Innovative Treatment for Heel Pain

Treatment of Plantar Fasciitis

Roundtable Discussion

Each issue, we ask 4 different practitioners how they treat a certain condition. This month's topic is plantar fasciitis, which is an irritation and swelling of the thick tissue on the bottom of the foot. Our participants are Eric M. Bluman, MD, PhD, Director, Orthopaedic Foot and Ankle Surgery, Director, Orthopaedic Traumatology, Madigan Army Medical Center in acoma, Washington; Enzo J. Sella, MD, Connecticut Orthopaedic Specialists in Hamden, Connecticut; Lowell Weil Jr, DPM, MBA,FACFAS,Fellowship Director, Weil Foot & Ankle Institute in Des Plaines, Illinois, and Babak Baravarian, DPM, FACFAS, Assistant Clinical Professor at the David Geffen School of Medicine at UCLA and Co-director of The Foot and Ankle Institute in Santa Monica, California.

What are your most common conservative treatments for plantar fasciitis and what seems to work best in your findings for conservative care?

Bluman: Conservative therapies are very important as the vast majority of patients (>90%) can be managed in this manner. I front-load conservative therapies. At their first visit, patients are prescribed stretching exercises, an icing protocol, silicone heel pads, NSAIDs, and dorsiflexion night splints. Usually activity modification, in addition to what the patient has already done themselves, is not necessary. This seems like a lot all at once, but I have found that it results in quicker resolution than if therapies are added on sequentially.

To ensure compliance with such an extensive regimen, education, and reinforcement is paramount. Ensuring that the patients have a high level of compliance not only with the frequency but also proper technique of conservative modalities employed is the goal. For this reason, I enlist the expertise of physical therapists to teach patients proper techniques for tretching and have them check the patients while performing the exercises and placement of the splints. In this way, patients receive teaching and evaluation before they leave the office.

It is important that the patient understands the success rate of conservative therapy as well as the time course for successful treatment. Many will not obtain a "quick fix" and may take a number of months for substantial improvement. Compliance with the stretching regimen is improved if the patient is aware that the exercises may exacerbate the plantar fascia pain for a couple of weeks before feeling better.

I supplement this teaching with instructions that I include on my Web site. This allows the patient to check on the details of their therapy at any time. If you do not have a physical therapist within your facility, Webbased instruction can be a critical adjunct early on in the regimen.

In my opinion, a stretching regimen makes the greatest contribution to successful nonoperative treatment of plantar fasciitis.

I do not utilize corticosteroid injections as I have found these to be unreliable. Not only is the initial response highly variable between patients, but those who do respond usually do so for only a short time. Multiple injections into the area are to be avoided as a possible complication is heel pad atrophy.

Should patients fail the initial round of conservative therapy, I utilize casting for 3 to 6 weeks. In those that fail casting, I will employ extracorporeal shock wave therapy.

Sella: My most common conservative treatments for plantar fasciitis include rolling the plantar arch with a frozen water bottle twice daily and stretching by doing the runner's stretch or by placing the forefoot on a stair and dropping the heel. However, the best stretching exercise I have found is the "tissue specific plantar fascia stretching," which is done by dorsiflexing the foot with one hand and forcefully running the opposite thumb from the origin of the plantar fascia distally about 2 inches. I found night splints to be successful in some patients with resistant symptoms but compliance is a problem. I prescribe NSAID for 2 to 3 weeks. If no better, I do inject the origin of the plantar fascia with aristocort and marcaine and repeat the injection in one month if still symptomatic. I found physical therapy with iontophoresis and/ or orthotics to be ineffective. I do prescribe inexpensive visco heels.

Weil: I always start out with a combination of mechanical and inflammation/ pain reduction. I recommend higherheeled shoes to relax the tight calf muscle complex, relax the plantar fascia, and transfer the weight from the heel forward. Patients are told to avoid bare feet, flats, sandals and onsupportive shoes. They are either dispensed a semicustom arch support or referred to the Internet to purchase it from our Internet store www.ourdoctorstore.com). Patients are referred to PT for training on stretching of the calf muscle complex. Patients are told to ice and are given a RX for anti-inflammatory, usually Celebrex. If after 4 to 6 weeks there is no improvement, then I consider a corticosteroid injection and orthotics. If they continue to have pain after these treatments, I might consider a second injection and night splint. I rarely exceed two injections.

