Prescribing Effective Treatments
Michael Shea, MD
Practice Essentials Series Editors:
THE PHYSICIAN AND SPORTSMEDICINE - VOL 30 - NO. 7 - JULY 2002
In Brief: Plantar fasciitis is one of the most common painful disorders experienced by people in running and jumping sports. While the prognosis for recovery with conservative care remains excellent—more than 90% of athletes ultimately respond—the prolonged duration of symptoms affects sports participation. Studies that examined various treatment options found mixed results, so finding the most effective treatment can be challenging. A logical treatment approach with emphasis on biomechanics, rehabilitation, and training adaptation will help expedite return to sport.
Plantar fasciitis is one of the most common overuse injuries, affecting approximately 10% of runners, as well as numerous athletes in basketball, tennis, soccer, gymnastics, and other sports.1 Overall, it is estimated that more than 2 million Americans receive treatment each year for the condition.2 Despite the number of patients who have symptoms, there is no clear treatment plan to assist physicians who care for them. Randomized trials have evaluated classic, as well as newer, therapies for plantar fasciitis. Based on a review of the literature and our extensive experience, we offer suggestions for treatment and return to sport.
Plantar fasciae are fibrous aponeuroses that provide important support for the longitudinal arches of the feet (figure 1). Microtears of the fascia from repetitive trauma lead to degeneration of collagen. Although often thought of as an inflammatory process, the fascial degeneration and necrosis found in plantar fasciitis is more similar to tendinosis than tendinitis.3,4
Extrinsic factors of plantar fasciitis include training errors, improper footwear, and unyielding surfaces. Intrinsic factors include pes cavus or pes planus, decreased plantar flexion strength, reduced flexibility of the plantar flexor muscles, excess pronation, and torsional malalignments.5
Key Clinical Findings
Athletes with plantar fasciitis experience severe foot pain that is aggravated by weight bearing with the first steps of the morning, then gradually subsides with activity. They usually describe a deep ache or bruise at the anteromedial region of the calcaneus on the plantar surface of the foot. Heel pain can often be reproduced by having patients stand on their toes or by passively dorsiflexing the metatarsal phalangeal joints. The classic physical finding is point tenderness at the plantar medial tubercle of the calcaneus. Evaluating the Achilles tendon may also be helpful. A tight heel cord with decreased dorsiflexion of the ankle is seen in 70% of patients who have unilateral symptoms.1
Diagnosis of plantar fasciitis typically arises from history and physical exam alone. Radiographs are rarely useful because they are generally normal or show only a horizontal heel spur. The significance of heel spurs is controversial but probably negligible. One study5 of 1,000 patients revealed a 13.2% prevalence of heel spurs, but only 5.2% of those patients reported any history of heel pain. Bone scans, magnetic resonance imaging (MRI), blood tests, nerve conduction studies, and other special tests are reserved for cases of obscure heel pain.
The differential diagnosis for the athlete with heel pain includes calcaneal stress fracture, tarsal tunnel syndrome, Sever's disease (calcaneal apophysitis) in patients 8 to 15 years old, flexor hallucis longus tendinitis, and fat pad syndrome. Paget's disease of bone, bone tumors (metastases and primary), and inflammatory arthritis (primarily Reiter's syndrome) should also be considered in perplexing cases.
Studies of Treatment Options
Several studies3,5,6 compared various treatment modalities for plantar fasciitis. While the mainstay of treatment remains stretching and nonsteroidal anti-inflammatory medications (NSAIDs), randomized controlled trials have evaluated night splints,7-9 dexamethasone iontophoresis,1 corticosteroid injection,10 orthoses,2 and surgery.3,5 Extracorporeal shock wave lithotripsy (ECSL) trials11-13 have studied small groups with follow-up as long as 3 years.
Night splints. Batt et al7 compared the effectiveness of two treatments for relieving pain in 32 patients who had plantar fasciitis. The control group received conservative therapy consisting of ibuprofen, heel cushions, and a stretching program for the gastrocnemius and soleus muscles. The study group received the same conservative interventions plus tension night splints. The study found improvement in all patients using night splints (average treatment time, 12.5 weeks). In the control group, 6 of 17 patients improved after 8.8 weeks. The remaining 11, who still had pain, were then crossed over to use night splints; 8 responded in an average of 13 weeks. The remaining 3 reported no significant change.
