After following the interesting discussion about porokeratomas where I learned a great, I must say, I found Dr Steinberg's approach calling for our various treatment methods for different pathologies a interesting idea.  To that end I'd like to start the discussion about plantar fasciitis/fasciosis.  As one of the most common pathologies we treat as foot and ankle specialists I'd like to hear about how the community treats this disorder.  How do you treat it on first presentation?  What follow-up protocols do you use?  When do you decide to approach this surgically?  What procedures have you found to be most successful?

 

Here's my basic algorithm on a new patient who's received no other treatment before initial presentation.  For the sake of brevity I'll assume a clear diagnosis by history and physical without concerns for "hidden" pathology like tarsal tunnel syndrome.

 

I start with education (etiology, etc); shoegear discussion (supportive shoes vs pronation control based on exam); gastroc and soleus against-wall stretches; NWB exercise like bicycle, swimming, etc.; gentle discussion about weight loss; frozen water bottle icing; massage to arch/heel before wieght-bearing.  I also do a low dye strapping with a dancer's pad/Reverse morton pad.  This is especially effective if I see pronatory changes and/or 1st ray elevatus.  I also take WB radiographs on the first visit.  I'll predict about 50% improvement over 2-3 weeks if the patient is fully compliant.

 

The next visit (2-3 weeks later) treatment then is based on response to the initial treatment.  If still very painful I'll inject the heel.  If the padding helps I'll discuss orthotics.  Many of my patients are low income and try to avoid paying for orthotics, so I'll sometimes try an OTC orthotic (I like Prolabs insert - firm but with a topcover and professional looking).  Night splints come next, then another injection (max 3 in a year for me).  If all else fails then physical therapy.

 

When surgery is necessary my preference is an endoscopic plantar fasciotomy +/- endoscopic gastroc recession based on Silfverskoild exam.  I've performed percutaneous fasciotomy with the Topaz device in only 2 patients.  Both resolved their symptoms completely at about 12 weeks.  This is a much slower resolution than I've seen with the EPF.  Postop NWB for about 2 weeks in a cam walker or BK cast (I've had one case of lateral heel pain postop in a patient who became too active too early). 

 

I'd love to hear the rest of our community's methods.  What pearls do you have?  Is ultrasound part of your practice?

  • Comments (9)
  • Dr Macy brings up a couple of good points.  When I practiced in Michigan ESWT was a noncovered procedure.  My partner did these and the occasional patient paid out of pocket.  Has coverage improved for ESWT?

  • It truly is amazing to hear how everyone treats heel pain differently, but interestingly enough, we all are around the same page...

    I agree in most part with Dr. Sherman, in that I disagree with Dr. Suzuki.  I will (and stress NEVER) give the injection on the first visit unless the pain is > 7/10.  Again, I stress this from my posting on To Ultrasound or Not to Ultrasound, I educate the patient, do my schtick with better shoes/inserts/etc. and try to get the patient into OTC orthos on 1st visit with PT exercises/heel cord stretches.

     

    Almost invariably, there is a major component of Gastroc Equinus involved and unless the pain is debilitating, I prefer not to inject the fascia, as the true pathology is masked by the equinus.

     

    The next visit (one week later) I am re-assessing the stretch of the fasica, and almost all the patients relate improvement at least 40% over the previous week.  At this point, I can truly assess the pathology via ultrasound and have an adequate plan of care for the patient. 

     

    As with Dr. Sherman, most of the patients in my demographic cannot tolerate NSAIDS, so I have to rely on PT modalities....

     

    Just my 2 cents....

     

    One more thought:  If its a penny for your thoughts AND you have to put your 2 cents in, who the hell is making 3% on the dollar off of you???

  • With minor modifications, I agree very much with Dr. Sherman.  Besides people not wanting to pay for orthotics, they also do not want to come in 3x per week between busy schedules and copays.

    I will x-ray and ultrasound virtually every time, with some consideration as to whether certain insurance companies cover sonograms.  Sonograms are wonderful educational tools with great visuals for the patient, especially if there is no spur on x-ray. 

    I will inject on a first visit if the pain is severe.  Because of the biomechanical nature of the condition, shoe advice is given, ice massage in one form or another.  I have taken to using the Powerstep prefab orthotic at the first visit.  Patients in the past found the taping quite annoying, especially at shower time or if their feet perspire a lot.  A reasonable fee for the Powersteps is presented as far better than a custom orthotic-which I suggest is needed about 1/3 of the time.  When there is significant pain remaining after 2 weeks, I'll add on an injection--2 cc. 0.5% marcaine with celestone soluspan.

    Many times with the more stubborn cases, I'll find a posterior tibial nerve component and when that appears to be bilateral, almost every time there are back issues to be resolved.

    I have yet to do a plantar fasciotomy in 28 years.  Guranteed some patients give up and go elsewhere for the persistent cases, but ESWT has worked very well for me for those who stick with our treatment plan.

    One other challenge is to keep the patients from being barefoot on hard floors at home.  Crocs can be helpful there too.

