Plantar Fascial Treatment Protocol based on Implied Need

Plantar Fasciitis Treatment Protocol
By Richard Blake, DPM
Pedro Pons, DPM
 

INTRODUCTION

      Treatment of plantar fasciitis, like other injuries, is based on need. There are many factors

 that influence the need of the patient. These factors include overall pain level/severity, duration

 of the pain, severity of their biomechanical demands, frustration of the patient, doctor’s experience

 with the presentation of the injury, and other factors.

      The authors feel that the treatment of plantar fasciitis always involves 3 areas of concern. These 

3 crucial areas for plantar fasciitis are 1) biomechanical considerations, 2) anti-inflammatory treatments,

 and 3) plantar fascial/achilles flexibility. Therefore, every office visit should deal with some treatment 

of each of these 3 areas, and subsequent visits, should add or subtract treatments based on symptom

 responses.

     You can divide need into simple, moderate, and severe. Much of this division reflects the art of

 medicine, however, treatment success can be greatly influenced by this approach. Need Analysis

 prevents cookbook approaches to treatment, and individualizes the treatment. It is important to 

realize that need can change between visits any way. For example, a simple need with a poor response

 to treatment can present at the next visit as a moderate need.

     Every health care provider will have a different method of deciding which patients have simple,

 moderate, or severe needs. Every health care provider will have different treatment modalities under

 each heading, adding to the art form. And every health care provider will use the modalities differently, 

some with better success than others, again adding to the complexity. The flow of this article truly

 reflects what most podiatrists do, and attempts to put it in a logical order.

NEED CATEGORIES

     When a patient presents to your office with plantar fasciitis, an initial determination of their need

 is made and treatment is started. The need category selected for the initiation of treatment can be

 solely due to the patient’s concerns, solely due to the healthcare provider’s experience, or a combination

 of both. One factor may totally overrule the others in selecting the treatment category. For example,

 a professional athlete with a multi-million dollar contract with a simple need may get moderate to

 severe treatments for the sake of speed of rehabilitation. Or, a patient with moderate needs but

 no health insurance may request simple treatments due to expenses.

     There are some of the common factors that influence need for each of the 3 categories.

Simple Need

·         Pain Level 0-2 on a scale of 0-10, worse in the morning and after workouts, not during

·         Duration of Symptoms < 1 Month

·         Biomechanical Demands Low (appear easy to fix if abnormality exists)

·         Low frustration from patient (want to know what it is and what they can do on their own to fix it

       and prevent it)

·         Provider’s extensive experience with success with simple means

·         Activity Level still high, although moderate symptoms

·         OTC products very helpful, but not completely eliminate problem

·         Physical Examination only slightly abnormal (for example, no limping or swelling)

Moderate Need

·         Pain Level 3-6 on a scale of 0-10, with pain during workouts, and very stiff in am

and after prolonged sitting

·         Duration of Symptoms between 1 and 6 months

·         Biomechanical Demands Abnormal, normally requiring custom devices

·         Moderate Frustration from patient (normally has tried multiple OTC treatments, or seen other

       healthcare providers)

·         Provider’s experience may be limited, influencing aggressive treatments

·         Activity Level reduced due to pain during activity, and/or some limping during the day

·         Previous treatments not helping get ahead of the problem

·         Physical Examination abnormal with at least two of these findings: limping, swelling, plantar bursitis,

      soreness on plantar fascial stretching, side to side compression soreness of the calcaneus

Severe Need

·         Pain Level 6 or greater on a scale of 0 to 10 at its worse, may take >30 minutes to loosen up  

       in the morning, limps during day, can not exercise, but hoping to be able to cross-train somehow

·         Duration of symptoms >6 months

·         Biomechanical Demands Severe (could be difficult to address completely)

·         Very Frustrated Patient since can not do their activity

·         Provider’s experience points towards the severity with considerations of casting, MRI scans, 

       injections, and/or surgery

·         Activity Level greatly limited, or a professional/semi-professional athlete who has an injury

·         Previous treatments are not helping, and perhaps making matters worse

·         Physical Examination abnormal with at least 3 of the above findings

TREATMENT MODALITIES FOR NEED CATEGORIES

     Let’s look now at the treatment modalities utilized regularly in the treatment of acute or chronic 

 plantar fasciitis based on the 3 implied need categories. It is not the purpose of this article to thoroughly

 explain each modality, but to present a protocol for its timely use. After presenting these categories, the

 next section will give examples of how it’s utilized. Next to each modality will be a notation for simple,

 moderate, or severe implied need category. With each visit, the healthcare provider can simply take

 an additive approach to the treatment by utilizing more and more modalities as symptoms dictate. Any

 treatment the patient does not feel improvement with/helpful can be eliminated. Never eliminate any

 helpful modality unless the treatment is progressing smoothly.

