Plantar fasciitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Medical Therapy

Many different treatments have been effective, and although it typically takes six to eighteen months to find a favorable resolution,[1] 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.[2] 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.

Orthoses

Custom foot orthoses may.[3] or may not[4] be more effective than prefabricated foot orthoses. Among prefabricated orthoses, foam covered rigid self-supporting plastic orthotic may[5] be better than other orthoses.

Compared to other therapies, randomized controlled trials have found:

  • Orthoses are more effective than night splints. [6]

Corticosteroid injection

Local injection of corticosteroids often gives temporary[7] or permanent relief, but may be painful, if not combined with a local anesthetic and injected slowly with a small-diameter needle.[8] Recurrence rates may be lower if injection is performed under ultrasound guidance.[9]

Stretching exercises

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.[10][11]

Night splints

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.

Ultrasonic shock waves

Ultrasonic therapy, also called ultrasonic shock waves or extracorporeal shock wave therapy, is a nonsurgical procedure, but must be done either under local anaesthesia either with or without intravenous sedation (twilight sedation). Ultrasonic shock waves can be classified as high power (electrohydraulic) and low-power (electromagnetic). Pulses of 0.34 mJ/mm2 or more require a regional nerve block[12]. However, the use of local anesthesia reduces effectiveness[13]. The proposed mechanism of ESWT is "destroying sensory unmyelinated nerve fibers and eliciting neovascularization in degenerative tissues"[14].

Meta-analyses of trails have found:

  • When all trials of over 100 patients are meta-analyzed, pain is reduced. However, there is no dose response effect, uncertain blinding, and no apparent registration of trials at public registries. (see Forest plot) .[15]
Forest plot
  • Low intensity ('energy <0.20mJ/mm2) to be significantly more successful than sham whereas high intensity (energy >0.2mJ/mm2) was not beneficial.[16]
  • Moderate (0.1 - 0.2 mJ/mm2) and high (> 0.2 mJ/mm2) may be more effective than low-energy (< 0.1 mJ/mm2) intervention.[17]
  • Beneficial[14]

Predictors of benefit include:

  • Absence of radiographic plantar spur.[12] Among patients with heel spurs, focusing therapy on the patient's indication of the most painful location may be better than focusing on the location of the heel spur.[18]
  • Focused waves may[19] or may not[14] be more effective than radial waves.
  • Using maximum tolerated impulse density. [20]
  • Local anesthesia reduces effectiveness[13], perhaps because the patient cannot direct the operator to the most tender location[18].

