Plantar Fasciitis: Evidence-Based Management

Robert D. Glatter, MD, FAAEM

Disclosures

October 10, 2007

Treatment Modalities

Stretching the Achilles tendon is generally included in most treatment plans for plantar fasciitis. Pfeffer and colleagues[8] looked at stretching as the only treatment: 72% of patients assigned to stretching alone noted improvement of symptoms compared with 88% of patients who utilized prefabricated splints along with stretching exercises. The study's main weakness was the lack of an observational control group to evaluate the effectiveness of the stretching program alone. DiGiovanni and colleagues[9] noted improvement of symptoms if the program utilized dorsiflexion of the forefoot and toes, as opposed to Achilles tendon stretching alone.

Recommendation. Achilles tendon stretching may be helpful, but there are few studies to support its practice.

Level of Evidence. Expert opinion; recommended in most treatment guidelines; no randomized controlled trials (RCTs) to confirm effectiveness over simple rest.

No randomized trials were identified that evaluated rest as an intervention for treatment of plantar fasciitis. There were 2 retrospective studies (514 patients) noted that asked patients to evaluate different therapies. Rest ranked third, behind casting and injection, among 11 other modalities examined in the study.[10,11]

Recommendation. Although rest is likely to be helpful, there is minimal support for this approach in evidence-based literature. Of note, most patients usually experience a decrease in pain within the first 6 months, independent of the initial treatment selected.

Level of Evidence. Expert opinion; no RCTs to demonstrate utility vs more active forms of therapy.

No studies were found evaluating the effectiveness of taping in the treatment of plantar fasciitis. Most taping methods tend to run the length of the longitudinal aspect of the plantar arch. Taping decreases the amount the arch flattens during the active stance phase. This also serves to prevent excessive pronation of the foot (ie, pes planus), which is known to be associated in patients with plantar fasciitis. Although taping is frequently used in the acute care of this ailment, no studies were located examining the effectiveness of taping in this setting.

Recommendation. Because taping has not been adequately studied in the literature, no clear recommendations can be offered in its role for management of plantar fasciitis.

Level of Evidence. None.

Night splints have been used to maintain the foot in dorsiflexion during sleep. The consensus of opinion is that this may allow the fascia to begin to heal with the plantar aponeurosis in full extension, thereby reducing the tension at the origin of the fascia at the calcaneus. In 1991, Wapner and Sharkey[12] described 14 patients with symptomatic plantar fasciitis for greater than 1 year who had not responded to multiple treatments. They were splinted in 5 degrees of dorsiflexion overnight. Eleven patients had no pain, with full relief of symptoms by 4 months.[13] Additional studies have demonstrated similar improvements.[14]

Probe and colleagues[15] in 1999 compared the use of shoe modifications, nonsteroidal anti-inflammatory drugs, and stretching with a similar program utilizing these interventions with the addition of night splints. A total of 116 patients in this study were followed for 3 months with no difference in outcome between the 2 groups. The reason for the outcome of the study is likely related to significant differences in patients in the 2 treatment arms. The group that demonstrated efficacy of night splints enrolled patients who had failed to respond to many modalities for long periods of time. The arm of the study that did not demonstrate a treatment advantage used splints as one of the initial treatment measures. The study is also limited in the small number of patients studied, making it problematic to demonstrate any significant treatment advantage from any modality used in the initial treatment of plantar fasciitis.

Recommendation. Night splints may have some utility in the treatment of persistent plantar fasciitis.

Level of Evidence. Evidence from RCTs (small/moderate).

A review of various biomechanical studies does not support the use of heel cups in the treatment of plantar fasciitis. Studies that have evaluated heel force impact demonstrate that the heel strike forces in patients with plantar fasciitis are similar in both painful and asymptomatic heels.[5] Another study that examined heel strike impact forces noted similar outcomes, with heel pads only proving useful in patients with localized pain from contusions as opposed to plantar fasciitis.[16] However, custom-made orthotics have been shown to reduce the tension in the plantar aponeurosis, whereas standard orthotics did not produce the same effect.[17] As stated earlier, because tension at the origin of the plantar aponeurosis is the likely etiology of plantar fasciitis, reducing the tension in the plantar aponeurosis would likely reduce pain and aid healing.

Recommendation. Heel pads are not recommended for the treatment of plantar fasciitis but may provide relief for patients with pain due to a heel contusion. Orthotics are recommended in the initial treatment of plantar fasciitis. Custom molded orthotics are more effective than preformed orthotics. The cost of custom-molded orthotics, however, may limit the utility of this treatment option.

Level of Evidence. Small RCTs showed a trend toward benefit.

Corticosteroids are frequently used to treat patients with plantar fasciitis. Different prospective RCTs have shown positive effects of using both iontophoresis[18] and percutaneous infiltration[19,20] techniques to reach the plantar fascia with steroid medications. However, all studies have noted the relief to be transient. After 30 days, no significant difference in pain relief was noted between treatment and control subjects. As a limitation, the RCTs have had small numbers of patients.

One risk of using steroid medication on the plantar fascia is the possibility of rupture of the fascia. Acevedo and Beskin[21] examined 765 patients with plantar fasciitis in their 1998 study. Steroid injections were performed in 122 patients overall. Of 51 patients experiencing a rupture of the plantar fascia, 44 of the patients received a steroid injection prior to rupture.

