The treatment of plantar fasciitis, in the presence or absence of a calcaneal spur, is to take the stress off the fascia.
- orthoses: heel pads and arch supports - the addition of a heel platform to the shoe ensures that the forefoot drops towards plantaris hence reducing the metatarsus-heel distance. Also orthoses designed to maintain the medial longitudinal arch (because the plantar fascia is stretched during flattening of the foot). These can have short-term but not long-term treatment benefits (1)
- footwear advice - do not walk barefoot on hard surfaces. Shoes should have cushioned heels and arch supports. (2)
- NSAIDs - useful in decreasing inflammation but the American College of Foot and Ankle Surgeons does not recommend the routine use of NSAIDs in treating plantar fasciitis due to lack of supporting data. (2)
- steroid injection (steroid or in combination with local anaesthetic) - can provide pain relief in an exquisitely tender area. An injection is best administered from the medial rather than the inferior aspect of the heel. It is necessary to undertake a series of minor withdrawals and insertions so as to infiltrate the whole breadth of the superior aspect of the inflamed fascia
- they have been shown to be efficacious in relieving pain; however, most studies report only short-term (up to 6 weeks), and not sustained (3) Counsel patient accordingly and obtain informed consent. May require the injection to be repeated: suggested maximum of 3 injections within 6 months
- there is a small but recognised risk of fascial rupture after injection (also after surgery), and a tiny risk of infection. Patient needs to rest for 24 hours after procedure
- structure-specific plantar fascia-stretching program or standard Achilles tendon-stretching protocol
- stretching of Achilles tendon - often patients with plantar fasciitis have tightness of the Achilles tendon - stretching interrupts a cycle in which the two disorders aggravate each other
- tight hamstrings and equinus are common in patients with plantar fasciitis and treatment of equinus is important for all stages of the condition. Stretching, aimed at the tendoachilles and the plantar fascia, is recommended 3 times daily with 10 repetitions of each stretch. (2) (4)
- extracorporeal shock wave therapy (ESWT)
ESWT has evolved as a non-invasive approach for recalcitrant plantar fasciitis pain and is a recommended second-line treatment. (2) Approximately 70% of patients with chronic or subacute plantar fasciitis who undergo ESWT experience meaningful improvement in their heel pain at 12 weeks. (2)
- surgery - considered if in cases of where pain is intractable and has not responded to prolonged (e.g.12 months) conservative treatment. Evidence of effectiveness is mixed, and complications include nerve injury, increased pain, fascial rupture and infection. It is considered a third-line option at best. (2)
Reference:
- 1. Landorf KB et al. Effectiveness of foot orthoses to treat plantar fasciitis: a randomized trial. Arch Intern Med. 2006 Jun 26;166(12):1305-10.
- 2. Schneider HP, Baca JM, Carpenter BB, et al. American College of Foot and Ankle Surgeons clinical consensus statement: diagnosis and treatment of adult acquired infracalcaneal heel pain. J Foot Ankle Surg. 2018 Mar-Apr;57(2):370-81.
- 3. David JA, Sankarapandian V, Christopher PR, et al. Injected corticosteroids for treating plantar heel pain in adults. Cochrane Database Syst Rev. 2017 Jun 11;6:CD009348.
- 4. DiGiovanni BF 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;85:1270-7