  • A lot more of this was covered in the Podiatry Management article on the topic (August, 2006), of which I was one of the “experts”. I got a number of comments back then and I may get them now, but I’ll repeat my protocol:

    Assuming we don’t have short Achilles’ tendons, a fracture or tumor or Tarsal tunnel syndrome or a complication of Gonoccocal arthritis, neuropathy, acromegaly, Reiter’s Syndrome, Behcet’s disease or S1 radiculopathy, I start off my treatment with Feldene™, 20mg QD (brand name, as I’ve found the generic to be worthless). This is assuming that they not attempting to heal a wound and are not a poorly controlled diabetic and have no prior history of diverticulum, gastric perforation or GERD and can take an Non-steroidal anti-inflammatory without problem. I also try and have them ice the area, insist they don’t do barefooted, especially on tile, concrete or wood floors and try an over-the-counter innersole in a good, supportive walking shoe. I see them back and 90% of my patients report COMPLETE relief of pain. No stretching, no BioFreeze, no night splint, no garbage just to increase the bottom line. For the approximately 10% of the patients that receive incomplete or (more rarely, no relief) from the Feldene™, 20mg QD, I’ll do an injection with a plantar approach, mixture consisting of 20mg/ml DepoMedrol mixed with 1% Lidocaine with epinephrine, 0.5% Marcaine plain and buffered back to physiologic pH with 8% NaCO2. I’ve never had anyone relieve their symptoms with one injection, and the second is scheduled in 2 weeks after the first. During that time, they are once again to wear a good shoe with an over-the-counter support, use ice to the area and stay off hard surfaces. If the pain subsides, I recommend a custom orthotic to help support the foot and have rarely seen the patient return with recurrent heel pain. If, after a series of three injections, spaced 2 weeks apart, the patient doesn’t receive relief or the pain goes away and comes back, we will talk about options. I see about 25 people a week for fasciosis pain and average one surgical approach a YEAR. I’m not Einstein and so if I can get rid of 99.99% of the heel pain I see without surgery (and without splints, stretching or other ancillary treatment).

     

    There you go.

  • Excellent protocol information.  Thanks to Dr Sherman!  That's the benefit for a young practitioner like me to be able to discuss issues like this with our more experienced clinicians.  I'll give your protocol a try and compare it to what I've been doing.  Great advice!  I'd love to hear about other protocols by our long term leaders.

  • I agree with the treatment methods mentioned above.  The only  disagreement I have is that  "low Dye" should be the correct spelling of the foot taping.   Dr. Dye  should not be robbed of notation of his  contribution. 

    Yours,   
    Dwight L. Bates, DPM, DABPS

  •  

    I developed and successfully used a protocol for plantar fasciitis/heel spur syndrome over a 25 year period that I estimate eliminated the most severe of the symptoms in 85% of patients within 3 weeks.  Although I saw so many heel pain patients that treating them became repetitive, these came to be among my favorite patients. Why ? Because they were so unhappy when they came in, it was so easy to help them, the rate of success was so high, and each one represented over $800 of income for my practice in a 3 week period of time.  Surveys show that heel pain represents around 50% of all new patient presentations in a general podiatry practice.  We see so many of these, that it really pays to optimize the treatment and employ it in a reproducible protocol. 
     
    Demographics
     
    First of all, the patients most likely to present with plantar fasciitis in my predominantly geriatric practice were heavy women with Forefoot Varus who took their grandkids to Disney World. In other words, heavy relatively inactive people, with a proclivity to late midstance pronation (and little resupination) who acutely increased their activity level. There were certainly other scenarios, but my staff and I used to to wink at each other when a patient fitting this description described new onset post-static plantar medial heel pain with this history.  They became very familiar to us.
     
    Work Up
     
    After hearing the history, I asked the patient the all important question:  “when you get up in the morning and take your first step, does it hurt immediately or do you have to walk a distance before the pain starts ?”  If they acknowledge first step pain, and also report pain during the day when first bearing weight after a sedentary period, you just about have your diagnosis of plantar fasciitis.  All that remains is to palpate the insertion of the plantar fascia into the medial tubercle of the calcaneus.  You do this gently, because if it's a bad case, pushing hard is cruel and unnecessarily.  I did always take an xray ( see To Ultrasound or Not to Ultrasound...that is the question !) l mostly to rule out the rare calcaneal stress fracture or bone tumor, but also so that I could show the patient as part of my discussion with them, as to what is, and what isn't (the heel spur), causing the the pain, and consequently, what we did and didn't have to treat to make them feel better.  I ALWAYS did a 5 minute education session with the patient, because helping the patient understand what caused the condition greatly aided my effort to get them to comply with treatment.  I figure I gave this talk 10x a week, 30 weeks a year for 25 years...I told myself so many times during those 7500 patient education talks that I should videotape it, but somehow, I never did.  IF I did, I would have 625 hours of my life back...but I digress.
     