Powell et al8 performed a crossover, prospective, randomized study using night splints on 37 patients who had a history of heel pain for more than 6 months. Only the first group wore night splints for the first month, then only the second group wore night splints for the second month. Neither group wore night splints the remaining 4 months of the study. At the end of the first month, patients in the first group had significant improvement but those in the second group did not. The second group improved during their period of splint wear. At the end of 6 months, 88% of the involved feet improved.
Probe et al9 compared the use of night splints versus conservative treatment in 116 patients for 3 months. No statistically significant improvement was found between the two groups at 4, 6, or 12 weeks.
Iontophoresis. Iontophoresis of 0.4% dexamethasone was compared with placebo iontophoresis in 36 patients. Patients underwent six treatments within 2 weeks. The dexamethasone group reported more rapid relief of symptoms and greater improvement at the end of the treatment period; however, no difference was found between the groups at the 1-month follow-up.1
Corticosteroid injection. Crawford et al10 compared injections of prednisolone acetate and local anesthetic to the anesthetic alone. They also evaluated the effect on patient comfort of a posterior tibial nerve block before the injections were given. Evaluation of the 106 patients revealed decreased pain in the steroid group 1 month after the injection but no difference at the 3- or 6-month follow-up. Anesthetizing the heel prior to injection did not increase patient comfort.
Orthoses. Two randomized trials of orthosis use for plantar fasciitis resulted in dramatically different results. Pfeffer et al2 assigned 236 patients to stretching alone or in combination with one of the following four interventions: silicone heel inserts, rubber heel cups, felt arch pads, or custom-molded polypropylene orthoses. After 8 weeks, patients noted the most improvement with silicone heel inserts; rubber heel cups were second. Prefabricated inserts outperformed stretching alone and customized orthoses. One major problem with this study design was that the customized orthoses were three-quarter length and, as such, would not control motion or support the first metatarsophalangeal joint, which plays an important role in plantar fasciitis.
Lynch et al6 randomly assigned patients in a prospective trial comparing three groups: corticosteroid injection plus NSAIDs; viscoelastic heel cup plus acetaminophen; and temporary arch pads followed by a custom orthosis. Treatment failed in 23% of the injection group and 42% of the heel-cup group but in only 4% of the orthosis group. Seventy percent of patients rated their result as good or fair in the orthosis group compared with only 30% in the injection group and 33% in the heel cup group.
Lithotripsy. ECSL holds promise as a possible alternative to surgery for patients who have chronic plantar fasciitis. Trials conducted in Germany studied groups of 30 to 50 patients.11-13 Good to excellent results, as measured by pain reduction, were reported in 70% to 75% of the enrolled patients. In one study,11 calcaneal bone marrow edema, seen on pretreatment MRI, was highly predictive for satisfactory clinical outcomes. Pain relief lasted up to 6 months in most trials. A study by Sistermann and Katthagen13 compared patients who received ECSL plus either ultrasound or x-ray focusing. More than 70% of patients in both groups were pain-free after 6 weeks; however, the degree of pain resolution at 36.9 months decreased significantly.
Are Study Findings Relevant?
In the literature, randomized trials often yielded conflicting results, and each study was affected by multiple variables. The relevance is even less clear for sports medicine physicians, because virtually all the studies examined nonathletic populations. Furthermore, none of the studies addressed returning an athlete to training. In the absence of definitive evidence, clinical experience and expert opinion will dictate treatment and return to sport for athletes who have plantar fasciitis.
Information from trials can influence care, because certain factors were consistent across multiple studies. Clearly, adequate recovery time is a critical treatment factor, because few interventions made a difference in less than 8 weeks. Stretching alone typically led to improvement in approximately 70% of patients when it was continued for 8 to 12 weeks. Most cases of plantar fasciitis resolve, and since 85% to 90% of patients respond to conservative therapy within 6 months, surgical referral is a late option.
Surgical trials14,15 document relief of symptoms in approximately 90% of patients, but postoperative recovery also takes months. Patients who opt for nonsurgical treatment of chronic plantar fasciitis, particularly those who have pain lasting longer than 12 months, may respond best to interventions with night splints and orthoses.
The effectiveness of interventions directed toward preventing plantar fasciitis have been difficult to measure, because no one foot type seems more prone to develop the condition than another. Studies16,17 have suggested that patients at highest risk are those who have pes planus with excessive pronation or pes cavus with supinated foot strike. Kibler et al18 demonstrated both strength and flexibility deficits in patients who have plantar fasciitis.
Robbins and Hanna19 also demonstrated that wearing shoes leads to the inability of the medial longitudinal arch to deflect when loading (foot rigidity), which reduces shock absorption. Sensory feedback during barefoot weight-bearing activity, largely from the glabrous epithelium of the foot, induced greater foot flexibility and contributed to fewer injuries while running. In this study, recreational runners showed more normal foot function after modifications that included barefoot walking.
