Conservative treatment involves a combination of stretching and strengthening exercises. Stretching of the calf and foot intrinsic muscles is a key part of treatment (Figs. 1-8). Each stretch should be held for 15 to 30 seconds per repetition. Wall stretches are done by having the patient lean against a wall while pushing hips into the wall (Figs. 4 and 5). Intrinsic muscle stretching is performed with the patient sitting down and passively stretching their toes into extension (Fig. 2). To strengthen the foot intrinsic muscles, towel curls, marble pickups, and toe tapping can be performed (Figs. 7 and 8).
Modalites found helpful for pain relief in plantar fasciitis include cold therapy in the form of ice massage or ice bath. Ice massage can be conducted using water frozen in a Styrofoam cup. Part of the cup is peeled off and then applied to the heel of the foot in circular motion for 5 to 10 minutes. Iontophoresis, a modality that drives medicine or other charged molecules through the skin using electrical charge, can decrease symptom recovery time (10). Iontophoresis can be done with 0.4% dexamethasone six times over 2 weeks to facilitate symptom relief. However, no long-term improvements were found at 6 weeks (11).
Nonsteroidal anti-inflammatory drugs can decrease pain during therapy, but may not assist with the physiological healing process. Options for nonsteroidal anti-inflammatory drugs to use include:
1. 800 mg Motrin® by mouth three times a day.
2. 500 mg Naprosyn® by mouth twice a day.
3. 200 mg Celebrex® by mouth daily.
In cases in which some local neuritis may be present because of fat pad atrophy, tricyclic medications or neuroleptic medications, such as gabapentin or pregabalin, may be helpful.
Orthotics as adjunctive therapy decrease local direct trauma with ambulation, provide some increased stability in stance and gait, and can provide some passive stretch. Heel cups are often prescribed and provide cushioning. Night splints, which keep the foot in slight 5° dorsiflexion, have shown to be helpful. However, patients often complain of difficulty sleeping with splint use, which affects compliance.
Steroid injection is widely used as the first-line invasive treatment. Ten milligrams triamcinolone or 2.5 mg dexamethasone diluted in 1 cc 1% lidocaine plain is injected with a 25-gage needle using the medial approach to avoid the fat pad. Adverse complications can include fat pad atrophy, infection, or plantar fascial rupture from repeated steroid use.
Surgery involves release of the medial plantar fascia with decompression of the abductor digiti quinti with or without heel spur excision. In a retrospective review of 870 patients with plantar fasciitis only 3% required surgery (12). Successful outcomes range from 50 to 90%. However, postoperative rehabilitation is prolonged and involves casting immobilization and crutch use for 3 to 4 weeks followed by about 4 weeks of physical therapy. Potential complications include infection, plantar hypesthesia, plantar fibrosis, and rupture.
Extracorporeal shock wave therapy (ECSWT) has been shown to provide relief in patients showing more than 4 mm fascial thickening by ultrasound. Results seem controversial and are affected by the concomitant use of local anesthetic during this procedure. The application apparatus is expensive and treatment cost ranges from $800 to $3000 depending on the number of treatments. Proper technical application is clouded by the lack of universal consensus of terms such as "high," "medium," or "low" energy. Low-energy ECSWT has been advocated and two classifications have been proposed by Mainz (low = 0.08-0.27 mJ/mm2) and Kassel (low = <0.12 mJ/mm2). However, upon reviewing several randomized, placebo-controlled clinic trials using ECSWT for plantar fasciitis, results were variable for significant difference between treated and placebo groups. These results may be explained by the technical variability regarding machine design, shock-wave intensity, focal energy, geometry of the shock-wave focus, frequency of treatment, and the use of different forms of placebo therapy (13). The accuracy of treatment localization is also variable. High cost and staff expertise prevents routine application of this method.
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