The technique for injection of the plantar fascia may be ultrasound assisted. However, there is no evidence that this technique improves outcome or reduces the incidence of long-term complications. The standard method of injection is the medial approach at the point of maximal tenderness on the medial aspect of the calcaneus. One should avoid the heel pad as a site of injection because this may result in significant discomfort for the patient.

Recommendation. The benefits of steroid injection appear to be transient, although they are commonly used in the initial treatment of plantar fasciitis. Steroids also have the potential to increase the likelihood of rupture of the plantar fascia. Corticosteroids should not be used in the initial treatment of plantar fasciitis due to the potential for harm and lack of a lasting beneficial effect.

Level of Evidence. Evidence from small to moderate RCTs and retrospective studies.

Extracorporeal shock-wave therapy (ESWT) has recently been advocated in recalcitrant cases of plantar fasciitis. It has often been viewed as a useful option prior to considering surgical treatment. Impulses of low-energy shock waves through ultrasound guidance are focused at the point of maximal tenderness across the base of the calcaneus in a transverse axis. These waves may help to accelerate the healing process via an unknown mechanism.[22]

There have been 2 small RCTs and 1 medium-sized RCT published in the past decade, but all have major limitations. Two studies by Rompe and colleagues[23,24] in 1996 utilized inconsistent patient selection criteria, and a subsequent investigation by Speed and colleagues[25] in 2000 was rather small with a high drop-out rate in the placebo group (5/15). An intention-to-treat analysis of this data would not have demonstrated any treatment advantage. In fact, due to issues related to cost and minimal evidence supporting use of ESWT, the health ministries of 3 European countries in 2000 put a hold on reimbursement for this procedure until further evidence emerges to support the validity of the treatment.[26]

Additional recent studies have not resolved the controversies over ESWT. A prospective RCT by Rompe and colleagues[27] in 2003 examined 45 runners with persistent heel pain and noted a significant decrease in pain at 6 months and 1 year in patients treated with 3 applications of 2100 impulses of low-energy shock waves.

Theodore and colleagues[28] also reported a beneficial effect from ESWT. However, there were significant limitations from this study. The initial improvement at 3 months was not convincing, with 56% of patients who received ESWT reporting improvement at 3 months, in comparison with 46% of patients receiving a placebo. There was also no long-term follow-up available. In fact, the authors permitted patients to cross over to the active treatment group after the 3-month assessment. In contrast to these studies, many other studies have failed to show benefit from the therapy. Multiple other studies have not demonstrated an advantage of ESWT.[22,29,30,31,32]

A Cochrane review of ESWT in 2003 noted that "there is conflicting evidence for the effectiveness of low-energy extracorporeal shock-wave therapy in reducing night pain, resting pain, and pressure pain in the short-term (6 and 12 weeks) and therefore its effectiveness remains controversial."[33]

Recommendation. ESWT may have some utility in the treatment of chronic plantar fasciitis. There are studies that have shown no benefit, while other studies show moderate improvement in a proportion of patients. It remains controversial at this time. There is no evidence of harm from the therapy.

Level of Evidence. RCTs (moderate sized) with systematic reviews.

Surgery is generally considered in patients who have not responded to conservative measures over a period of 1 year. In fact, a study by Wolgin and colleagues[11] showed that a large proportion of patients will have a reduction in their symptoms between 6 and 12 months.[11]

Specifically, a plantar fasciotomy is performed along with neurolysis of the nerve to the abductor digiti quinti.[34] Both endoscopic and open fasciotomy have been performed, with both techniques demonstrating similar outcomes seen only in retrospective patient survey data.[35] There are no prospective studies on whether the open or endoscopic technique is associated with better functional outcomes. In multiple studies, between 70% and 90% of patients experienced initial relief after undergoing surgery.[34,35,36,37,38]

However, based on long-term follow-up, the results are not as favorable. Davies and colleagues[38] found that less than 50% of patients (48%) were satisfied with the results, although they initially noted improvement following surgery.[38] Nearly 33% of patients reported continual forefoot and midfoot pain, although they were initially satisfied postoperatively with their outcomes.[34,36]

This may be related to the fact that undergoing a fasciotomy leads to flattening of the longitudinal arch and a redistribution of the peak forces of ambulation from the heel to the midfoot.[37] This shift of forces often leads to pain in the midfoot and forefoot during ambulation. In fact, Yu and colleagues[39] noted recurrent plantar fasciitis, arch instability, and structural failure due to overload on MRIs of patients with persistent or recurrent pain following plantar fasciotomy.

Recommendation. Surgery should be considered for patients with persistent plantar fasciitis who fail to respond to conservative measures. Some patients will take up to 1 year to experience relief of pain using noninvasive approaches. ESWT should be considered prior to considering surgery. Surgery may provide short-term relief, but long-term results are not favorable. Prior to undergoing surgery, patients should be aware of the possibility of problems developing in the midfoot and forefoot secondary to the division of the plantar aponeurosis.

Level of Evidence. No RCTs; cohort studies show improved outcome following surgery.

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