Evidence based treatments for Plantar Fasciitis

  • Friday 21 November 2014

Plantar fasciitis is one of the more common injuries seen in my practice. This condition affects over 2 million people in the Europe alone and results in over one million visits to the doctor.

Although the diagnosis is relatively straight forward (I use diagnostic ultrasound at the initial consultation to confirm a diagnosis), successful treatment can be more difficult. I suspect the main reason for this difficulty is because the pathology of plantar fasciitis is one of degeneration rather than inflammation.

Classical symptoms of plantar fasciitis include pain at the heel. At least in the initial stages, heel pain 'warms up' and improves with movement. In more severe cases, pain is more mechanical in nature and worsens with walking and other activity. Examination reveals tenderness at the inside aspect of the heel. Factors that increase risk of developing this condition include obesity, flat feet, inward rolling of the feet (pronation), limited range of movement of the ankle (particularly dorsiflexion) and poor footwear.

I find diagnostic ultrasound an invaluable tool at confirming the diagnosis of plantar fasciitis. Not only can it give me information about the severity of the pathology, but it can also exclude other pathologies include a not so uncommon condition called plantar fibroma or less commonly a partial tear of the plantar fasciitis. In addition, a normal appearance of the plantar fascia on ultrasound excludes plantar fasciitis and may warrant further imaging (such as MRI) to search for other causes (examples include arthritis of the joints in the heel, bone tumours).

By the time patients turn up at my doorstep, they've usually trialed a range of simple treatments including anti-inflammatories, ice, massage and stretching. Nevertheless, I think it's worth continuing with these simple measures. In fact, recent studies have indicated that stretching of the plantar fascia had the best long-term results. I also think a trial of a night splint is worth considering as there is some evidence (albeit limited) of the effectiveness when used with other treatments.

What happens if these simple measures fail? Options include injections or shockwave therapy. I usually leave the decision up to the patient and his/her preference.

A recent review of cortisone injections in plantar fasciitis suggests we should be using these injections more frequently. According to the review, there is increasing evidence of short and long-term benefits of cortisone injections in plantar fasciitis particularly with imaging guidance. In fact, the authors go so far as to suggest that a cortisone injection should be the first line treatment of plantar fasciitis. Call me a naysayer, but I respectfully disagree. Although I'm an advocate of a cortisone injection for difficult cases, I think the supporters of early cortisone injection don't appreciate the potential harmful effects of cortisone. These risks include plantar fascia rupture, fat necrosis of the heel pad and infection. Advocating a first-line cortisone injection downplays these risks. Nevertheless, I think a cortisone injection is a good 'second line' option if simple conservative treatments fail AND the patient understands there is a risk (albeit small) of other problems. To reduce these risks, I strongly advocate the use of image guidance for all cortisone injections (I've written about image guidance and injections previously) and a low cortisone dose.

I must quickly mention the role of platelet-rich plasma (PRP) injections for plantar fasciitis. Blood or PRP injections involve taking blood from the arm and injecting it directly into pathological joints, tendons or ligaments. Some advocate 'spinning' the blood down to separate the cells from the 'plasma'. The plasma component is filled with platelets that contain significant levels of different growth factors that supposedly improve healing. Unfortunately, a systematic review of PRP injections for foot and ankle pathology (including plantar fasciitis) suggests no significant benefit. It's probably a good thing as PRP injections will set you back over $1000 per injection in USA and probably more in London.

The other 'second line' treatment option is shockwave or extracorporeal Shock Wave therapy. Shockwave involves the use of a machine that delivers a series of local shockwaves to the pathological area. The explanation of how shockwave works is still debatable, but I suspect it works by desensitizing nerves that transmit pain messages to the brain. A recent systematic review of shockwave therapy has shown excellent short-term pain relief, but long term positive effects are yet to be proven. Notwithstanding these limitations, I think shockwave is a good option for patients who are a little apprehensive about cortisone injections.

Last but not least, I've included surgery as an option. Similar to other surgical procedures that I've written about previously, I would not advocate the use of surgery unless ALL other options have failed. Surgery is certainly not something I would advocate as a first or second line option. However, it may suit some people who have failed all conservative options.


Tags: evidencetreatment

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