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 1st MPJ motion simple/moderate
3.
Low Dye taping to
control excessive pronation simple/moderate
4.
Spica Taping to
restrict 1st 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.
