By: Marc J. Michaud, MD
Plantar Fasciitis is the Most Common Ailment I See
As a foot and ankle surgeon, plantar fasciitis is the most common ailment that I see in the office. Patients complain of pain along the course of the plantar fascia and especially at the insertion to the heel. It is estimated that more than 2 million Americans will seek treatment for plantar heel pain each year. Multiple causes have been proposed and a confusing array of treatment remedies have been described. Non-operative treatment is the mainstay of treatment, with a success rate of greater than 90%. However, it may require 6 to 12 months for the pain to resolve. There are many treatment options available, but what works and what does not?
Symptoms and Causes
Nobody is immune from developing this painful affliction as it can affect athletes and sedentary people alike. Occupations vary as well, although prolonged standing or walking is a common reason. In a healthy individual the heel absorbs 110% of a patients’ body weight with walking, which increases to 200% with running. The exact cause is unknown but repetitive micro trauma to the insertion of the plantar fascia and to the bottom of the heel is the suspected mechanism. This repetitive trauma results in inflammation and persistent pain. A tight Achilles tendon can increase the load applied to the plantar fascia during normal walking and standing activities, and is often seen with plantar fasciitis. Pain when first getting out of bed in the morning is a common complaint. This is felt to be due to the plantar fascia trying to heal while the foot is in the relaxed position. This healing is accompanied by shortening which is “re-torn” while taking that first step in the morning or after inactivity.
Methods of Treatment
Initial treatment includes relative rest with activity modifications (non-impact exercises such as biking, swimming and an elliptical walker are encouraged), and ice and non-steroidal anti-inflammatory drugs (if not contra-indicated). Plantar fascia and Achilles tendon stretching exercises are the most effective methods of treatment. I recommend stretching and massaging the plantar fascia first thing in the morning on both feet, for thirty seconds each, before getting out of bed in the morning. A night splint can accomplish this as well but must be worn for three months. Typical Achilles stretches include the runner’s stretch, as well as slowly lowering the heel on a stair riser. Stretching can irritate the fascia and calf for 2 to 4 weeks before pain improvement begins, so do not get too discouraged if you do not feel immediate relief. I often prescribe an inexpensive off-the-shelf orthotic, which supports the arch and cushions the heel for improved daily comfort. Physical therapy seems to be effective and may quicken the recovery. Steroid injections may be of help but has been associated with rupture of the plantar fascia if repeated injections are done.
Other treatments include arch straps, casting, walking boots, air bladders and custom orthotics, all of which have had varying levels of success but are inconsistent and can get expensive. Recently, shock wave therapy to the heel had some measure of success but this did not extend to patients with chronic plantar fasciitis. A new treatment option that may be beneficial is platelet rich plasma (PRP) injections. This procedure involves obtaining a patient’s blood and spinning it in a centrifuge to separate the red blood cells and concentrate the plasma, which is high in healing growth factors. The plasma is then injected into the area of injury. Research is currently in progress so we will have to see if the initial excitement is warranted. At this time the insurance companies to do not cover this procedure as it is considered experimental. However, if all other treatment options have been exhausted, this relatively inexpensive treatment may have some merit.
Although this condition is painful and annoying, with simple non-operative measures there is a light at the end of the tunnel.