Plantar fasciitis

Associate Editor-In-Chief:

Overview
Plantar fasciitis, formerly known as "policeman's heel", is a painful inflammatory condition caused by excessive wear to the plantar fascia of the foot or biomechanical faults that cause abnormal pronation of the foot. The pain usually is felt on the underside of the heel, and is often most intense with the first steps of the day. It is commonly associated with long periods of weight bearing. Obesity, weight gain, jobs that require a lot of walking on hard surfaces, shoes with little or no arch support, and inactivity are also associated with the condition.

This condition often results in a heel spur on the calcaneus, in which case it is the underlying condition, and not the spur itself, which produces the pain.

Treatment
Many different treatments have been effective, and although it typically takes six to eighteen months to find a favorable resolution, plantar fasciitis has a generally good long-term prognosis. The mainstays of treatment are stretching the Achilles tendon and plantar fascia, resting, keeping off the foot as much as possible, discontinuing aggravating activity, cold compression therapy, contrast bath therapy, weight loss, arch support and heel lifts, and taping. To relieve pain and inflammation, non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen are often used but are of very limited benefit. One small, placebo-controlled study has shown a beneficial effect from glucosamine.

Care should be taken to wear supportive and stable shoes. Patients should avoid open-back shoes, sandals, and flip-flops.

Local injection of corticosteroids often gives temporary or permanent relief, but may be painful, if not combined with a local anesthetic and injected slowly with a small-diameter needle. Recurrence rates may be lower if injection is performed under ultrasound guidance.

In cases of chronic plantar fasciitis of at least 10 months duration, one recent study has shown high success rates with a stretch of the plantar fascia.

Night splints can be used to keep the foot in a dorsi-flexed position during sleep to improve calf muscle flexibility and decrease morning pain. Pain with first steps of the day can be markedly reduced by stretching the Achilles tendon before getting out of bed. Patients should be encouraged to lessen activities which place more pressure on the balls of the feet. Over-the-counter arch support may help, and prescription orthoses are often prescribed. These can be made of many different materials, some of which may be hard and may press on the origin of the plantar fascia. Softer, custom devices, of plastizote, poron, or leather, may be more helpful. Orthoses should always be broken in slowly.

Therapeutic ultrasound has been shown in a controlled study to be ineffective as a treatment for plantar fasciitis. More recently, however, extracorporeal shockwave therapy (ESWT) has been used with some success in patients with symptoms lasting more than 6 months. The treatment is a nonsurgical procedure, but must be done either under local anaesthesia either with or without intravenous sedation (twilight sedation). The basic premise behind ESWT is that in chronic pain (over six months) the brain no longer perceives the pain (even though the patient feels pain) and so no longer is sending signals to fight the pain. ESWT basically re-inflames the area and in doing so increases blood flow to the area as a means to heal the area. It can take as long as six months following the procedure to see results. Like any procedure there are varying degrees of success.

Surgery
Surgical procedures, such as plantar fascia release, are a last resort, and often lead to further complications such as a lowering of the arch and pain in the supero-lateral side of the foot due to compression of the cuboid bone.

Recent research has indicated that an ultrasound guided needle fasciotomy is the most effective surgical intervention for Plantar Fasciitis. This is a minimally invasive procedure where a needle is inserted into the Plantar Fascia and moved back and forwards to disrupt the fibrous tissue that proliferates as a result of the chronic inflammation.

Alternative treatments
Plantar fasciitis and other forms of foot pain are sometimes treated in acupuncture clinics. Although there are no large research studies, one case series on the use of electroacupuncture for treating plantar fasciitis in eleven patients found that nine reported greater than 50% reduction in pain.