This can be such a stubborn problem that it is easy to get very frustrated. Very few people need surgery for this since there are so many options for treatment. 30 years ago 1 in 10 patients required surgery, now surgery is less than 1%. The treatment options are so numerous that we are normally limited only by our time and imaginations to develop a successful treatment plan. Each week there should be improvement once active treatment begins. If improvement plateaus, a change in treatment protocols should be made. Analyzing what is working and what is not working should be part of the process.
The patient and health care provider deal constantly with the 3 areas of treatment---anti-inflammatory, stretching or flexibility, and mechanics (one being the transference of pressure from the painful areas to non-painful areas). Most cases of plantar fasciitis need simple solutions like daily icing (anti-inflammatory), plantar fascial and achilles stretching 3 times daily (flexibility), and arch support (either custom orthotics or store-bought arch supports). Some more stubborn cases of plantar fasciitis need the above along with physical therapy to improve flexibility and anti-inflammatory measures, custom-made orthotics if not already manufactured, night splints to gentle stretch out the plantar fascia, cortisone shots if a bursitis under the heel bone is found, and many other options.
In resistant cases, 3 months in a removable cast can help calm down the inflammation. The moral of the story with plantar fasciitis is never give up. Keep trying to find the right combination of anti-inflammatory, flexibility, and mechanical changes. Good luck. Also remember that 25 to 30% of all cases I see for plantar fasciitis for a second opinion, have something else. Neuritis, bursitis, stress fractures, and plantar fascial tears all head the list in the differential diagnosis. I hope this helps and gives you encouragement. Dr Rich Blake
Here is a video on the stretches to do and not do when you have plantar fasciitis.
When I talk about mechanical changes that effect plantar fasciitis, there are many Golden Rules of Foot and come into play.
Golden Rule of Foot: When designing an orthotic device, or using an OTC arch support, the patient must feel that the weight is being transferred into the arch (even borderline obnoxiously) and the heel is feeling protected.
Golden Rule of Foot: The most stress on the plantar fascia and achilles is when the heel just comes off the ground. Treatment of plantar fasciitis therefore typically involves staying in elevated shoes, orthotic devices, clogs, and remaining flat footed in some exercises like the elliptical, and not getting off the seat in cycling.
Golden Rule of Foot: A negative heel stretch (where the heel drops below the ball of the foot) can irritate the plantar fascia with all of the body weight suspended at its attachment. This is in stark contrast with the same position of the Downward Dog in Yoga which never seems to bother the plantar fascia with body weight well in front of the plantar fascial attachment.
Golden Rule of Foot: Plantar Fasciitis patient hurt less walking on their heels than flat footed. If you think you have plantar fasciitis, try to walk barefoot normally, on the balls of your feet, and then on your heels. If you hurt the most on your heels, you probably do not have primary plantar fasciitis, and more bursitis, plantar fascial tears, or heel stress fractures. All three of these are diagnosed by MRI.
The video below discusses heel evaluation.
My initial visit for plantar fasciitis typically includes:
- Teaching the patient Support the Foot taping (www.supportthefoot.com) and giving them a few extra strips.
- Rolling ice massage with frozen sport bottle 5 minutes 3 times per day
- Plantar fascial and achilles stretches (see video above) 3-5 times a day. Typically, gastroc and soleus stretches 1-2 times per day, and plantar fascial stretch 5 times.
- Mechanical changes based on their activities, like no barefoot around the house, and staying flat footed on the elliptical.
- Consideration of physical therapy, night splints, removable boot, all based on their symptoms, speed on healing needed, etc.