Persistent Plantar Fasciitis

author : AMSSM
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I've had plantar fasciitis issues for a few years now. I've been using generic plantar fasciitis insoles. I'm having some custom insoles done tomorrow. Is there anything else that will help?

Member Question

I've had plantar fasciitis issues for a few years now. I've been using generic plantar fasciitis insoles from the Dr.Scholl's Active Series and it doesn't matter if I wear them when I run or not, my feet are still killing me. I massage them almost on a daily basis with anything I can get my hands on (handle of a dumbbell, lacrosse ball, frozen golf ball, the stick, you name it!) I also use a foam roller to relieve some of the tension in my muscles which seems to help a bit but I'm still facing this PF issue. I should add that I do only running now (no more time for tris) and mostly only workouts (tempos, track workouts and such) and I also do three days of hard strength training per week so my legs are almost always in a state of soreness. I'm having some custom insoles done tomorrow and I hope that it will help. 

What have you found that works? Do you run with inserts or use them only for walking?

Answer by Nathaniel Baer, MD, MA and Melissa Novak, DO
Member AMSSM

I am sorry that you are experiencing such persistent foot pain! You raise multiple important issues leading into your question and we will address a few topics in response. 

Plantar fasciitis and pain of the heel bone (calcaneus) are common medical issues that affect runners and triathletes as well as non-athletes. Discomfort commonly affects the bottom of the heel and may extend to the mid-foot. The pain can be highly variable in its severity, disability and chronicity. It is estimated that up to 1 in 10 people will develop some type of heel pain during their life and many will seek care from orthopedic, sports medicine or primary care physicians.

Ultimately, up to 80% of heel pain experienced by athletes may be caused by plantar fasciitis. In a 2002 survey of running injuries, plantar fasciitis was the 3rd most prevalent injury. The plantar fascia is a band of connective tissue that originates at the heel bone. It traverses the sole of the foot between the foot bones and the skin, and then inserts into the farthest foot bones and closest toe bones. The fascia is relatively inelastic and is incredibly strong. Stretching across the foot, it helps provide conformation and stabilization of the arch of the foot and bones at rest as well as in motion. When walking or running, the fascia comes under significant tension as the force of the body drives down through the heel and arch of the foot and when pushing forward through the toes.

As the plantar fascia it is connected directly and indirectly to many surrounding structures, a number of stresses can be translated into force on the tissue that initiates the onset of pain. Generally, the onset of plantar fasciitis pain is gradual over days to weeks, and most commonly starts in one foot. It is most commonly related to a change in repetitive stress on the foot such as new patterns of walking, standing, running or jumping, though obesity and ankle pronation are also risk factors. New incorrectly fitting footwear can also be a trigger, even when activity level does not change.

We can think of the pathology, symptoms and treatments for plantar fascia pain as occurring in stages across time.

In the acute phase of plantar fasciitis, up to the first four weeks, pain can be a symptom of local inflammation. Discomfort is commonly worse with the first steps in the morning, or after any prolonged period of being off the foot, and subsequently improves to a dull ache. Non-steroidal anti-inflammatory medication (NSAIDS) like Ibuprofen and Naproxen are beneficial for pain, however, there is no evidence that taken alone they impact recovery. We do know that massage and direct manual therapy is beneficial to recovery as is stretching of the plantar fascia itself. While calf tightness likely impacts the development of plantar fasciitis, calf and hamstring stretching has not proven to be an effective treatment for recovery. Taping (anti-pronation) can assist some. Heel cups or foot orthotics are also recommended and during this period it is reasonable to try any quality over the counter brand. Importantly, exercise reduction, is often necessary.

When plantar fasciitis continues beyond 3-4 weeks, pain is thought to be an indication of small tears, degenerative change and remodeling of the connective tissue, rather than an active inflammatory process. The 1-3 month range is considered the sub-acute period. Pain may be less prominent with first steps, but continues to be progressive with activity and main remain a dull ache at rest. As plantar fascia pain continues beyond three months, the chronic phase, pain is often highly localized to the heel bone and is present mostly with weight bearing exercise. 

Additional treatments for pain progressing into the sub-acute and chronic phases are often less thoroughly researched, more invasive and may have higher complication rates. Non-steroidal anti-inflammatories have no clear role in prolonged discomfort, as inflammation is not the cause of pain. Despite this, corticosteroids have good evidence of benefit, though they can be used only a few times and have clear possible side effects. In practice a steroid injection is very rarely used, especially for weight bearing athletes. Additionally botulin toxin injections and acupuncture have some evidence of potential benefit though there are fewer studies to date. Night splints, while difficult for many patients to tolerate, have benefit by elongating the fascia, particularly when used in combination with orthotics, which continue to be an important intervention.

