Plantar Fasciitis

Introduction

Plantar fasciitis is typically a self-limiting condition. Studies have reported a resolution incidence of up to 90% with nonsurgical measures. Patients respond differently to various treatments due to varying degrees of pathology, body habitus and lifestyle.​

Traditional therapies aim to decrease the presumed inflammation and include icing, NSAIDs, rest and activity modification, corticosteroids, splintage, shoe modifications and orthoses. Other treatment in use, are designed to create an acute inflammatory reaction with an aim to restart the healing process and include autologous blood injection, platelet-rich plasma (PRP) injection, extracorporeal shock-wave therapy (ESWT), and surgery. Formal physical therapy can include components that target both goals. These treatment modalities are used in combination.

 

Conservative Treatment

Rest

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

 

NSAIDs

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.

 

Injections

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.

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

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.

 

Splints

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.

 

Orthosis

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

 

Physical Therapy

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

Fasciectomy

Surgery is indicated in resistant cases after failure of conservative treatment for 6-12 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.

 

Percutaneous partial fasciotomy

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.

 

Cryosurgery

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.

 

Bipolar radiofrequency microdebridement

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.

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, randomized, double-blind studies are still needed. As with any surgical procedure, the risk-benefit ratio must be determined.

 

References

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