plantar fasciitis treatment and cure

All you have to do is scour the internet, or talk to friends or co-workers and you will see that it seems like everyone has had a different treatment. Because of this, no one treatment will work for everyone.

To further complicate matters, there are multiple theories on what is plantar fasciitis and based on the theory that you subscribe to, treatment can vary from one doctor to the next.

Most of us can agree that over-working of the plantar fascial ligament is what caused the initial pain. Some experts will argue that the ligament is just strained, while others will argue that over straining the ligament causes micro tears in the ligament, which probably will not show up on an MRI.

Then there is the theory on how to treat the problem. Some doctors argue that since the ligament in inflamed, anti-inflammatory measures are the way to go, while others argues that heel pain, particularly heel pain of long duration (greater than three months) is caused by the brain no longer perceiving the pain due to lack of inflammation. In these cases, treatment is geared towards increasing inflammation, so that the brain can once again realize there is a problem down there and bring nutrients down to the inflamed ligament, in order for healing to occur.

In my practice, treatment is based on the length of time the problem has been present and the severity of the pain. A patient who developed plantar fasciitis yesterday as a result of hiking should be treated differently then the patient who has had heel pain for three months.

conservative treatment for plantar fasciitis

• Orthotics- depending on the cause of heel pain, my favorite treatment is the use of orthotics. A plantar fasciitis orthotic is a device that fits in your shoes and supports the arch and plantar fascial ligament in an effort to keep it from overstretching when you walk. As far as I am concerned, an orthotic has to be the cornerstone of any treatment for heel pain. (the only exception is heel pain a couple days duration) Unless you can "rest" the plantar fascial ligament, without the use of an orthotic, the ligament will continue to be over stretched and thus continually irritated and will only delay the healing process. I use both custom-made prescription devices and over the counter type orthotics. Click here for more information on orthotics for heel pain.

  I have found that pre-made orthotics in many patients work quite well. Unless you have an extremely high arched foot or very rigid low arched foot, a pre-made orthotic can be very effective. The pre-made orthotics that we offer to the right may go a long way in alleviating your heel or arch pain.

  Once the patient is in a proper fitting orthotic and by proper fitting I mean an orthotic that actually supports the arch. Most store bought orthotics attempt to cushion the bottom of the foot but fail to actually support the arch (plantar fascial ligament). Once this is accomplished, additional conservative treatments may be instituted and in most cases should dramatically improve the heel pain.

  ...a short video on why orthotics are so important in treating heel pain.

• Foot strapping- in acute episodes of pain, strapping the heel can be very effective in reducing pain.
• Short term oral anti-inflammatory medication- this can be very helpful in those who have been suffering for a while and for those whose symptoms just began. People with acute pain tend to respond better and in many cases this may be all that they need. Keep in mind, anti-inflammatory medication is not a long term solution due to the potential for side effects.
• Cortisone injections- cortisone injections can be helpful, usually done in a series of three over a three-week period, especially if you suspect an associated bursitis.
• Physical therapy- may be beneficial as well. I usually reserve this for patients who have been suffering for some time. I usually request ultrasound therapy as well as deep tissue plantar fasciitis massage which loosens up the ligament but also creates some inflammation for increased blood flow to the heel. If I feel that there is also a neuroma, or pinched nerve, involved in the mix, I will usually begin a series of denatured alcohol injections,the purpose of which scleroses or deadens the nerve.
• Night splints- during the night the plantar fascial ligament will tighten up from lack of use. The first steps that people take in the morning can be very painful as their body weight stretches out the ligament. The use of a plantar fasciitis night splint can be helpful in certain individuals to keep the ligament from tightening up and thus making those initial steps in the morning far less painful. If you are one of those individuals who has excruciating pain getting up in the morning than I would strongly suggest considering a night splint. It should dramatically improve your situation and will also be very helpful in eradicating your heel pain. My recommended night splint is a low profile night splint seen to your right. Most people find the typical bulky night splint very uncomfortable to sleep with, while this low profile night splint serves the same purpose and is much more comfortable to wear.
• Walking cast- in very severe cases including partial tear of the plantar fascial ligament, a plantar fasciitis boot can be very helpful. Sometimes, being non-weightbearing may be necessary.
• Plastic heel cup- another type of heel pain may be caused by nothing more than a bone bruise and actually have nothing to do with the plantar fascial ligament that we have been discussing.

  The one part of the body where we need to have fat, is the heel. In this case the fat works to cushion the heel bone. As we age, the one part of the body where we actually lose fat is on the bottom of the foot. In these individuals since there is little fat under the heel bone, it becomes bruised from constant walking. It should also be pointed out that some younger individuals do not have much fat under the heel as well.

