Web Exclusive: Treatment of Plantar Fasciitis Takes Patience




The good news about plantar fasciitis, a common form of heel pain, is that pain usually resolves faster if the patient receives treatment soon after symptoms start.

“Early intervention is the key,” says Debra Palmer, RN, MSN, an orthopaedic nurse practitioner with Kaiser Permanente in San Diego. “The longer you put up with it, the longer it will take to go away.”

Unfortunately, many patients wait months before seeking medical treatment. A 1994 study showed their patients delayed six to 19 months after onset of symptoms.

Considered an overuse injury, plantar fasciitis results from repetitive stretching and microtears of the plantar fascia. This fibrous band of tissue supports the arch and extends from the heel to the toes. The condition accounts for about 1 million outpatient visits a year, according to data from the National Ambulatory Medical Care Survey.

Risk Factors and Symptoms

A combination of factors contributes to plantar fasciitis, Palmer says. Risk factors include —
• Overweight
• Age between 40 and 60, more often women than men
• Prolonged standing or walking, especially on hard surfaces
• Increased weight-bearing exercise, particularly running and walking
• Pregnancy
• Wearing shoes with poor arch support or with stiff or thin soles
• Possibly flat feet (study results differ)

Heel spurs don’t cause plantar fasciitis and are no longer considered a risk factor, Palmer says.

The classic symptom of plantar fasciitis is pain on the bottom of the heel that is worse when the patient steps out of bed in the morning. Pain also gets worse after prolonged weight-bearing activity and when the person stands on tiptoe, climbs stairs, walks barefoot, or wears high heels. Patients describe the pain as dull, stabbing, or throbbing. Usually the most tender spot is at the anterior medial region of the heel, but sometimes the pain radiates forward into the arch. The condition usually happens in one foot at a time.

While taking a history, nurses should ask patients who have these symptoms about possible triggers. Have they begun or increased weight bearing during work or exercise? What shoes do they wear?

Initial Treatment

Most cases of plantar fasciitis respond to conservative treatment. However, some authors say healing can take six to 18 months. Palmer says she uses a treatment algorithm that helps most of her patients get better in nine months. Her initial treatment includes —
• Rest and eliminate the aggravating factor if possible
• Ice the heel for 15 to 20 minutes as needed
• Take anti-inflammatory medicines at least twice a week (unless contraindicated)
• Switch to well-cushioned shoes
• After the pain improves, start stretching exercises

Most experts recommend stretching exercises as an important part of initial treatment. Many clinicians recommend Achilles tendon stretches, also called calf stretches. However, a study published in August 2006 from the University of Rochester (N.Y.) showed a non-weight-bearing stretch of the plantar fascia is even more effective than the Achilles tendon stretch for patients with chronic plantar fasciitis.

The best time to do the plantar fascia stretches is before you get out of bed in the morning, says Deirdre Fleming, RN, MS, a family nurse practitioner at Massachusetts General Hospital Sports Medicine Center in Boston.

Besides stretching, athletes should stop the sport that aggravates the heel pain. But they don’t need to be sedentary, Fleming says. “You can swim, bicycle, or do other activities that have a low impact on the joints.”

Other treatments of plantar fasciitis include taping the heel, a custom orthotic inserted into the shoes, a fixed ankle orthosis (prefabricated boot) and wearing a night splint, a splint on the calf and foot worn during sleep. Taping may give only short-term benefit, and night splints had mixed outcomes, according to a January 2008 review of the literature published in The Clinical Advisor.

In Palmer’s experience, night splints work well early in treatment for patients with the classic symptom of heel pain upon rising from bed. She recommends wearing a boot for patients whose pain interferes with activities of daily living. Custom orthotics, she says, tend to have a higher success rate if the patient benefited from an over-the-counter insert.

Treatment of Chronic Heel Pain

For chronic plantar fasciitis, the next step in treatment at MGH Sports Medicine Center is cortisone injections or extracorporeal shock wave therapy, Fleming says. ESWT applies sound waves to the heel area. The Food and Drug Administration approved ESWT in 2000 for adults who have had plantar fasciitis for at least six months that has not responded to other treatments.

“More studies are needed to determine if ESWT is effective for treating plantar fasciitis,” Fleming says.

Botox may be another option. At least two studies showed botulinum toxin A may reduce pain in plantar fasciitis.

Surgery is a last resort and has a success rate of only 50%, according to Palmer. What often works best for healing plantar fasciitis is a combination of treatments, she says. “Just as no one thing causes plantar fasciitis, no one treatment will make it go away,” Palmer says. “A quick fix isn’t going to work.”

Plantar fasciitis can recur. If that happens, Palmer recommends taking immediate action and restarting treatment. To prevent a recurrence, continue stretching exercises; wear shoes with a shock-absorbing sole, good arch support and no heel; and maintain a healthy weight, Fleming advises.

Kathleen Louden is a freelance health writer.


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