Biomechanical Changes 

·         Weight Shift Effect (most pain is at the heel in plantar fasciitis)

1.      Heeled Shoes simple

2.      Heel Lifts simple

3.      Arch Supports simple

·         Cushion/Suspension Heel Effect

1.      Soft Heel Pads simple

2.      Soft-based Arch Supports moderate

3.      Deep Heel Cupped Orthotic Devices moderate

·         Reduction in Pull on Plantar Fascia Effect

1.      Orthotic Devices (Custom or OTC that control excessive pronation or supination) moderate/severe

2.      Morton’s Extension to restrict 1^st MPJ motion simple/moderate

3.      Low Dye taping to control excessive pronation simple/moderate

4.      Spica Taping to restrict 1^st MPJ motion severe

5.      Shoe gear with stiff forefoot area simple/moderate

6.      Shoe gear which control pronation/supination simple

Anti Inflammatory Measures

·         Topical Applications

1.      Ice Packs moderate

2.      Ice Massage simple

3.      Biofreeze moderate

4.      Rolling ice massage with frozen plastic bottle simple

5.      Contrast Baths (alternating hot to cold) moderate/severe

6.      NSAID gels (i.e. Voltaire gel) moderate/severe

·         Oral Medicines

1.      NSAIDs simple/moderate

2.      Steroid Burst severe

3.      Glucosamine simple

4.      Zyflamend simple

·         Injectables

1.      Cortisone (long or short acting) moderate/severe

2.      Traumeel moderate

3.      Local Anesthetic to break pain cycle severe

·         Physical Therapy Modalities

1.      Electro-Galvanic Stim moderate/severe

2.      Iontophoresis moderate/severe

3.      Ice Slushes/Contrast Bathing moderate

4.      Ultrasound moderate

·         Miscellaneous

1.      Acupuncture moderate

2.      Anodyne moderate

3.      ECSWT severe

4.      Activity Modification to avoid inflaming area simple

5.      Cast Immobilization  moderate/severe

6.   PRP injections moderate/severe

Plantar Fascial/Achilles Flexibility

·         Gentle Stretches

1.      Gastrocnemius simple

2.      Soleus simple

3.      Plantar Fascial simple

4.      No negative heel stretches simple

·         Posterior Sleeping Splints

1.      Evening Use moderate/severe

2.      Day Use moderate

·          Physical/Massage Therapy moderate

·         Active Release Therapy/Graston Therapy moderate/severe

CHECKLIST FOR TREATMENT

·       Biomechanical Changes

1.      Heeled Shoes

2. Heel Lifts 

3. Arch Supports

4. Soft Heel Pads 

5. Soft-Based Arch Supports 

6. Deep Heel-cupped Orthotic Devices 

7. Custom Made Orthotic Devices Soft 

8. Custom Made Orthotic Devices Semi-rigid 

9. Custom Made Orthotic Devices Rigid 

10. Morton’s Extension 

11. Low Dye Taping 

12. Spica Taping 

13. Shoe gear with stiff forefoot area 

14. Shoe gear to control over-pronation or oversupination

·       Anti-Inflammatory Measures

1. Ice Packs 

2. Ice Massage 

3. Biofreeze 

4. Rolling ice massage with frozen sport bottle 

5. Contrast Baths 

6. NSAID gels 

7. NSAID oral medication 

8. Oral Steroid Burst 

9. Glucosamine 

10. Zyflamend 

11. Cortisone Shot 

12. Traumeel Injection 

13. Local Anesthetic Injection 

14. Electro-Galvanic Stim Physical Therapy 

15. Iontophoresis 

16.Ice Slushes 

17. Ultrasound 

18. Acupuncture 

19. Anodyne 

20. ECSWT 

21. Activity Modification 

22. Removable Casting

·       Plantar Fascial/Achilles Flexibility

1. Gastrocnemius Stretches 

2. Soleus Stretches 

3. Plantar Fascial Stretches 

4. No negative stretches 

5. Posterior Sleeping Splint for night and/or day use 

6. Physical Therapy and/or Massage Therapy

7. Active Release Therapy/Graston Technique

INITIATING TREATMENT BASED ON NEED

     After your history and physical examination of the patient with plantar fasciitis, the authors

 recommend that 3 to 6 treatments be initiated based on their implied need with a 4 week

 follow-up for simple need and 2 week follow-up for moderate to severe need. With each

 visit, at least one treatment modality added or changed should be in each category---biomechanical,

 anti-inflammatory, and flexibility. Here are common treatment recommendations for Simple, 

 Moderate, and Severe Need of a patient with plantar fasciitis on the initial visit.