Baravarian: We have set up an algorithm at our offices to help with conservative care. We try to use the motto of teaching a person to fish instead of feeding them fish. What I mean is that I have found that cortisone injections on the first visit are of little use as people do not tend to change the underlying mechanical or lifestyle factors that are causing the plantar fasciitis problem in the first place.

We have our own orthopedic physical therapist at our locations and tend to be very happy with the outcome of physical therapy on plantar fasciitis. We will often use therapy for 2 weeks after the initial visit in order to educate the patient on home exercises and stretching and relieve the immediate pain.

On the two-week visit, we will either continue with home or office-based physical therapy or add orthotics or over-thecounter arch supports if there is still pain. We emphasize the importance of stretching at this time.

If a patient is found to be improving but still has moderate pain, we will often proceed with a single cortisone injection at one month after initial reatment and will also add the use of a night splint. We often will also use advanced diagnostic studies at this point to confirm that the diagnosis is only plantar fasciitis.

What testing do you perform to be sure you are treating only plantar fasciitis and ruling out other issues, and at what time in the treatment regimen do you perform these tests?

Bluman: I want to know on initial presentation if there may be complicating or distracting issues such as a neuropathy of the tarsal tunnel or systemic disease. I do not like to wait to rule these out until just prior to surgery as this may result in treatment of the wrong condition or inadequate treatment of a correctly diagnosed condition.

Compression neuropathy of the first branch of the lateral plantar nerve can sometime mimic the pain of plantar fasciitis. To rule this out, I use Tinel's and Phalen's testing.

Testing to rule out a systemic etiology such as a seronegative arthropathy should be initiated as soon as the clinician suspects the possibility. A presentation of bilateral plantar fasciitis increases my suspicion. Treatment of those with systemic etiologies may require specific pharmacotherapy.

Sella: Plain films are important to rule out a stress fracture or erosive changes in the bone that may indicate some systemic problem. If suspicious for a systemic disease, I do blood work. If not sure, I do a Tc99 bone scan. At 6 weeks, if not improved, I do an MRI. Ultrasound may also be used. It's cheaper, but you need an expert ultrasonographer to read it. Some of the most resistant cases have an entrapment of the first branch of the lateral plantar nerve. I always check for a tinnel sign, and if positive or suspicious, I will order an EMG and nerve conduction test.

Most patients with uncomplicated plantar fasciitis get better within 2 years and may be treated symptomatically as described above. Those who do not get better may have a nerve entrapment, a systemic disease, or a severe enough inflammation of the plantar fascia that conservative treatment cannot cure. Those patients need surgery.

Weil: I believe that the symptoms of the patient dictate consideration of other issues contributing to the heel pain. In an initial presentation, if the patient is healthy yet suffering from bilateral pain, that's a red flag for some other entity such as radiculitis. Additionally, pain that does not occur during typical plantar fasciitis situations such as pain when at rest or lying down, or pain that is not noticeable when first rising from rest but worsens throughout the day and activities, makes one think of neurologic entities or radiculitis. If I believe that there is a neurologic contribution, I will consider diagnostic nerve tests such as EMG and NCVs, and/or referral to a back specialist. Additionally, I find it rather common that people will initially present with very typical plantar fasciitis symptoms but, over time, those symptoms will subside yet the patient still has heel pain. The patient doesn't know the difference, but the heel pain is now not necessarily plantar fasciitis but some other entity that must be worked up. Lastly, if typical heel pain care does not obtain expected results over 2 to 3 months, I would consider other causes such as seronegative diseases or neurological manifestations and make appropriate referrals.

Baravarian: Standard lateral radiographs are taken on the initial visit to rule out a cyst, fracture and check for plantar and retrocalcaneal spurs. I think that radiographs are necessary for prevention of legal problems but are of little diagnostic use. We use diagnostic ultrasound extensively in our locations and find it an invaluable tool to show the level of fasciitis, the amount of fasciosis or scar formation, and also check and make sure that the fascia is truly involved in the underlying problem.

If we suspect another potential source for the heel pain, such as a stress fracture, cyst or tendon damage, or even a potential nerve irritation that may be dueto a space occupying lesion, we use an MRI for further information.