  You can perform a simple test to see if this is the source of your heel pain. Press directly under the heel bone with your finger. If you can actually feel the bone and there is pain upon pressure and this pain is not evident as you move your finger a little bit forward, toward the toes, then you may have a bone bruise. Next, with your other hand, place it around the heel encompassing the outside, back and inside portion of the heel. Squeeze slightly, which will force whatever fat you have back under the heel. Now, with your other hand, press the bottom of the heel bone again. If you notice less pain with the heel cupped and the fat underneath, compared to when the fat was not pushed back under the heel, then there is a very good chance you have a bone bruise.

  The best treatment I have found for this condition is through the use of a hard plastic heel cup that sort of looks like an egg shell. Placing this heel cup on your heel either directly under or over your sock or stocking forces whatever fat you have in the heel area back underneath the heel to cushion the heel bone. This will generally work far better than an orthotic or even a gel type heel cup.
  
  

  
  
  
  
  

aggressive treatments for plantar fasciitis

When conservative therapies fail to alleviate the problem, more aggressive treatments are called upon. I have found, and the literature will bear me out that 90-95% of heel pain sufferers will respond to the conservative treatments I have discussed.

If you have reached the point where conservative measures have failed and are thinking of the more aggressive therapies I would suggest you have an MRI of the heel prior to consenting to those treatments. Other less common causes of heel pain include stress fractures of the heel bone as well as possible tears in the plantar fascial ligament, along with ruptures of the adjacent muscles attaching into the heel. Sometimes a bone cyst may be present in the heel bone as well. Tarsal tunnel may also be a culprit in heel pain, either from an over stretching of the nerve or from a growth like a cyst pressing on the nerve. All these should be evident in the MRI.

Within the last couple of years many who treat heel pain have started to make a distinction between plantar fasciitis, which we have been discussing and what is known as plantar fasciosis. Plantar fasciitis represents an inflammation on the bottom of the heel for which the various treatments we have already discussed, are indicated, in an effort to quiet down the inflammation and reduce pain.

The latest trend in treating heel pain is making a distinction based on how long you have been suffering from your heel pain. If your heel pain has been present for a minimum of two to three months you may actually be experiencing plantar fasciosis. In this condition the pain may actually be due to scarring and fibrosis on the bottom of the heel. Ligaments as well as tendons are poorly vascularized, meaning they tend to get most of their blood supply from surrounding tissue as they do not have enough of their own blood supply. So, what happens in plantar fasciosis is you are left with chronic pain, the body is not attempting to heal itself and all the previous treatments you have received, at best, are giving you temporary relief. Once a diagnosis of plantar fasciosis is made treatment is aimed at improving the blood supply to the heel ligament in an effort to promote healing as it is blood that brings nutrients to an injured area in order to make it well.

Some of the newer treatments being used to increase blood flow to the area are listed below.

• Extracorporeal shock wave therapy (high impact)- The science behind this is the same theory used to break up kidney stones. It is high power ultrasound directed at the site of pain. There is strict FDA regulations as to when it is indicated; basically all other options other than surgery have failed. In my experience I have seen some very dramatic results but I also must report that some patients have been no better off after the procedure. It should also be noted that the procedure is covered by some but not all insurance companies and that it can be costly if you have to pay for it out of your own pocket. Click here for more detailed information on shock wave therapy.
• low impact shock wave therapy- whereas the previously stated high impact shock wave is very expensive and does require anesthesia, low impact shock wave therapy is far less expensive (because the machinery is less expensive), does not usually require anesthesia, but may require 3-5 treatment sessions spaced 1-2 weeks apart in order to work. It too is a non-invasive therapy like high power shock wave therapy and is usually performed right in the office. When both these therapies became available a number of years ago, it was initially thought that high impact shock wave therapy was more effective as it only required one treatment. Recent studies have shown that low impact shock wave is just as effective even though it will require more treatments.
• Platelet-rich plasma therapy (PRP)- the patient's blood is drawn and spun down creating a small amount of platelet rich material. PRP contains growth factors and bioactive proteins that influence the healing of tendon, ligament, muscle, and bone. This material is then injected into the heel at the site of most pain. Some doctors will inject it under ultrasound guidance. There is a often a short lived pain experience by the patient due to the amount of inflammation that is created. That and the fact that blood has to be drawn and that an injection into the heel has to occur are the only real downsides to the treatment. Since your own blood is being injected, there is no problem with cross contamination. Once again the idea here is to re-create inflammation by the introduction of a high concentration of platelets in order to get the healing process going once again. Because we are looking to produce inflammation, the use of anti-inflammatory medication would be contra-indicated after the procedure.

