Plantar Fasciitis: Top 10 Treatments

Plantar Fasciitis

 

The top 10 common treatments for plantar fasciitis:

 

1. Plantar Fascial wall stretch for 30 seconds 5-10x/day

2. Rolling ice massage 2-3x/day for 5 minutes

3. No negative heel stretches

4. Avoid barefoot walking (something like dansko sandal at home)

5. OTC or custom orthotic devices to transfer weight into the  arch (you must feel that the   heel is protected and weight is in the arch)

6. Physical therapy or acupuncture (2x/week for 4 weeks and then re-evaluate)

7. Posterior sleeping splints when morning soreness over 5 minutes (these can be used at any time as rest splints when you are going to sit 30 minutes or more)

8. Low dye/arch taping daily initially and then with strenuous activity (Try Quick Tape from www.supportthefoot.com for tape that works and lasts up to a week)

9. Activity modification to avoid “bad pain”

10. Calf stretches (straight and bent knee) 2x/day

This can be such a stubborn problem that it is easy to get very frustrated. Very few people need surgery (even if you have a heel spur noted on x ray) for this since there are so many options for treatment. I once did a thorough review of the literature and found easily 72 different treatment options that made sense. These treatment options are so numerous that we are normally limited only by our time and imaginations to develop a successful treatment plan. Each week (or every 2 week interval) there should be improvement once active treatment begins. If improvement plateaus, make a change. Analyzing what is working and what is not working should be part of the process.

When treating plantar fasciitis we typically deal constantly with the 3 areas of treatment---anti-inflammatory, stretching or flexibility, and mechanical support (transference of pressure from the painful areas to non-painful areas or limiting the pull of the fascia by less pronation, less big toe joint dorsiflexion, or less impact stress to the arch). 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, and many other options. Cortisone shots are actually never given for plantar fasciitis, since you do not want to inject and weaken the plantar fascia. Cortisone is given to the area under the heel (typically a bursitis which develops secondary to the chronic inflammation) and away from the fascial bone attachment. 

In resistant cases, 3 months in a removable cast can help calm down the inflammation and strengthen the plantar fascia which may have some micro tearing not well visualized on MRI or felt by the patient. 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 support. 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, plantar fascial tears all head the list in the differential diagnosis that may need completely other forms of treatment. 

The above was an excerpt from my book “Secrets to Keep Moving”. 

Plantar Fasciitis:General Principles of Treatment

 Plantar Fasciitis is one of the most common problems facing podiatrists. 

Several Golden Rules of Foot are common.

Golden Rule of Foot: Plantar Fasciitis begins gradually over weeks and months before effecting athletic performance. It does not come on suddenly.

Golden Rule of Foot: Even bad cases of plantar fasciitis have no swelling. Heel swelling typically is a sign of something worse like an actual tear in the fascia or a stress fracture in the heel bone. 

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 options should be made, but not the basic conservative treatment protocol. Analyzing what is working and what is not working should be part of that 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 of the more stubborn cases of plantar fasciitis need all of 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. I presently would not recommend this unless I got an MRI. The MRI typically will show you why a case of stubborn plantar fasciitis is not improving. The moral of the story with plantar fasciitis is to 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. The patient should never feel that the majority of the pressure is in the heel. 



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 sometimes 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 as the body weight well in front of the plantar fascial attachment into the heel.

Golden Rule of Foot: Plantar Fasciitis patients 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:

1. Teaching the patient Support the Foot taping (www.supportthefoot.com) and giving them a few extra strips. Every podiatrist and PT will have some version of taping. 
2. Rolling ice massage with frozen sport bottle 5 minutes 3 times per day
3. 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. Nothing should hurt when you stretch however.
4. Mechanical changes based on their activities, like no barefoot around the house, and staying flat footed on the elliptical. 
5. Consideration of physical therapy, night splints, removable boot, all based on their symptoms, speed on healing needed, etc, or getting an MRI if a tear or stress fracture is suspected. 

I sure hope this helps. Rich

Plantar Fasciitis: Top 10 Treatments

The top 10 common treatments for plantar fasciitis:

1. Plantar Fascial wall stretch for 30 seconds 5-10x/day

2. Rolling ice massage 2-3x/day for 5 minutes (see discussion below)

3. No negative heel stretches

4. Avoid barefoot walking (something like dansko sandal at home)

5. OTC or custom orthotic devices to transfer weight into the  arch

6. Physical therapy or acupuncture (2x/week for 4 weeks and then re-evaluate)

7. Posterior sleeping splints when morning soreness over 5 minutes

8. Low dye/arch taping daily initially and then with strenuous activity

9. Activity modification to avoid “bad pain”

10. Calf stretches (straight and bent knee) 2x/day

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. I once did a thorough review of the literature and found easy 72 different treatment options.  These 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, make a change. Analyzing what is working and what is not working should be part of the process.

Deal constantly with the 3 areas of treatment---anti-inflammatory, stretching or flexibility, and mechanical support (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 support. 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, all head the list in the differential diagnosis.

Dr Rich Blake and the Center For Sports Medicine Singing Group (aka Richie and the Saints) from Saint Francis Memorial Hospital in San Francisco sing " I Want A Hippopotamus For Christmas" at a Christmas Bash. Since there are hardly anymore record stores, see if iTunes is selling it.

Here the MRI section is a little closer to the heel bone showing some greater inflammation settling under the heel (called bursitis). Again, no tear is noted but in both views the plantar fascia would be considered thicker than normal from scarring. The health care provider must treat the intense inflammation initially before actual work can begin on the thickened plantar fascia (this is where ART or Graston shines--Active Release Technique--not colored crayons and ceramic bowls)

This is a great MRI scan showing intense inflammation around the plantar fascia just in front of the heel bone. The pain was so severe the MRI was done to rule out a tear in the plantar fascia or a calcaneal (heel bone) stress fracture. With the MRI you can look at the plantar fascia in all 3 body planes to make sure you are not missing anything.

Plantar Fasciitis or Plantar Heel Bursitis: Rolling Ice Stretch

    The Most Time-Effective Treatment for Plantar Fasciitis is a 5 minute Rolling Ice Stretch. It combines anti-inflammatory, mechanical massage, and plantar fascial stretch all beneficial in helping plantar fasciitis. If there is a plantar bursitis, an additional 5 minutes of massage just to the bottom of the heel is performed. A plastic bottle of any shape (patients do have their favorites) is filled 1/2 to 2/3 full of water and then frozen. The water will expand with freezing. Then, a towel is placed on the ground, and from a sitting or standing position (I personally like standing but not with full body weight), the arch from heel to toes is gradually massaged from 5 minutes. Patients are told to gently massage the skin for the 1st minute, the 2nd minute they can massage a little deeper into the soft tissues, and the 3rd to 5th minutes the massage should get deep into the deeper tissues (fascia, muscle, and tendon). This treatment should be done three times daily. The bottom of the heel gets its own 5 minutes if a bursitis is present. Remember with icing the 4 to 1 rule. If you ice for 5 minutes, the tissue is tight for the next 20 minutes, prone to pull if used, so be careful to go easy on it during the thawing-out phase. This treatment can be used for many months until the final healing of the plantar fasciitis.

Plantar Fasciitis Treatment Flow Chart