Effective Protocol for the Management of Plantar Fasciitis
Enthesopathy of the plantar aponeurosis, otherwise known as plantar fasciitis, is one of the most common causes of foot pain presenting to the family practitioner, podiatrist, and orthopedist.
The classic symptom is poststatic dyskinesia, or pain upon first arising from a night’s sleep or after travel. The diagnosis is not difficult to make, and once a differential diagnosis is considered and other causes of heel pain are ruled out,1 proper treatment of this condition can be initiated.
Historically, podiatrists have approached the treatment of this condition in two concurrent ways: reduction of stress on the plantar fascia and medical management. Mechanical stress reduction has traditionally been achieved by wearing supportive footwear. Years ago, podiatrists applied adhesive tape dressings directly to the foot. This treatment provided temporary relief; however, the adhesive tape stretched over time and needed to be reapplied after several days to remain effective. Over-the-counter shoe inserts or custom orthotics are a more elegant and standardized method of providing support and continue to be the standard in treating the mechanical aspect of this problem.
The introduction of the first generation of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, piroxicam (Feldane), and naproxen, has given clinicians a powerful tool to medically treat the inflammatory aspect of this condition. Corticosteroid injections have been used as a second-line treatment when NSAID therapy in combination with mechanical support does not provide adequate relief. There is no consensus, however, regarding the number of injections one may give a patient. The generally accepted maximum number is three into one heel given at appropriate intervals.
Physical therapy in the form of stretching and night splints is effective in some cases. I do not recommend exercise during the acute phase because it is usually too painful to attempt stretching during that time. After the condition is resolved, proper stretching may help to prevent recurrence.
Most clinicians agree that about 90% of plantar fasciitis cases resolve after conservative care. If the condition persists, the third line of treatment becomes procedural. Until about 1990, the most common procedure was surgical removal of the plantar calcaneal spur. Contrary to popular belief, the plantar spur is not the cause of plantar fasciitis. This osseous projection is thought to arise from the chronic tension on the heel at the origin of the plantar fascia.
Radiographically, the spur appears sharp in two dimensions, but in 3-D it is actually a shelf of bone projecting from the entire plantar surface of the calcaneus. Barrett and Day determined that the success of heel spur excision was primarily due to release of the attached plantar fascia, not to the spur excision itself.2 The endoscopic plantar fasciotomy (EPF) procedure they invented remains in widespread use by podiatric surgeons. Other surgical approaches include in-step fasciotomy and open fasciotomy. Of these, EPF provides the fastest recovery time, fewer complications, and a good outcome.
Since 1993, extracorporeal shock wave therapy (ESWT) has been used in Europe to treat tennis elbow and plantar fasciitis. There are two popular forms of this treatment. The first involves high-energy shock waves and requires the use of anesthesia during one treatment episode. The other is low energy and may require several treatments spaced at appropriate intervals. Overall, ESWT is about as effective as EPF surgery.
The use of a thermal tendon microdebrider and minimally invasive percutaneous biopolar radiofrequency plantar fasciotomy are being utilized by some foot and ankle surgeons. Newer, noninvasive therapies that are rapidly gaining popularity include cold laser and pulsed radiofrequency energy (PRFE).
The obesity epidemic in the United States is widely recognized as contributing to the rise in incidence of this condition by mechanically stressing the plantar fascia. In addition, some occupations may increase a person’s risk for plantar fasciitis, such as those that require squatting, stooping, standing, or walking for long periods or those that require climbing ladders or poles. This common condition is also rampant among athletes. Those who practice sports medicine or who treat active-duty military often are swamped with patients complaining of plantar fasciitis.
Pearls of Treatment—Dr. Meltzer’s Protocol
In more than 30 years of podiatric practice, including the treatment of soldiers and athletes, I have developed a successful treatment protocol I am pleased to share with this readership.
I have found that the longer the patient has had the condition, the longer it takes to resolve. If a patient has had pain for 2 to 4 weeks, it is usually easy to resolve it in one or two visits. If the patient has had it for more than a year, I tell him or her that it will take a while to resolve and to be patient with treatment. Regardless of the duration, plantar fasciitis should not be permitted to progress to chronic pain. If conservative treatment is not effective within 3 to 6 months, a procedure should be considered.
I use the “Meltzer Scale” to assess treatment progress. Using a 0 to 10 scale on which 10 is 100% resolved and 0 is pretreatment, I ask the patient where he or she stands on the second visit following treatment. If the patient responds with a number—for example, 5—I document that the patient reports a 50% improvement in symptoms. I have found that once patients report 70% or better, most are satisfied.
I have the most experience with the cyclooxygenase-1 (COX-1) agents. Compliance is important, because it is well known that drug compliance increases with decreased daily dosing schedules. In that regard, I tend to favor the once-daily NSAIDs, such as meloxicam (Mobic) 15 mg per day and piroxicam 20 mg per day. The twice- and three-times-daily dosage regimen agents are no less effective, but if patients miss a dose, they are not receiving the full therapeutic effect of that NSAID.
Because patients will not be on these drugs indefinitely, the question is when to stop. I employ “Meltzer’s Rule.” I tell patients to stop the drug when they experience two successive days without pain. The reverse of this rule is that if the pain persists for 2 days, they need to continue on the medication until the next visit. I have not observed good long-term results using oral prednisone tapered dosing. In my experience, the inflammatory process requires suppression over a period of 1 to 3 months with NSAIDs.
As I previously noted, proper biomechanical control and support are necessary to treat this condition successfully. If clinicians are not completely familiar with their use, they would better serve their patients by referring them to a podiatrist. Patients who suffer from plantar fasciitis are 50% likelier to have a subsequent recurrence. Many patients will need to wear orthotics indefinitely for prophylaxis.