  This is a procedure that is mostly done as an out-patient procedure because most private offices do not have the equipment available to spin down the patient's blood. It is also my understanding that the injection itself is not covered by insurance so for most people this becomes an out of pocket expense. Lastly, because of its increased popularity over the last few years, studies are finally coming to light as to the procedures effectiveness. In general these newer studies have shown that platelet-rich plasma injections may not be any more effective than cortisone injections. For this reason I would not consider this procedure as a first line treatment for plantar fasciosis, but rather to be considered if more available treatments fail to work. (Podiatry Today, June 2013."Point-Counterpoint: Is PRP Beneficial For Chronic Plantar Fasciosis?" p.33)

• Topaz Coblation Therapy- this is an invasive procedure that is usually carried out in the operating room under sedation. In this procedure a number of small holes are made in the area of the most pain; a needle is inserted into each hole and an electrical charge is given off. The electrical charge results in microscopic cutting of the plantar fascial ligament, creating an increase in blood flow (inflammation) and break up of the scar tissue that may be present. Even though this is a relatively minor invasive procedure there will be some down time following the procedure as recovery can be slow and somewhat painful.
• Dry needling- whereby anesthesia is first infiltrated into the heel area. Then using ultrasound guidance, an empty hypodermic needle is inserted into the plantar fascial ligament in the area giving the patient the most pain. This is repeated multiple times. The theory here, once again, is to create blood flow into a structure that is generally poorly vascularized. The increased blood flow of course then brings nutrients into the area to heal the plantar fascial ligament, just like blood normally does for other injured parts of the body.

  It is also felt that the actual needling of the plantar fascial ligament will also help break up any scar tissue that may have formed. The authors of the original study also recommended directing a cortisone injection into the area once the dry needling was finished to reduce inflammation.

  In my opinion I do not think the cortisone injection is very helpful for a couple of reasons. One, more than likely patients who are undergoing this procedure have already had one or more cortisone injections (which did not work) and for anyone who treats plantar fasciitis, it is not very difficult to direct the cortisone into the painful area even without ultrasound guidance.

  Two, one of the theories regarding recalcitrant heel pain is that the brain is not recognizing the inflamed plantar fascial ligament and thus is not doing what needs to be done to fight the inflammation. This is part of theory already mentioned above regarding the concept of plantar fasciosis.

  So, in my mind I would be more inclined to avoid the cortisone injection and allow the inflammation to happen.

  After the office procedure it is recommended that the patient wear a walking boot for one week to protect the plantar fascial ligament because since it has been punctured in multiple areas this may actually weaken the ligament and there is a chance of rupture. After the boot is removed I would recommend wearing a good orthotic for a couple more weeks.

  The benefits of this procedure is that the authors of this study suggest a 95% success rate, but please keep in mind this was done on a small population of people with heel pain. They also found that relief lasts upwards of ten months and probably longer is the patient takes the necessary steps to avoid re-injury. Relief may not be immediate, but should occur within two to three weeks. This treatment is a one time treatment, performed in the office and since it is not a surgical procedure there is overall less risk and less expense.

• FAST procedure- another interesting approach in treating heel pain is by reducing the amount of scar tissue that has developed on the plantar fascial ligament. A procedure known as the FAST procedure, (Fasciotomy and Surgical Tenotomy) attempts to do just that by first identifying excessive scar tissue with the use of ultrasound guidance. A small stab incision is made at the level of scar tissue, an ultrasound probe is inserted into the small incision and the ultrasound energy breaks up the scarring. Normal surrounding tissue is unharmed. Again using ultrasound guidance, the surgeon is able to visualize when adequate scar tissue has been removed.

  This procedure can be performed under mild sedation or even just straight local anesthesia. It is suggested the patient remain non-weightbearing for one week and gradually return to bearing full weight over the following two weeks.

• Radio-frequency nerve ablation- another technique that is gaining popularity in dealing with the neuroma aspect of heel pain is radio-frequency nerve ablation. This is an office procedure where local anesthesia is first injected into the most painful area of the heel, usually more to the inside of the heel. A probe is then inserted into this area and radio-frequency energy creates heat in a very small area, which disrupts the myelin sheath (the outer covering of the nerve). Disruption of this sheath no longer allows pain sensation to be carried along this particular nerve and thus the pain is eliminated. This procedure as well as denatured alcohol injections can be helpful in treating a variety of heel pain including scarring from previous heel surgery, nerve entrapment and heel bursitis as well as the actual plantar fasciitis.
• Surgical intervention- lastly, when all else fails, surgical correction should be entertained. Today’s foot specialist is trained in doing both conventional large incision procedures and minimal incision procedures. Keep in mind, that surgery for a heel spur or plantar fasciitis can have a very long recovery period. The simple truth of the matter is that after surgery, every time you step on that heel you are basically aggravating the surgical site and for that reason the healing process can take a long time. Thankfully, most cases of heel pain can be resolved without surgical intervention.

