Plantar fasciitis - conservative care
When we start to develop a treatment plan for plantar fasciitis it's important to go back and re-read my prior post on the causes and contributing factors for plantar fasciitis. In that post you'll see that plantar fasciitis is an overuse syndrome caused by the calf. Our goal in treatment is to break into that re-injury cycle and make a subtle change in how the leg, ankle and foot work with each step.
In a case of plantar fasciitis that is only 4-6 weeks old, I always start my patients on a program of calf stretches. From experience over the years I've learned that many patients don't expect to be given a physical therapy assignment. That's work and who wants to do that, right? So I stress the importance of stretching with my patients. Is stretching your calf in bed before you get up adequate? Not at all. I like to get my patients using a stretching block. The stretching block makes a patient feel committed to the stretches. The stretches are simple, you just stand with the ball of the foot up on the block for a minute. With the first stretch of the day the calf will contract and tighten. With the second stretch it'll loosen a bit. And by the 6th stretch of the day the calf will actually start to lengthen. Frugal guy that I am I used to have patients stretch on a step or book. But I found without the commitment of the stretching block they would invariably come back saying that they forgot to stretch. Another common response I hear from patients is, "I remember how you told me to stretch but what I've been doing is..." No. You need to really do the 6 stretches per day for a minute each time.
Plantar fasciitis -stretching and heel lifts
So what if the patient won't stretch? That's when I move into a stretching splint or night splint. Stretching by day is easy and cheap. Stretching with a night splint is the same thing except you need to buy a splint. Another option is physical therapy. I think PT is a great way to motivate and educate patients.
The other important component of care for treating patients newly diagnosed with plantar fasciitis is understanding that low heels are bad and higher heels are good. Remember the old folk remedy of the cowboy boot that I spoke of in an earlier post? The cowboy boot simply elevated the heel which weakens the calf. When you weaken the calf
you decrease the amount of force delivered by the calf to the heel and fascia. Do you need a cowboy boot - no, not at all. But the example is used to stress the importance of not going barefoot and wearing a heel lift. Cork heel lifts can be trimmed with scissors to fit in about any shoe. Another important distinction to make is the difference between a heel lift and a heel cushion. Lifts are firm and cushions are soft. A lift is used to weaken the calf by elevating the heel. A cushion can't do that. Although many products are marketed as 'used to treat plantar fasciitis' they are cushions and just don't hit the mark in how plantar fasciitis should be treated. The most popular cushion I see is grey and blue 'plantar fasciitis cushion made by Dr. Scholl's. If you're reading this article, I'll bet you're either wearing one or have looked at them in the foot care section of your drug store or at Wal-Mart. Right? Remember, cushions may feel good but you need a lift to break the re-injury cycle.
In my experience, if you have a motivated patient who wears the lifts, avoids going barefoot and does their stretches 6/day, you'll see 7/10 patient will have a significant improvement with their heel pain. But what if there's no improvement? The next step I use is injectable cortisone. The cortisone that your doctor will use is a synthetic analog of what your body actually produce on a daily basis. There's a number of different types of cortisone. Some are long acting, some short acting. With experience, your doctor has found what mixture of cortisone works best. Doctors are a bit like bartenders in this regard, mixing what we call the perfect 'cocktail' of steroids. I tell my patients that I'm mixing up and injecting into one spot about the same amount of cortisone that you would produce on a normal day. It's just that I concentrate that dose in one location. Cortisone acts as an anti-inflammatory agent. There may be some soreness following the injection, just like a flu shot or immunization. But what we're looking for is the response over the next 3-5 days. Cortisone has the potential to decrease the inflammation associated with plantar fasciitis and relieve pain.
Plantar faciitis - cortisonwe injections
Does cortisone work in every case of plantar fasciitis? No. But is works consistently well. It's important to remember that a cortisone shot is not a substitute for the stretches and heel lifts. Cortisone is used to supplement that mainstay of care - stretching and heel lifts. Although the number of cortisone injections given by any doctor may vary, in my practice I'll try two separated by about 3-4 weeks. Excessive use of cortisone in the treatment of heel pain may result in fat pad atrophy of the plantar heel. There's no rule book for the use of cortisone and even more ironic is the fact that there's not literal guide for how much cortisone to use. Doctors just rely on their training and prior experience to judge the frequency and dosing of cortisone injections.
So we've helped 7/10 patients with stretches and heel lifts. I'd say another 1 or 2 patients will respond to cortisone. So that leaves another 1 or 2 patients who still hurt. This is where it gets harder to see progress. These patient who fail to respond to care are often the patients who have had plantar fasciitis for a long time, greater than 6 months. What do we do next? First and foremost is to stress the need for a heel lift and continued stretching (don't give that up yet). I'll often prescribe an orthotic at this stage. I'll incorporate a heel lift in the orthotic to be sure we get the lift under the heel that we need. Orthotics will act to support and rest the fascia.
The final consideration in treating plantar fasciitis is time. Most cases of plantar fasciitis will respond in time. It's not easy to remember this when every step hurts. To explain this a little more, let me tell you a story about a patient I saw several years ago. The patient was a woman in her mid fifties. She had failed all conservative care and we had begun talking surgery to fix her plantar fasciitis. And then she disappeared from my practice. She came back in several years later with a problem unrelated to heel pain, a nail problem as I recall. Going back through her chart I noticed we had been talking about surgery for her plantar fasciitis. She said, "Oh that. That's gone. When you started talking about surgery I wasn't interested in doing that so I got options from 4 other doctors. The first three all had different opinions. The fourth doctor asked me to tell him more about the stretches that Dr. Oster had recommended. I answered honestly that I hadn't really done them. He recommended that I do 8 stretches a day. I did that and the pain went away." Imagine that.
Additional topics in the blog series include -
Plantar fasciitis | History
Plantar fasciitis | Causes and contributing factors
Plantar fasciitis | Differential diagnosis of heel pain
Plantar fasciitis | Surgical treatment
Plantar fasciitis | Additional treatment methods
Plantar fasciitis | Surgical complications