References

  1. Young, Craig C., Rutherford, Darin S. & Niedfeldt, Mark W. (2001). "Treatment of Plantar Fasciitis". American Family Physician. 63 (3): 467–74, 477–8.
  2. Lynch DM, Goforth WP, Martin JE, Odom RD, Preece CK, Kotter MW (1998). "Conservative treatment of plantar fasciitis. A prospective study". J Am Podiatr Med Assoc. 88 (8): 375–80. doi:10.7547/87507315-88-8-375. PMID 9735623.
  3. Wrobel JS, Fleischer AE, Crews RT, Jarrett B, Najafi B (2015). "A Randomized Controlled Trial of Custom Foot Orthoses for the Treatment of Plantar Heel Pain". J Am Podiatr Med Assoc. 105 (4): 281–94. doi:10.7547/13-122.1. PMID 25941995.
  4. Pfeffer G, Bacchetti P, Deland J, Lewis A, Anderson R, Davis W; et al. (1999). "Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis". Foot Ankle Int. 20 (4): 214–21. PMID 10229276.
  5. Walther M, Kratschmer B, Verschl J, Volkering C, Altenberger S, Kriegelstein S; et al. (2013). "Effect of different orthotic concepts as first line treatment of plantar fasciitis". Foot Ankle Surg. 19 (2): 103–7. doi:10.1016/j.fas.2012.12.008. PMID 23548451.
  6. Roos E, Engström M, Söderberg B (2006). "Foot orthoses for the treatment of plantar fasciitis". Foot Ankle Int. 27 (8): 606–11. PMID 16919213.
  7. McMillan AM, Landorf KB, Gilheany MF, Bird AR, Morrow AD, Menz HB (2012). "Ultrasound guided corticosteroid injection for plantar fasciitis: randomised controlled trial". BMJ. 344: e3260. doi:10.1136/bmj.e3260. PMID 22619193.
  8. Genc H, Saracoglu M, Nacir B, Erdem HR, Kacar M (2005). "Long-term ultrasonographic follow-up of plantar fasciitis patients treated with steroid injection". Joint Bone Spine. 72 (1): 61–5. PMID 15681250.
  9. Tsai WC, Hsu CC, Chen CP, Chen MJ, Yu TY, Chen YJ (2006). "Plantar fasciitis treated with local steroid injection: comparison between sonographic and palpation guidance". J Clin Ultrasound. 34 (1): 12–6. PMID 16353228.
  10. Janet Cromley (November 13, 2006). "A foot hold that spurs healing". Los Angeles Times.
  11. Digiovanni BF, Nawoczenski DA, Malay DP, Graci PA, Williams TT, Wilding GE, Baumhauer JF (2006). "Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up". The Journal of bone and joint surgery. American volume. 88 (8): 1775–81. PMID 16882901.
  12. 12.0 12.1 Malay DS, Pressman MM, Assili A, Kline JT, York S, Buren B; et al. (2006). "Extracorporeal shockwave therapy versus placebo for the treatment of chronic proximal plantar fasciitis: results of a randomized, placebo-controlled, double-blinded, multicenter intervention trial". J Foot Ankle Surg. 45 (4): 196–210. doi:10.1053/j.jfas.2006.04.007. PMID 16818146.
  13. 13.0 13.1 Rompe JD, Decking J, Schoellner C, Nafe B (2003). "Shock wave application for chronic plantar fasciitis in running athletes. A prospective, randomized, placebo-controlled trial". Am J Sports Med. 31 (2): 268–75. PMID 12642264.
  14. 14.0 14.1 14.2 Chang KV, Chen SY, Chen WS, Tu YK, Chien KL (2012). "Comparative effectiveness of focused shock wave therapy of different intensity levels and radial shock wave therapy for treating plantar fasciitis: a systematic review and network meta-analysis". Arch Phys Med Rehabil. 93 (7): 1259–68. doi:10.1016/j.apmr.2012.02.023. PMID 22421623.
  15. Ultrasonic shock waves for plantar fasciitis: a living systematic review. GitHub. Available at https://github.com/openMetaAnalysis/Ultrasonic-shock-waves-for-plantar-fasciitis/. Accessed Aug 17, 2015
  16. Yin MC, Ye J, Yao M, Cui XJ, Xia Y, Shen QX; et al. (2014). "Is extracorporeal shock wave therapy clinical efficacy for relief of chronic, recalcitrant plantar fasciitis? A systematic review and meta-analysis of randomized placebo or active-treatment controlled trials". Arch Phys Med Rehabil. 95 (8): 1585–93. doi:10.1016/j.apmr.2014.01.033. PMID 24662810.
  17. Dizon JN, Gonzalez-Suarez C, Zamora MT, Gambito ED (2013). "Effectiveness of extracorporeal shock wave therapy in chronic plantar fasciitis: a meta-analysis". Am J Phys Med Rehabil. 92 (7): 606–20. doi:10.1097/PHM.0b013e31828cd42b. PMID 23552334.
  18. 18.0 18.1 Dorotka R, Sabeti M, Jimenez-Boj E, Goll A, Schubert S, Trieb K (2006). "Location modalities for focused extracorporeal shock wave application in the treatment of chronic plantar fasciitis". Foot Ankle Int. 27 (11): 943–7. PMID 17144957.
  19. Lohrer H, Nauck T, Dorn-Lange NV, Schöll J, Vester JC (2010). "Comparison of radial versus focused extracorporeal shock waves in plantar fasciitis using functional measures". Foot Ankle Int. 31 (1): 1–9. doi:10.3113/FAI.2010.0001. PMID 20067715.
  20. Chow IH, Cheing GL (2007). "Comparison of different energy densities of extracorporeal shock wave therapy (ESWT) for the management of chronic heel pain". Clin Rehabil. 21 (2): 131–41. doi:10.1177/0269215506069244. PMID 17264107.

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