Foot & Ankle

Conservative Treatment

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Rest

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Rest, activity modification, 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 immobilisation in a walker boot may be necessary. In one study, 25% of patients considered rest to be the most effective form of treatment.

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NSAIDs

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In one study, 79% of patients were successfully treated with NSAIDs. The key to NSAID therapy is consistent, daily dosing throughout the acute phase of treatment, however their potential side effects should be kept in consideration.

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Injections

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Corticosteroid injections are generally reserved as a tertiary level of treatment after failure of other primary conservative measures in severe recalcitrant cases. Whether or not injected corticosteroids alter the long-term pathology of chronic inflammation, many patients experience acute symptomatic improvement.

 

One study found that ultrasound-guided steroid injection provided short-term pain relief for up to 4 weeks and improvement in plantar fascia swelling for up to 12 weeks. Whether or not the use of ultrasound guidance improves outcome is unknown.

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A recently published RCT compared the results of steroid injections, PRP injections and placebo injections on a total of 90 patients with 18 months follow-up. The authors concluded that both the steroid and PRP were safe and effective, however the patients with steroid injections showed better improvement in the short-term and the patients with PRP injections arm showed better results in the long-term.

 

ESWT

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Two meta-analyses concluded that shockwave therapy could be a safe and effective nonsurgical treatment for plantar fasciitis. ESWT has been observed to increase blood flow in the treated area, and preliminary data indicate increased endothelial nitric oxide levels as the mechanism.

 

Multiple studies have shown success rates of 50-90%, however some studies recommend that it be used only after other noninvasive, proven measures have failed. Another study showed that ESWT induces an immediate analgesic and anti-inflammatory effect, as well as long-term tissue regeneration. Focused ESWT seems to be superior to radial ESWT. 

 

A study comparing shockwave treatment with conventional physiotherapy for treating plantar fasciitis showed that shockwave treatment yielded earlier pain reduction and functional improvement, but it was no more effective than conventional physiotherapy 3 months after the end of treatment.

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Splints

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A number of studies have shown that a high percentage of patients using night splints had improvement of their symptoms. A prospective trial showed that the comfort afforded by the night splint resulted in 95% patient compliance. Some studies suggest that the splints are especially useful in individuals who have had symptoms of plantar fasciitis for longer than 12 months.

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Orthosis

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In general, over-the-counter and custom-made orthoses appear to be equally effective in treating plantar fasciitis. However, one RCT found that ethylene vinyl acetate prefabricated inserts may be more beneficial than custom-made ones in uncomplicated plantar fasciitis.

 

Another randomised, prospective study found that more supportive orthotics resulted in better pain relief when compared with softer, non-supportive orthotics.

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Physical Therapy

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Stretching of the Achilles tendon has become a key component in the resolution of heel pain. One study found that 83% of patients treated with stretching exercises experienced successful relief. Stretches targeted at the plantar fascia are particularly important. A level 2 clinical trial studied the effect of passive dorsiflexion on the toes with simultaneous stretching of the Achilles tendon. 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.

 

Surgical Treatment

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Fasciectomy

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Surgery may be considered with caution in resistant cases after failure of conservative treatment for 12 months and may be needed in less than 10% cases.

 

Plantar fascia release is the mainstay of treatment. Overall, surgical release has a 70-90% success rate. A study by Bazaz and Ferkel found that endoscopic plantar fascia release provided significantly improved outcomes for patients, specifically those with less severe symptoms.

 

Potential complications of surgery include flattening of the longitudinal arch and heel hypoesthesia. Longitudinal arch strain appears to account for over 50% of the chronic complications.

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Percutaneous partial fasciotomy

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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.

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Cryosurgery

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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. A larger study of study of 137 feet reported a 77% success rate with cryosurgery at 2-year follow-up.

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Bipolar Radiofrequency Microdebridement

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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.

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In one study, patients achieved an average AOFAS score of 92 out of a possible 105 at an average of 11 months after operation. 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. Long-term, randomised, double-blind studies are still needed. As with any surgical procedure, the risk-benefit ratio must be determined.

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References

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• Chen H, Ho HM, Ying M, Fu SN. Association between plantar fascia vascularity and morphology and foot dysfunction in individuals with chronic plantar fasciitis. J Orthop Sports Phys Ther. 2013 Oct. 43(10):727-34.

• Pohl MB, Hamill J, Davis IS. Biomechanical and anatomic factors associated with a history of plantar fasciitis in female runners. Clin J Sport Med. 2009 Sep. 19(5):372-6.