Patient #1 Diagnosis Plantar Fasciitis with Simple Need

     Need based on following facts: duration 6 weeks, hurts am and after running only, OTC inserts

 help him run without pain, physical examination shows only pinpoint tenderness to medial calcaneal

 tubercle. Treatment recommended:

    

     Biomechanical:

1.     Teach self low dye taping technique for daily use (or version of)

2.     Use shoes for day to day activities with OTC arch supports (or Hapad-like

      self-adhering medial longitudinal support

     Anti-Inflammatory:

1.     Rolling ice massage BID for 5-10 minutes

2.     Glucosamine drink/tablets TID or NSAIDs after activity only

     Flexibility:

1.     Gastroc/Soleus/Plantar Fascial Stretches 30 sec hold times 5/day

2.     Avoid negative heel stretching/strengthening

Patient #2 Diagnosis Plantar Fasciitis with Moderate Need

     Need based on the following facts: duration 3 months, level 5 pain in am taking 30 minutes 

to loosen, then pain develops 5 minutes into his normal 45 minute run causing him to limp. 

Significant over-pronation noted in gait, especially running, with very tight Achilles tendons. 

The pain was severe on palpation of the medial calcaneal tubercle with an obvious plantar 

calcaneal bursitis. Patient signed up for marathon in 6 months and wants to get into more 

serious training. Treatment recommended:

Biomechanical:

1.     2 above mentioned modalities for simple need, plus…

2.     Custom orthotics with deep heel cups due to significant over-pronation

3.     Shoe gear to control over-pronation while running

Anti-Inflammatory:

1.     Rolling ice massage BID for 5-10 minutes for the bursitis

2.     Ice Pack 20 minutes after activity

3.     Activity Modification with no running, but cycling, elliptical, etc to cross train

4.     NSAID (normal dose for age and weight) until back to running

5.     6 visits of Physical Therapy (2/week for 3 weeks) to emphasize reduction of bursitis 

      and Achilles/plantar fascial flexibility.

     Flexibility:

1.     2 above mentioned modalities for simple need, plus…

2.     Physical Therapy for flexibility as mentioned above

3.     Posterior Sleeping Splint until am soreness is eliminated, then shift to sitting periods 

     during daytime

     Patient #3 Diagnosis Plantar Fasciitis with Severe Need

           Need based on the following facts: duration > 1 year, with up and down course of 

      symptoms and Sporadic treatments. Patient very frustrated does not believe it can ever go away.  

      Symptoms range from 0 to 8 depending on activity. Definitely can not do 50% of the weight 

      bearing activities she could do prior to symptoms. Therefore, 100% disabled for some activities, 

      especially high-impact aerobics. Physical examination shows plantar heel swelling, possible 

      bursitis, soreness on stretching of the plantar fascia, soreness on side-to-side compression of the 

      heel, over-pronation in gait. Patient states she limps for about 2 hours each morning until the 

      symptoms feel better, but never gone. Treatment recommended:

                          An MRI to rule out tear or fracture should be ordered ASAP

      Biomechanical:

1.     Low Dye taping along with custom orthotic devices for full time use

     Anti-Inflammatory:

1.  Cortisone Burst with oral Prednisone followed by NSAIDs

2.     Contrast Baths BID to reduce bone edema (20 minutes total with alternating hot and cold water

3.     Physical Therapy 2-3 times/week for inflammation reduction for 12 visits

4.     Activity Modification to include removable cast, perhaps crutches, emphasis to cross-train 

      biking or swimming.

     Flexibility:

1.     Posterior Sleeping Splints for evening use

2.     Active Release Therapy or Graston as symptoms begin to calm down

3.     2 above mentioned areas in simple need

     Visits 2 to 6

          Following the first visit, treatments are maintained or changed with each subsequent visit. Careful 

         attention to each of the three areas of treatment is analyzed:

Are the biomechanical changes being made helpful, and can be modified further for better results?

Is the inflammatory process being adequately eliminated, or should I make other recommendations?

Is the Achilles or plantar fascial inflexibility hampered the progress, and can further changes to the 

stretching regimen be made?

Summary

     This is a brief overview of developing a thoughtful treatment plan for each individual that presents

with the diagnosis of plantar fasciitis. Need Analysis is a very useful tool in this regard and it 

presents a method to avoid a cookbook approach to every patient with all their unique symptom 

presentations and athletic/life goals. Some patients do not get completely better even with the 

best treatment. But the healthcare provider should work towards minimizing the number of these 

patients by fine-tuning the treatment process. If the true uniqueness of the patient is recognized, 

the course of treatment of your next 100 patients will be 100 different paths and 100 different victories.