Part 1 of two-part blog on plantar fasciitis (PF) covered risk factors and prevention. This blog will consider the various ways we can treat it, including a newly researched exercise that has shown a lot of promise and does not require as much time commitment!

How do I treat it?

If you have not been able to avoid PF and have been dealing with it for a long time, it can feel like nothing will help. If you have developed it and have high BMI, it is reasonable to diet (take medical advice if necessary) and exercise (within pain guidelines) for weight loss. Other proven risk factors, heel spur and thickened plantar fascia, would require surgery to change, and evidence shows this should not be first-line treatment. Many people have found PF to be a stubborn condition because they either seek treatment too late (by using various self treatments) or they are treated with less effective treatments.

Below I will try to help detail what treatments are worth considering, including equipment, rehab, medical, and surgical treatments that are used and what we know about them. I will finally give more details about this new exercise-based approach that has recently been shown to be very effective!

Low risk and/or cost:

• Footwear
  • Do not wear flip-flops! However, if you like the toes to be open and free, an orthotic shaped sandal has been shown to be as good as a shoe with an orthotic at reducing PF¹.
  • Avoid long-term use of high heels, as it makes the calf work at a high level and will lead to stress on the plantar fascia via the achilles. However, short term use may offload and give relief.
  • Avoid flat very flexible shoes as they will put stretch on the achilles and allow a lot of stretch on the plantar fascia via the windlass mechanism.
  • Runners are suggested to have a shoe that has a relatively stiff forefoot to limit big toe dorsiflexion (it puts stress on the plantar fascia), a firm mid-foot with reasonable arch support to control pronation, and a larger drop (10mm+) to take tension off of the achilles tendon. The key is not to base your decision of off some category (i.e. motion control, stability, neutral), as the research is now showing it’s best to find a shoe that suits your movement preference. A fellow PT wrote a nice blog on general running shoe selection, and also a video on this topic by a chiropractor who specializes in running injuries.
• Orthotics
  • Effective in the short and long term if correctly prescribed. Overall there was no noted difference between over-the-counter or custom². However, custom orthotics may have better compliance³.
• Running technique: increase step-rate
  • Excessive plantar loads over the rear-foot have been found in both runners with acute and chronic PF compared with injury-free runners⁴. It has not been proven that this loading causes PF (I suspect it does) or that reducing loading helps PF (I suspect it also does). Loading is increased with higher vertical oscillation (bounce) which we tend to see when step rate is low. This higher loading has been seen in runners with PF⁵ and I see this issue a great deal in recreational runners. A simple gait change that will reduce loading is increasing step-rate⁶. This can be done using a metronome app, or an app such as Jog-Tunes, or Spotify. If pain levels are in the caution or danger zone, running should probably not be undertaken; once pain is settled, working on a better step-rate is probably wise.
• Taping
  • Low Dye⁷ taping and calcaneal⁸ (heel) taping have been shown to reduce first-step pain in the short-term. A You Tube Video by a well respected sports podiatrist shows this technique well.
• Night splints
  • Shown to reduce pain in the short-term, but not shown to prevent recurrence in the long term (2-years)⁹. Appears to combine well with daytime orthotic usage¹⁰. An example is the Strassburg Sock, which is available locally at Fleet Feet.
• Specific Exercises
  • Studies showing a loss of foot volume due to muscle atrophy suggest that exercises to help build the intrinsic foot muscles may be helpful to offload the plantar fascia¹¹. See this video for an example.
  • Plantar fascia specific stretching (hands on by self) is beneficial in both the short and long term^12-13. There may be some benefit to stretching the achilles due to its attachments to the plantar fascia but the effect is not thought to be as large¹⁴. All stretches should be done within reasonable pain guidelines as you can cause excessive irritation and can reduce muscle performance.

• Manual therapy
  • Soft tissue (muscle) treatments are useful as long as they do not irritate the plantar fascia. These treatments can be performed by or under the care of a Physical Therapist:
    • Myofacial release has been shown to have some short term benefit¹⁶.
    • Trigger point release has also been shown to have some benefit¹⁷. However, there is also quite a debate in the medical literature about trigger points and if they really exist¹⁸ so the premise that much of this literature is found on may be flawed which makes the research questionable.
    • Some therapists may employ instrumented soft-tissue techniques such as Graston technique, but I have found no strong evidence to supports its use and have heard my fair share of stories about very irritated (sore) patients.
  • Side note: studies suggest that treatments of the joints, the ankle, or mid-foot are ineffective¹⁵. This makes sense as PF affects the soft tissues not the joints. The only reason I could see benefit would be in a very chronic case where the joints have become stiff.

