Treatment

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) e.g. full length or 3/4 length accomodative inlays of medium density plastozote.
  
  
• footwear advice - do not walk bearfoot on hard surfaces. Shoes should have cushioned heels and arch supports.
  
  
• NSAIDs - useful in decreasing inflammation
  
  
• 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
  • there is weak evidence for short-term benefit, but no evidence of long-term benefit (1). 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
  • there is study evidence that a program of non-weight-bearing stretching exercises specific to the plantar fascia was superior to the standard program of weight-bearing Achilles tendon-stretching exercises for the treatment of symptoms of proximal plantar fasciitis (2,3)
    
    
• physiotherapy and ultrasound
  
  
• surgery - considered if in cases of where pain is intractable and has not responded to prolonged (e.g.12 months) conservative treatment. No good evidence of effectiveness, and complications include nerve injury, increased pain, fascial rupture and infection (1)

Reference:

1. ARC (February 2004). Hands On - practical advice on management of rheumatic disease, 2.
2. Digiovanni BF et al. J Bone Joint Surg Am. 2003 Jul;85-A(7):1270-7
3. Digiovanni BF et al. J Bone Joint Surg Am. 2006 Aug;88(8):1775-81