Plantar fasciitis treatment
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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Plantar fasciitis is the most common cause of heel pain on the bottom of the foot.
Risk factors include excess weight, pregnancy, sudden changes in training routines in athletes, or chronic use of non-supportive footwear, such as flip-flops.
Chronic overstretching of the plantar fascia, a thick cord of tissue that connects the heel to the base of the toes, can lead to microscopic tears at the fascial insertion into the calcaneus (heel bone). This leads to severe pain in the heel due to localized inflammation. The pain is usually located on the medial (great toe) side of the calcaneus.
Pain is most severe with the first few steps after a period of inactivity. Examples are getting out of bed to walk in the morning… or getting up to walk after sitting for a prolonged period of time. This id often referred to as "first step pain."
Many therapies have been used for this problem. These include orthotics (shoe inserts that support the arch), heel cups, and night time splints. The efficacy of these methods is highly variable.
Among the physical therapy modalities that have been used are ultrasound, laser, stretching, and iontopheresis (electrically driven low dose steroids).
Corticosteroid (“cortisone”) injections have often been given. While these are effective for short term relief, they do have many potential side effects including atrophy of the heel fat pad, nerve and muscle damage, and rupture of the plantar fascia.
Fat pad atrophy leads to recurrent heel pain and that is another side effect of steroid injection.
Extracorporeal shock wave therapy has been touted as an effective treatment but there have been few large controlled studies.
Surgery has been used as well with mixed results.
Among the newer forms of therapy are the use of platelet-rich plasma (PRP), an ultraconcentrate of whole blood that contains a large number of platelets, cells that have many growth and healing factors.
Using ultrasound guidance to localize the site of pathology and also to help “chisel” any interfering bone spurs, is mandatory when applying PRP. Most patients respond to one course of treatment. Because this is a painful area, we normally do a tibial nerve block with ultrasound guidance when doing this procedure.
One other possible treatment approach is the use of botulinum toxin injected using ultrasound guidance. This has been reported by some investigators to work as a result of its anti-nocioceptive (anti-pain fiber) properties.
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