One of the most exciting tools we use is a neurosensory device or PSSD device. This is used to check possible sensory nerve problems of any nerve in the body. It is excellent for picking up low level neuritis and nerve compression syndrome associated with or mimicking plantar fascitis. Both tarsal tunnel syndrome and calcaneal nerve entrapment can be documented and differentiated.

How long do you perform conservative care prior to surgical treatment?

Bluman: I generally do not move to surgical care before 10 months of conservative therapies have been exhausted.

Sella: Most patients, unless they have an entrapped Baxter's nerve, get better in 2 years. I wait at least one year before doing surgery.

Weil: I believe that conservative care should be utilized for at least 4 months. There is much research that shows that 80% to 90% of plantar fasciitis will be successfully alleviated within that period of time with proper conservative care. Usually patients have suffered with their heel pain for months prior to seeking medical treatment, and making them suffer beyond that 4 to 6 month time frame seems unfair. Because of the advent of ESWT, I tend to go that route a lot sooner than I would surgical intervention. I would start to consider ESWT for patients after 3 to 4 months of failed conservative care. Additionally, if I have a diagnostic ultrasound or MRI showing thickening of the plantar fascia or fasciosis, then I will move forward with ESWT or surgical options more quickly. Because ESWT is noninvasive and never been shown in the literature to have any negative side effects, I am comfortable instituting it more quickly than I might a more risky invasive procedure.

Baravarian: We differ according to the patient. We have gone as short as3 months and as long as 2 years, but we tend to average at least 6 months. If a patient has had multiple other doctors' care prior to seeing us, we definitely speed things along and don't spend as long repeating prior treatments.

What are your surgical treatments, and what seems to work best in your results?

Bluman: The only surgical treatment that I utilize in my patients with uncomplicated plantar fasciitis is a medial partial plantar fasciotomy. I remove a length of fascia the width of Kocher clamp to prevent it from scarring back to itself. I do not use endoscopic fasciotomy as I find it a "long run for a short slide." The endoscopic technique takes much longer to set up, and I do not believe the savings in incision length are clinically significant. I have no experience with radiofrequency-based therapy of plantar fasciitis.

Sella: I use an oblique incision to expose and decompress the first branch of the lateral plantar nerve (Baxter's nerve) and then release 2/3 of the plantar fascia under direct vision. I have no experience with endoscopic plantar fascia release.

Weil: I use ESWT, Topaz, and percutaneous plantar fasciotomy. I believe ESWT is the most appropriate first treatment after conservative care has failed. We have been performing ESWT since 2000 and have had excellent success. We have published an 82% success rate at one year, and recent long-term studies have shown that number to only fall slightly to 78% at more than 3 years. I have had the opportunity to use many different ESWT technologies and have participated in the FDA trial on 3 units as well as multiple other clinical studies on the technology. Based on the results of these studies, ESWT definitely has significant benefits that are comparable to invasive surgical procedures. More recently, low energy, multiple treatment ESWT (radial shockwave) without the anesthesia has proven to be at least as good as higher energy treatments without the added burdenof anesthesia, local or intravenous. The FDA trial that we participated in evaluating the EMS Swiss DolorClast was the highest success against placebo of any FDA submission for ESWT. At this time, the DolorClast, with 3 treatments without anesthesia, is my preferred use of ESWT in 95% of my shock wave cases.

When ESWT has either failed or is not appropriate, then my preferred surgical technique is minimally invasive Topaz plantarfasciotomy. Topaz has been shown to be extremely effective in treating chronic tendonapathies and fasciopathies throughout the body, especially in cases with documented scar tissue formation. Over the last 2 years, we have been using Topaz to treat fasciosis in a percutaneous situation. We introduce the Topaz wand through 10 to 20 skin punctures with a k-wire. The Topaz wand is then introduced into the plantar fascia and multiple small Topaz fasciotomies are performed. We have an ongoing randomized, double blind, prospective study of this technique versus a percutaneous plantar fasciotomy and have found the Topaz patients to have a less painful and quicker recovery with slightly better results at one year following the procedure. The added benefit is that the plantar fascia remains completely intact and foot mechanics are not altered.