• Bolívar YA, Munuera PV, Padillo JP. Relationship between tightness of the posterior muscles of the lower limb and plantar fasciitis. Foot Ankle Int. 2013 Jan. 34(1):42-8.

• McPoil TG, Martin RL, Cornwall MW, Wukich DK, Irrgang JJ, Godges JJ. Heel pain--plantar fasciitis: clinical practice guildelines linked to the international classification of function, disability, and health from the orthopaedic section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008 Apr. 38(4):A1-A18.

• Wrobel JS, Fleischer AE, Matzkin-Bridger J, Fascione J, Crews R, Bruning N, et al. Physical examination variables predict response to conservative treatment of non-chronic plantar fasciitis: Secondary analysis of a randomized placebo controlled footwear study. PM R. 2015 Sep 23

• Theodore GH, Buch M, Amendola A, et al. Extracorporeal shock wave therapy for the treatment of plantar fasciitis. Foot Ankle Int. 2004 May. 25(5):290-7

• Yucel I, Yazici B, Degirmenci E, Erdogmus B, Dogan S. Comparison of ultrasound-, palpation-, and scintigraphy-guided steroid injections in the treatment of plantar fasciitis. Arch Orthop Trauma Surg. 2009 May. 129(5):695-701.

• McMillan AM, Landorf KB, Gilheany MF, Bird AR, Morrow AD, Menz HB. Ultrasound guided corticosteroid injection for plantar fasciitis: randomised controlled trial. BMJ. 2012 May 22. 344:e3260.

• Ball EM, McKeeman HM, Patterson C, Burns J, Yau WH, Moore OA, et al. Steroid injection for inferior heel pain: a randomised controlled trial. Ann Rheum Dis. 2013 Jun. 72(6):996-1002.

• Kumar V, Millar T, Murphy PN, Clough T. The treatment of intractable plantar fasciitis with platelet-rich plasma injection. Foot (Edinb). 2013 Jun-Sep. 23(2-3):74-7.

• Mahindra P, Yamin M, Selhi HS, Singla S, Soni A. Chronic Plantar Fasciitis: Effect of Platelet-Rich Plasma, Corticosteroid, and Placebo. Orthopedics. 2016 Mar-Apr. 39 (2):e285-9.

• Aqil A, Siddiqui MR, Solan M, Redfern DJ, Gulati V, Cobb JP. Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: a meta-analysis of RCTs. Clin Orthop Relat Res. 2013 Nov. 471(11):3645-52.

• Dizon JN, Gonzalez-Suarez C, Zamora MT, Gambito ED. Effectiveness of extracorporeal shock wave therapy in chronic plantar fasciitis: a meta-analysis. Am J Phys Med Rehabil. 2013 Jul. 92(7):606-20.

• Gollwitzer H, Saxena A, DiDomenico LA, Galli L, Bouche RT, Caminear DS, et al. Clinically relevant effectiveness of focused extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: a randomized, controlled multicenter study. J Bone Joint Surg - Am. 2015 May. 97:701-8.

• Baldassin V, Gomes CR, Beraldo PS. Effectiveness of prefabricated and customized foot orthoses made from low-cost foam for noncomplicated plantar fasciitis: a randomized controlled trial. Arch Phys Med Rehabil. April 2009. 90(4):701-706.

• Walther M, Kratschmer B, Verschl J, Volkering C, Altenberger S, Kriegelstein S, et al. Effect of different orthotic concepts as first line treatment of plantar fasciitis. Foot Ankle Surg. 2013 Jun. 19(2):103-7.

• DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am. 2003 Jul. 85-A(7):1270-7.

• Fallat LM, Cox JT, Chahal R, Morrison P, Kish J. A retrospective comparison of percutaneous plantar fasciotomy and open plantar fasciotomy with heel spur resection. J Foot Ankle Surg. 2013 May-Jun. 52(3):288-90.

• Cavazos GJ, Khan KH, D'Antoni AV, Harkless LB, Lopez D. Cryosurgery for the treatment of heel pain. Foot Ankle Int. 2009 Jun. 30(6):500-5.

• Sorensen MD, Hyer CF. Bi-Polar Radiofrequency Microdebridement in the Treatment of Chronic Recalcitrant Plantar Fasciitis. Presented at the American College of Foot & Ankle Surgeons Annual Meeting, 2009, Washington, D.C.

• Sunil H. Shetty, Amit Dhond, Manit Arora, Sandeep Deore, Platelet-Rich Plasma Has Better Long-Term Results Than Corticosteroids or Placebo for Chronic Plantar Fasciitis: Randomized Control Trial, JFAS, Article in Press; DOI: https://doi.org/10.1053/j.jfas.2018.07.006.

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