    The Treatment Plan
     
    Injection
     
    So now to the all important treatment plan that worked so well.  I was a bit more aggressive in treatment than Dr. Shapiro, largely on the evidence of how likely it was that patients would accept the plan and get better fast.  I went right to medical treatment with injectible steroids. I have to credit my most influential teacher, Keith Kashuk, DPM, for first showing me this technique, which I didn't change much over my career.  I first measured the approximate location of the subcalcaneal bursa from the lateral xray, from plantar and posterior.  I transferred this measurement to the patient's foot, and did a 2 part injection from medial into the bursa.  I pre-loaded a 3 cc syringe with 3 ccs of 0.5% Marcaine, and a 1 cc syringe with my steroid of choice (usually dexamethasone acetate).  After thoroughly freezing the skin with Ethyl Chloride, I first injected the Marcaine.  Leaving the needle in, I removed the 3cc syringe from the needle, inserted the 1 cc syringe and injected the steroid. The entire injection, after freezing the skin, took less than 5 seconds.
     
    Biomechanical Control
     
    I then ALWAYs applied a low-dye strapping over skin adherent, because (and this is the #1 KEY to success in treating plantar fasciitis), if you don't stop the re-injury, which is being caused by the pulling of the plantar fascia off of it's insertion into the calcaneus, any relief that you give the patient will only be temporary.  I would tell the patient that if we did no treatment, and they simply went 100% off weightbearing for 3 weeks, I would  guarantee that they'd feel better, until they injured it again. Few took me up on the offer.
     
    Physical Therapy 
     
    I then started the patient on 3x weekly physical therapy:  Ultrasound, Elect Stim, Whirlpool.  Did this add significantly to the efficacy of the treatment ?  After 25 years, I have to say I was not convinced that 30 min 3x a week of these modalities really was a big help.  What it did accomplish was to let my assistant put a fresh low-dye strapping on every other day, which I believe WAS very significant, believing so strongly as I do in the value of biomedical control for this condition. It also gave us more opportunities to touch the patient and show them that we cared, and we also got to see if they were being compliant.
     
    The Results
     
    About 50% of patients were better in a week, about 35% in the next 2 weeks.  What did I define as better ?  A loss of ALL of the sharp pain, with just some residual dull ache.  Most patients took longer (a few more weeks) to lose that mild dull ache sensation than the sharp pain, but 85% were thrilled to have lost the sharp pain.
     
    Orthotics
     
    The last part of the treatment plan, and arguably the most important, is Orthotics, because ALL the above will be temporary in most patients unless the chronic injury, the  excessive pulling on the plantar fascia, is stropped.  Yes, there are some presentations of acute plantar fasciitis, but over the years, I found that most were over pronators, and most had 3-8 degrees of Forefoot Varus, which was the underlying cause.  Control the overpronation with a forefoot posted orthotic, posted to up to 5 degrees, and you stop the re-injury in most cases. Since orthotics are an out of pocket expense for most patients, I figure 1 out of 3 ended up getting orthotics.  I showed each of them how a firm heel counter, like what they get with a good running shoe, can help control the excessive pronation, too. Since 2 out of 3 didn't get orthotics, I was able to see how they did without good biomechanical control, and I can tell you, is wasn't pretty.  Many developed recurrences.
     
    A Protocol is Needed
     
    One last comment.  You all know that there are many different ways to treat plantar fasciitis.  I believe it takes a protocol that includes a good anti-inflammatory to reduce the acute fasciitis/bursitis, and biomechanical control to prevent the re-injury. It doesn't take much stimulation to keep a plantar fasciitis inflamed.  I'd give my patients the analogy of a camp fire that has all but burned out, when a breeze starts to blow, “fans” the fire and re-ignites it.  With biomechanical control via orthotics and correct shoes added, most patients stayed symptom free, except for occasional "break through" episodes when their orthotics wore down(or they stopped wearing them), they increased activity or for other unknown reasons.  With the treatment protocol that I describe above, you will have tremendous success with treating this very common condition, actually smile when new heel pain patients come in, and get to see a big smile on their faces, as well.

     

     

  • Good points about the injections.  Occasionally I'll give an injection on the first visit, especially for those in severe pain.  More often I'll go with the above noted approach without an injection which hides any benefit from the initial treatment. 

     

    Also good point about the number of injections.  I had stuck to the dogma since residency with no evidence to back it up!

  • I agree with your general approach. In fact, since you outlined the treatment plans so well, I don't have much to add!

    Re: Steroid injections, I am much more aggressive, in a sense that I may recommend a steroid injection on the first visit.

    Often times, plantar fasciitis (or fasciosis? whatever the latest term is) is an acute problem for most people (ie. weekend warrior who walked too much in the Disney land one day),   so you can possibly make the pain go away real fast & make you look real good (when it works). I usually map out the most tender spot with a marking pen, then I would drop the steroid of your choice by aiming there.

    I don't really subscribe to the "only 3 steroid shots per year" dogma. If you look at the rheumatology references, there is no study that suggests "steroid injection degrades the cartilage or ligaments in human." That myth came out of decades-old studies on rodents (rat studies). Having said that, if 1-2 steroid injections are not helping, you would have to re-think the diagnosis.

    Just my 2 cents...