High Risk and/or High Cost:

• Dry Needling
  • There is some chance that it might help 1 in 4 patients, however it can also harm 1 in 3 patients¹⁹. The adverse affect would be bruising and increased pain. Since the odds of being successful are less than the odds of having an adverse event, and in the absence of long term benefits, I would not consider this a front-line treatment. Dry needling is often referred to as trigger point dry needling so it falls under the same debate mentioned with manual therapy. It is also worth pointing out that it is not covered by most insurers.
• Extra corpeal shockwave therapy (ESWT)
  • This is the conversion of sound waves into a shockwave similar to what is used to treat kidney stones. Research had already pointed to some benefit in chronic cases but had not defined parameters. However, a recent study found that moderate-to-high-focused ESWT without anesthesia is beneficial for chronic PF²⁰. We should keep in mind that another study found it less beneficial than stretching¹²; so if the cost is high, I would suggest trying stretching first. Again, it is also worth pointing out that it is not covered by most insurers.
• Corticosteroid injections
  • It is clear that there can be relief of symptoms with steroid injection²¹, but there is much debate to how long a relief it gives, and there is also concern over the potential development of a plantar fascia rupture.
  • A recent study²² conducted over four years found that of 286 patients, 35 had ruptures of which 33 were attributed to plantar fasciitis. Some suggest a rupture mimics a surgical plantar fascia release, a procedure that might be considered in chronic cases that are resistant to conservative measures. However seeing this is not the aim of the injection people agree it is not a desirable effect.
  • There is some concern of heel pad atrophy (which would increase plantar fascia loading), but this has not been proven.
  • If considering this treatment it is well worth discussing the risks with your provider
• Botulinium Toxin A (Botox) injections
  • These have been found to be superior to corticosteroid at 1 and 6 months and do not have the potential side effects described above²³. They have also been shown to have sustained effect at 1 year²⁴.
• Platelet Rich Plasma (PRP) injections
  • This emerging treatment is supposed to promote growth factors in the injected tissue. There may be some promise, but currently the studies are limited²⁵. 
• Surgery
  • A more extreme option, and one usually considered once conservative measures are deemed to have failed. It is suggested that better outcomes are found in those who have surgery within 1-2 years of symptom onset
  • A recent retrospective review²⁶ quoted studies suggesting anything from 10-50% of patients being unsatisfied with surgery. This review found 25% of their patients would not recommend the surgery.
  • Historically an open partial or complete release of the plantar fascia (plantar fasciotomy) and removal of heel spur was the treatment of choice. The concern of this is that even with relief of PF there is going to be some change to foot mechanics which may cause other problems²⁷. For this reason some recommended against this in people with flat feet.
  • There are various risk factors with the above surgery technique and as such some are performing endoscopic plantar fasciotomy.
  • A recent study²⁸ compared partial fasciotomy with release of the medial gastrocenimus (calf) and found the later had superior effects.
  • This is not an exhaustive summary of surgical options, and is meant as a starting point that one might use for research. If you are considering surgery for PF it is well worth seeing a foot and ankle specialist surgeon and one who is a member of the American Orthopaedic Foot and Ankle Society (AOFAS)

What doesn’t help

• Ultrasound and electrical stimulation
  • No evidence shows this to be beneficial. In fact there is little evidence that shows ultrasound to be useful in many conditions and as such (and following several other clinicians across the country) I don’t have one in the clinic!
• Kinestiotape
  • Again, no evidence has been shown that this is an effective tool to treat PF. Compare this with the low dye taping technique we have already mentioned.

A new exercise approach:

With these traditional techniques many patients still experience PF, and clinicians remain frustrated. High load resistance training has been getting more attention as a superior treatment for tendinopathies (e.g. achilles). Recent research²⁹ has tested this approach for 3 months with PF, compared with stretching. The high load group did exercises every two days for the 3-months, whereas the stretching group did them three times a day. If you have PF you might be thinking high-load and PF, are they crazy! However, the exercise  is done slowly and controlled to not irritate. The study started the patients off with 12 repetition maximums (the most load you can do through full range with good form over 12 reps) for three sets, up for 3seconds, pause at top for 3seconds and down for 3 seconds. After two weeks they were instructed to add a backpack with books to apply load, and then after four weeks they were instructed to use 8RM for five sets.

The thought is that the tissues will change/normalize structurally by increased delivery of collagen in response to the high load^30-31. It used to be thought that the key part of the muscle contraction to stress was the eccentric phase, but recent research suggests it does not matter³². What is key is placing enough load on the tissue to get the right balance between catabolic and anabolic reaction. This next paragraph will hopefully make you see the benefit in trying this approach.

The study²⁹ found that at 3 months there was a significant relief in symptoms in the high load group. On a scale called the foot function index the high load group had a score 29 points lower than the stretching group. A difference of 7 is the minimal relevant difference in this score so a difference of 29 is pretty impressive! At 12 months, significant difference was not seen, which was attributed to likely compliance issues with the exercises.

This approach is by no means a miracle treatment and the research is in its infancy. Using modern technologies that patients could perhaps use at home may help to give feedback to better define what level of loads are needed.

Conclusion

There is a multitude of options to treat PF. Many will give good short-term effects of up to four weeks, and are reasonable to try. However, many of those treatments are time intensive. Others have better outcomes in the long run, months to years, and are also worth trying. Some of these are more passive, such as footwear and orthotics, and can create a feeling of dependence. The new approach to exercise therapy is an active approach that is not time consuming. It can be continued to be applied even once pain has gone, and although unproven it may then reduce the risk of pain returning. Sadly for some. even these new approaches may not reduce your pain, and in those cases you need to do every piece of research you can into the various surgical options and the surgeons that offer them.

Reference List:

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