Because plantar fasciitis typically arises from overuse, we focus treatment on rehabilitation and restoration of normal biomechanics.
Exercises to strengthen major muscle groups in the lower leg are prescribed to help improve walking and running form. We advise dynamic exercises, performed barefoot, that include walking on toes, walking on heels, and walking backward, each while holding light to moderate weights. Particular emphasis on calf exercises helps restore the normal function of the Achilles-calf complex because it connects with the plantar fascia. Heel raises, done while standing on a step, allow the patient to drop the heel below the level of the step and thus provide eccentric stress and Achilles stretching. Barefoot walking and running drills are prescribed as a functional stretch for the arch, to restore more normal arch muscle activity, and to strengthen push-off from the affected side (see "Healing Heel Pain: Help for Plantar Fasciitis").
Anti-inflammatory modalities provide pain relief. Ice, particularly an ice bath, is the mainstay of anti-inflammatory treatment. We advise patients to ice for 10 minutes per treatment (as tolerated), warning them of the discomfort of using an ice bath. Arch massage with a frozen juice can is an alternative for those who can't tolerate ice baths. Treatments are performed after activity and at the end of the day. NSAIDs play a limited role and should be offered primarily for short-term pain relief.
Corticosteroid injection is reserved for individuals who want more rapid pain relief or a faster return to training. Little evidence supports using multiple injections, and we do not advocate repeat injection. Iontophoresis is expensive and offers only brief pain relief; therefore, we rarely use it. Similarly, low-intensity laser therapy offers no clear benefit. ECSL has been evaluated only for recalcitrant plantar fasciitis, and the studies were not primarily directed at athletes. Further clinical trials are needed to determine ECSL's utility.
Orthoses and night splints are often beneficial. Inexpensive prefabricated orthoses, such as viscoelastic heel inserts, rubber heel cups, and felt inserts give substantial pain relief to plantar fasciitis patients. Most individuals seem to respond to these, which reduces the need for expensive customized orthoses. We also make customized orthoses for numerous endurance athletes because even after an acute bout of plantar fasciitis resolves, symptoms that recur from intense training can be lessened.
Night splints are a safe adjunct to treatment and, with declining prices, have become a reasonable treatment option. No guidelines exist for selecting which plantar fasciitis patients should try night splints, but most evidence suggests benefit for patients in whom other conventional treatments have failed. Commercial splints are available from orthopedic supply companies, or the clinician can make a simple one.20
Return to Play
Patients who prematurely return to sports with certain injuries run the risk of rupturing the plantar fascia; however, a study21 of symptom resolution in plantar fasciitis patients who rupture the aponeurosis does not clearly demonstrate a slower recovery than those without rupture. Another theoretical concern in patients who have unilateral plantar fasciitis is that favoring the affected foot may sufficiently alter gait to contribute to injury at another anatomic site. Absolute rest has not been shown to heal or speed resolution of symptoms, leading most physicians to recommend relative rest. We advise the athlete that continued training is possible, but it is expected to be painful and requires training modification.
We advocate return to training at about 60% of the preinjury level. For running athletes, certain workouts (eg, speed drills and hill running) are higher risk and should be replaced with other options. Similarly, athletes should avoid drills that emphasize jumping until most symptoms resolve. To avoid shifting the injury to another anatomic area, we advise athletes that they cannot train in weight-bearing activity unless they can do it without limping or serious form breakdown. Swimming, biking, and other forms of non-weight-bearing training appear to be safe substitutes.
Additional training time is devoted to the specific daily rehabilitation program. If the athlete makes steady progress with lessening symptoms, we suggest increasing the training load no faster than 10% weekly. All weight-bearing activity is done with some form of shock-absorbing orthoses. This approach prevents most athletes from developing the intrinsic foot weakness that may contribute to recurrence.
Plantar fasciitis is a self-limiting condition that, while painful, resolves with conservative treatment in more than 90% of patients. Proper biomechanics, good rehabilitation and stretching, and adequate training modification can reduce the time athletes spend away from sport.
Dr Shea and Dr Fields are family practice physicians at Moses Cone Family Practice in Greensboro, North Carolina. Dr Fields holds a certificate of added qualifications in sports medicine. Address correspondence to Karl B. Fields, MD, Moses Cone Family Practice, 1125 N Church St, Greensboro, NC 27401.
Disclosure information: Drs Shea and Fields disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.