When pain is chronic and refractory to a full range of conservative and common intermediate measures, treatment may include extracorporeal shockwave/sound wave therapy, and as a last resort surgery to release part of plantar fascia, or, partial calf muscle resection. Uncommon treatments with preliminary data to suggest potential benefit include platelet rich plasma to stimulate healing, percutaneous needle fasciotomy to release tissue and cryosurgery to destroy diseased tissue.

Foot orthotics in plantar fasciitis are a common treatment and deserve further discussion. There is at least some evidence that these shoe supplements can be useful in all phases of injury, and are best used in combination with other treatments. Orthotics are not modern inventions, they have been utilized for over 150 years for various foot ailments and were one of the first interventions trialed in the 1970s when incidence rate of plantar fasciitis increased in the burgeoning running population. The benefit is achieved through altering the internal forces of the foot during running, functionally decreasing impact and stress on the heel, arch and fascia. While contemporary evidence on the best type of orthotic (pre-fabricated vs custom), the amount of benefit and the duration of use is mixed, the conclusion of multiple individual studies and reviews (including a Cochrane review in 2008) supports the use of orthotics. It is reasonable to start with pre-fabricated over the counter inserts in the acute and sub-acute time period. Again, they should be combined with other treatments. If no benefit is achieved, a custom device can be tried, as these allow specific interventions like offloading or groove creation to decrease friction along the tender fascia. Orthotics can be used for standing, walking or running.

With appropriate conservative treatment, 70-80% of plantar fasciitis pain should improve or resolve in a few weeks to a month or so. When started early, conservative treatment is more likely to succeed, though some patients may ultimately fail to respond regardless of timely initiation. While many interventions have been studied, none are universally beneficial and few have been rigorously researched in large numbers.

When any pain thought to be plantar fasciitis fails to respond to conservative treatment over 3-4 weeks, it may be time to consult a medical practitioner for two reasons. Most importantly, the diagnosis should be confirmed, as there are other causes of heel pain. Inflammation of tendons, thinning of the fat pad on the bottom of the heel bone, nerve damage, inflammation of bursa (small fluid filled sacs that reduce friction between bone and overlying tendon or muscle) and heel or foot fractures may have similar pain. Less commonly, pain can represent a broader issue like bone infection, systemic inflammatory disease, metabolic disorders and, very rarely, cancer. Additionally, if plantar fasciitis is confirmed, it is reasonable to start a discussion about how to escalate treatment, including the risks, benefits and acceptability of more invasive treatment.

In summary, plantar fasciitis is a common form of heel pain than can progress to a non-inflammatory chronic condition. The disorder is highly responsive to conservative measures of treatment (including rest!), which should be used in combination. Foot orthotics are appropriate treatment at any stage of chronicity. If over the counter models do not help, it is reasonable to proceed to custom orthotics, combining them with other treatments. When not improving with basic interventions, the diagnosis of plantar fasciitis should be reconsidered as other conditions have similar presentations. If the diagnosis of plantar fasciitis is confirmed, treatment can be escalated.

Nathaniel Baer, MD, MA
Internal Medicine Resident
Oregon Health & Science University

Melissa Novak, DO
Primary Care Sports Medicine
Oregon Health & Science University

Works Cited

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Berbrayer, D, Fredericson, M. Update on Evidence-Based Treatments for Plantar Fasciopathy. PM&R. 2014;6:159-169.

Dipreta, J, Rosenbaum, A, Misener, D. Plantar Heel Pain. Medical Clinics of North America. 2014;98:339-352.

Garrett, TR, Neibert, PJ. The Effectiveness of a Gastrocnemius-Soleus Stretching Program as a Therapeutic Treatment of Plantar Fasciitis. Journal of Sport Rehabilitation. 2013;22:308-213.

Hawke, F, Burns, J, Radford, J, du Toit, V. Custom-Made Foot Orthoses For The Treatment Of Foot Pain (Review). The Cochrane Library. 2008;(3).

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Philbin, TM, Feinblatt, JS. Plantar Fasciitis/Faciosis. In Sports injuries of the foot: evolving diagnosis and treatment.; : 129-150.

Werd, MB, Knight, EL, Kirby, KA. Evolution of Foot Orthoses in Sports. In Athletic footwear and orthoses in sports medicine. New York: Springer; 2010: 19-35.

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date: April 16, 2015

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The American Medical Society for Sports Medicine (AMSSM) was formed in 1991 to fill a void that has existed in sports medicine from its earliest beginnings. The founders most recognized and expert sports medicine specialists realized that while there are several physician organizations which support sports medicine, there has not been a forum specific for primary care non-surgical sports medicine physicians.

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