What Is the Best Treatment for Plantar Fasciitis?

Published on 11/03/2015 by admin

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Chapter 67 What Is the Best Treatment for Plantar Fasciitis?

Plantar fasciitis is a painful heel syndrome of unclear cause. Chronic or acute injury to the origin of the plantar fascia at the medial tubercle of the calcaneus is thought to produce a cycle of microtrauma and degenerative changes. Plantar fasciitis affects both active and sedentary adults with studies reporting that up to 10% of runners and a similar proportion of the general population are affected.14 A significant occurrence also is reported in military personnel and professional athletes.5,6 Increased body mass index, extended time standing, and limited ankle dorsiflexion are risk factors predisposing to plantar fasciitis.7 The high prevalence, substantial pain, and decreased tolerance for activity result in large numbers of patients seeking treatment. The cumulative number of office visits in the United States is estimated to be nearly 1 million visits each year.1

TREATMENT

Plantar fasciitis tends to improve in most cases regardless of the treatment selected.811 As a result, conservative management is effective for nearly 90% of patients.12,13 The conservative treatments used in management of plantar fasciitis vary widely and are dependent on physician specialty.1 Common treatments include nonsteroidal anti-inflammatory drugs (NSAIDs), stretching, insoles, taping, physical therapy, and night splints. If these simple and noninvasive modalities prove ineffective, additional treatment options include iontophoresis, injections, extracorporeal shock wave therapy (ESWT), and surgical treatment. This chapter reviews the various treatment methods for plantar fasciitis, and the effectiveness and safety of these treatments as supported by the best available evidence.

Stretching

Stretching protocols for the treatment of plantar fasciitis include stretching the Achilles tendon with or without stretching of the plantar fascia. Limited evidence is available from controlled trials to establish the effectiveness of stretching.14 Prospective studies comparing a plantar fascia–specific stretching protocol before the first morning steps and Achilles tendon stretching for treating chronic plantar fasciitis found a greater improvement in pain symptoms with the plantar fascia–specific stretching after 8 weeks (Level of Evidence II).15 Long-term follow-up at 2 years was incomplete but suggested no difference between Achilles tendon stretching and the plantar fascia–specific groups, although both groups showed improvement (Level of Evidence III).16

Orthoses

The use of orthoses is intended to change loading characteristics of the plantar aponeurosis. Studies using cadaveric limbs suggest that support of the medial longitudinal arch can decrease strain of the plantar aponeurosis.21 Several randomized, controlled trials have examined the use of insoles in management of plantar fasciitis. A recent study comparing custom insoles, sham insoles, and prefabricated insoles found minor improvement in symptoms 3 months after treatment with prefabricated or custom insoles compared with sham (Level I).22 Prefabricated insoles have been found to be as effective as custom insoles at a reduced total cost.2224 Insoles may be equally effective and offer improved patient compliance compared with night splints.24,25 A randomized, placebo-controlled, double-blind study conducted with 101 patients compared magnetic insoles with sham magnetic insoles and found no statistically significant improvement in pain symptoms after 8 weeks of treatment (Level II).26

Night Splints

Tension night splints stretch the plantar fascia over several hours while the patient sleeps by maintaining a constant ankle dorsiflexion. A trial comparing night splints with conservative treatment with conservative treatment alone found no significant difference in symptoms (Level I).27 Roos and coworkers28 compared insoles with night splints and found no significant difference in pain reduction and improved compliance with insoles (Level II). 28 Three studies reported that patients find night splint treatment uncomfortable and difficult to maintain, resulting in decreased compliance.24,28, 29 A systematic review found that the evidence for the effectiveness of night splints is inconclusive (Level II).3

Iontophoresis

Iontophoresis uses an electrical potential generated by bipolar electrodes to transfer charged ions and ionizable materials including some medications through the skin to provide anti-inflammatory or analgesic treatment.31 Conflicting results have been published for the effectiveness of dexamethasone iontophoresis. In a double-blind study with 39 subjects comparing iontophoresis using dexamethasone with a placebo, significant improvement on the Maryland foot score was reported at the end of the 2-week treatment period (3.80; 95% confidence interval [CI], 0.76–6.84) but not after 1 month (0.30; 95% CI, −2.16 to 6.76) (Level I).31 A second randomized, controlled trial with 31 subjects compared iontophoresis with taping and 0.4% dexamethasone, 5% acetic acid, or 0.9% NaCl placebo. The graphical data presented in the study indicate no statistically significant improvement with dexamethasone treatment in six measured outcomes at 4 weeks and less relief of pain symptoms compared with the control group at 2 weeks of treatment. In the group treated with acetic acid, there was a significant improvement in morning stiffness at 4 weeks with no reported statistically significant difference in three measures of pain at 4 weeks and no significant improvement compared with placebo in all six parameters at 2 weeks (Level I).18

Steroid Injection

Previously published reviews have found limited evidence to support the use of steroid injections in the treatment of plantar fasciitis.3,8 Steroid injection with and without nerve block was compared with placebo in a double-blind, randomized, control trial with 91 participants (Level I).32 The study found a statistically significant benefit at 1 month with steroid injection but not at 3 and 6 months. In addition, it was reported that tibial nerve block was not effective at relieving pain associated with steroid injection. A prospective study with 132 patients comparing steroid injection with ESWT or placebo found a statistically significant improvement in pain symptoms for the group receiving steroid injection over ESWT or placebo (Level II).33 The participants in this study reported VAS pain scores that were significantly lower than for the control and ESWT groups at 3 and 12 months. Potential adverse side effects of steroid injection include fat pad atrophy and plantar fascia rupture.

Extracorporeal Shock Wave Therapy

ESWT utilizes application of mechanical waves similar to those used in lithotripsy but of lower energy density, usually less then 0.36 mJ/mm2 per pulse. Therapy consists of 500 to 6000 pulses delivered at 2 to 4 Hz to treat plantar foot pain. The mechanism by which ESWT provides benefit is investigational. Current theories include stimulation of healing after increased release of growth factors and neovascularization in the environment of local tissue injury35,36 or alteration in the chemical function of small axons producing analgesic effects.37,38 The possibility of a noninvasive treatment for chronic plantar fasciitis has generated significant interest, and several studies investigating the effectiveness of this technique have been published. Many of these trials are not of sufficient quality to provide a reliable assessment of the effectiveness of ESWT.3,8, 39, 40 The studies investigating ESWT have been in many cases sponsored by the equipment manufacturers, and the randomized control trials have produced conflicting results. Good quality, randomized, placebo-controlled, double-blind clinical trials have found no significant benefit to ESWT,4143 whereas other randomized, controlled trials4447 have found ESWT to be beneficial. The reasons for the discrepancy in reported results are unclear. A lack of uniformity of therapy exists from study to study, with differing methods for assessment of therapy, and in some studies, significant problems with study design have been reported.3,40 Differences also exist in the definition of the terms high energy and low energy, as well as in the amount of energy used in various studies. No controlled trials adequately define and identify indications for high- or low-energy protocols for ESWT. In addition, differences in criteria for patient inclusion in the studies make it difficult to compare the trials directly. Table 67-1 summarizes double-blind, randomized studies comparing ESWT with placebo. The reported adverse reactions, including skin redness, bruising, pain, numbness, tingling, and local swelling,42,44, 46 likely do not pose serious health risks. However, clear evidence supporting the use of ESWT treatment in the treatment of plantar fasciitis has not been reported.