residual pain.

We treat chronic cases of fasciopathy with what we call adjuvant therapy. This category includes shockwave therapy, platelet-rich plasma (PRP) therapy, amniotic cell injection or any other treatment that will result in inflammation and a response from the body to heal the region. We tell patients not to ice the heel and to stay away from anti-inflammatory treatments or medications. This often requires three to five shockwave treatments every five to seven days or two PRP or amniotic injections a month apart. More than 90 percent of our patients have resolution of pain with this line of treatment.

So what about the 10 percent or so who still have pain? These patients often have nerve entrapment of a severe chronic plantar fascia issue that is not resolving with conventional adjuvant treatments. We refer the heel nerve pain cases for electromyography (EMG), a nerve conduction velocity (NCV) test and evaluation for potential back pain. If there is nerve involvement, either the pain management specialist treats the back or we may treat the lower extremity nerve region with cortisone injection attempts. If nerve pain continues, we may consider a nerve release, which I often will perform in conjunction with a fascia release of the medial and central band for completeness. However, this is very, very rare.

For those patients who are not responding, we will increase the removal of damaged tissue and continue to support and stimulate the tissue with PRP. Our group was one of the initial investigators for the Topaz procedure (formerly ArthroCare and now Smith and Nephew) and designed that multiple hole plantar approach using the Topaz probe for a percutaneus microfasciotomy.

Over time, I have switched to the TenJet system (HydroCision), which is a high pressure water jet that works through a very small cannula hooked to suction. Under ultrasound guidance, I will find the region of scar tissue and damage. Then through a needle size medial approach, I will break up the scar tissue with the TenJet water system and remove the scar tissue with the suction tip. I will often add a PRP injection at that time. Our decision making for this type of procedure is sometimes quicker if the first PRP or amniotic injection did not help the patient very much, and if the amount of damage is extensive on ultrasound. In such a case, I will perform the TenJet procedure in conjunction with the second PRP injection.

Patients are allowed to bathe in three days, walk in a boot immediately and are back in shoes in two weeks. They bear partial weight with crutches for three weeks and have therapy for scar break up one week after the procedure. Often, patients are fully back to normal at six weeks post-procedure.

In Conclusion

Through the use of this systemic approach, we have had almost 100 percent resolution of plantar fascia heel pain. Patients learn what is causing the pain and change their habits with stretching, shoe modification and the use of orthotics to prevent the return of pain long term, and the fascia is rarely sacrificed.

Dr. Baravarian is an Assistant Clinical Professor at the UCLA School of Medicine, and the Director and Fellowship Director at the University Foot and Ankle Institute in Los Angeles (https://www.footankleinstitute.com/podiatrist/dr-bob-baravarian ).

Reference
1.     Singh D, Angel J, Bentley G, Trevino SG. Fortnightly review. Plantar fasciitis. BMJ. 1997;315(7101):172-175.