  My surgical treatment of choice for heel spurs and plantar fasciitis is a small incision approach performed on the bottom of the heel. This procedure is relatively quick with minimal trauma to the foot, thus allowing the foot to heal quickly.

  Basically I palpate where the patient is experiencing the most pain and mark the spot with a surgical marker. Once the patient is sleeping, I am able to insert a needle through the bottom of the foot where I previously marked the foot. Using fluoroscopy I am then able to see how close I am to where the plantar fascial ligament attaches into the heel bone. If I am not close enough I can re-insert the needle until I am satisfied I am right at the attachment point.

  I then make a small stab incision where the needle is located. The incision is usually less than a half inch long. Through that incision I take a scalpel and detach the plantar fascial ligament from its attachment to the bone. In these cases we do not want to totally detach the ligament, for this can result in destabilization of the lateral side of the foot and result in lateral column pain (see below).

  Once the ligament is severed, I then take a bone rasp and smooth out any bone spur that may be present. Keep in mind, a bone spur may not always be present. After that I place 2-3 sutures to close the incision.

  Update, November 2010 Like any surgical procedure there are inherent potential complications. One of the problems with any surgery on the plantar fascial ligament is it that will tend to weaken the function of that ligament. This can lead to a condition known as lateral column pain. At a medical conference I just attended we were shown a "before" x-ray prior to a partial plantar fascial release and then an x-ray taken ten years later revealing a marked drop in the arch of the foot. Now, even though the patient was not having any problems with his foot, the fact that his arch had collapsed so much would lead one to believe that he will eventually suffer from early arthritic changes within the foot as a result of the change.
  
  

  WHAT ABOUT STRETCHING FOR PLANTAR FASCIITIS?

  
  
  

  I would not say there is a raging debate going on in the medical profession about stretching for plantar fasciitis, but if you do enough research you will find those that recommend stretching the ligament while there are others who feel it is counter productive.

  I guess I fall somewhere in between and here is my feeling on the subject.

  If your heel pain is from an acute problem (wearing flip flops one day and doing a lot of walking, as an example), and the pain is not outrageously painful, and most of your pain is evident when you first stand up on the foot and then dissipates as you walk, then stretching the arch of the foot is not a bad idea simply because the plantar fascial ligament is tightening up and the "looser" you can keep it, the less pain you will have.

  However, if your heel pain is more the result of a biomechanical problem meaning it is a result of the way your foot functions or if you happen to be overweight and have a job where you stand all day on hard floors, or you are an athlete who developed the problem while participating in your sport, then perhaps stretching of the ligament is not your best bet.

  In all these examples just cited, the plantar fascial ligament has been over-stretched and has become inflamed. Continuing to stretch in an attempt to make it feel better, may actually make your symptoms worse or at the very least, may delay the healing process.

  But, even in these cases there is an indication for stretching but it is not the plantar fascial ligament; it is the achilles tendon.

  Many cases of non-traumatic plantar fasciitis occur simply due to a tight heel cord. An equinus (tight heel cord) is when your foot has the limited ability to bend upwards at the level of the ankle. In most cases the foot will not bend beyond 90 degrees to the lower leg. Without the ability of the ankle to adequately bend upwards, the foot is forced to compensate by flattening out. What happens when a foot excessively flattens out or pronates? You over-stretch the plantar fascial ligament.

  In this scenario, depending on your age, doing calf stretches to try and increase the range of motion at the ankle joint may be of benefit. In general, the older you are, the less effective stretching exercises will be. As a side note, in many cases where we find a tight heel cord and are going to make an orthotic for plantar fasciitis, we will also add a heel lift to the device. Adding a heel lift reduces the tension on the achilles tendon and thus does not force the foot to pronate as much.

  In instances where the tight heel cord is the culprit, an achilles tendon lengthening may be performed to resolve the problem.
  
  

  REFERENCES

  Mayo Clinic

  American Podiatric Medical Association

  Cleveland Clinic
  
  

  continue....home remedies for plantar fasciitis treatment
  
  

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