Baravarian: I have been very excited about the potential of allowing the body to treat itself. We have begun using platelet rich plasma and topaz coblation in almost all cases prior to fascia release. I call these treatments "in between" care in that you are not cutting or releasing the fascia, but it is more invasive. The idea in both cases is to break up the scar or fasciosis and stimulate the body to enhance the amount of blood in the traumatized area in order to allow for healing. The Topaz procedure also seems to break up nocioceptor cells in the fasciosis area that relieve pain. We are currently working with Arthrocare on a study of fasciosis and the Topaz procedure and have had amazing results. I use a percutaneous technique with multiple pinsize fenestrations of the skin and fascia. The recovery is fast and wehave yet to have any complications. We have about 80% success with the Topaz procedure.

If the calcaneal nerve is involved, we prefer an open nerve release and fascia release. If the Topaz or platelet rich plasma injections fail, we will often
perform an endoscopic release of the fascia. We are currently also starting to use more endoscopic gastrocnemius recessions with some of our plantar fascitis/ fasciosis chronic cases that seem to be due to a severe equinus problem.

What should surgeons be careful with in their surgical care?

Bluman: In addition to preventing neurovascular complications, the surgeon should ensure that the entire origin of the plantar fascia is not excised. Only the medial 50% to 60% of the origin should be excised. Excessive resection may lead to eventual pes planus with lateral column overload.

Sella: Surgeons who use a transverse incision or who do it endoscopically should be especially careful not to cut the nerve. It is also important not to release the lateral slip that will destabilize the calcaneo-cuboid joint.

Weil: The most important thing that surgeons should be careful of in surgical care is patient expectations. When patients come to me for second opinions about previous surgery, I usually find that their problems are due to unrealistic expectations. These expectations range from reduction in pain to return to activity and sports to being able to wear any shoes-or no shoes at all. Many patients expect quicker and better resultsthan are reasonable, and being upfront and honest about these expectations can nip problems in the bud. The other common problem I will see is that after plantar fasciotomy, many patients have nerve pain that was likely damaged during their endoscopic procedure or lateral column pain following the release of the plantar fascia. Because plantar fasciotomy procedures are relatively simple, some may take proper technique for granted, or utilize the procedure sooner than is necessary, which can set up problems later.

Baravarian: Find out what the real problem is and use diagnostic studies to protect yourself and make the proper choice. I see a lot of cases of nerve problems diagnosed as fasciitis and also see a lot of frustrated patients who have seen a good doctor for a long time with no answers. If conservative care is not working, consider the platelet rich plasma or Topaz coblation techniques as potential "in betweens" of conservative care and fascia release. Also, don't be in a hurry to let patients walk on the foot. Let the surgery settle for a couple weeks. Finally, don't forget to treat the equinus if it is a serious problem.

Give us your final thoughts and ideas on future evolving treatments in the care of plantar fasciitis.

Bluman: Continued development of noninvasive/minimally invasive therapies as well as novel anti-inflammatory treatments will make the open surgical management of this disease even less common in the coming decades.

Sella: This condition is a kind of plague for both the surgeon and the patients.I hope that good, double blind, randomized studies will show benefits from high frequency extra-corporeal shock wave therapy.

Weil: I believe that the use of diagnostic ultrasound and MRI will help us understand and recognize chronic problems such as plantar fasciosis earlier. If we determine that there is degenerative tissue that will not respond to conservative care, we can move on to more appropriate treatment alternatives earlier, thereby eliminating the treatment alternatives that are doomed to fail. By moving faster to more appropriate treatment alternatives for the proper pathology, we can reduce patient suffering and the overall cost of care.

Stimulating healing of the plantar fascia seems to be the future. Where once sacrificing the plantar fascia was not thought to have consequences, it has become very evident that plantar fascia is a vital structure required in the normal function of the foot. Therefore, evolving procedures like ESWT and Topaz that spare the plantar fascia certainly hold more promising long-term outcomes.

Baravarian: I believe that the future of fasciitis/fasciosis and also tendinosis is in stimulating treatments that allow the body to heal itself. You will see a great deal of research and many studies showing the benefits of allowing the body to heal itself, such as with coblation or platelet rich plasma injections. I rarely see a need any longer for fascia release and think that such a procedure will be seldom performed in the future.