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In Part 1 of this entry, I discussed the key features of plantar fasciitis – what exactly it is, the symptoms, the causes, and who is likely to get it. Today I’d like to let you know of your treatment options – including both self-treatment and available professional treatment.
After the diagnosis of plantar fasciitis has been made by a regulated health professional, you will have a few options for professional treatment:
1. “Hands on” manual therapy – different therapists have different techniques –but in essence, all hands-on therapeutic techniques are generally aimed at reducing the tension in the plantar fascia. One specific technique – called Active Release Techniques – has been shown to be quite effective in reducing such tension, and specifically, breaking up “adhesions” and tough dense tissue that develops in the fibers of the injured plantar fascia.
2. Therapeutic Exercises – your practitioner should give you some exercises that are designed to stretch the appropriate tissues. Such stretches should not focus just on the plantar fascia, but also on appropriate neighbouring muscles that may be contributing to your pain and dysfunctional mechanics of your gait. A thorough assessment, not just of the plantar fascia, but of all of the muscles and structures involved in movement, would determine which muscles are dysfunctional, and hence, which are contributing to the plantar fascia problem. Your Achilles tendon, for example, if insufficiently flexible, can lead to an overstress of the plantar fascia during the landing phase of each step. If the Achilles tendon is not addressed (in this example), an underlying contributor to injury is being ignored – and the problem is likely to persist. Further, prescription of some simple strengthening exercises may also be appropriate, as long term physical stress and damage of plantar fascia (and related anatomy) will weaken those tissues.
3. Custom orthotics – if a cause of your plantar fasciitis is faulty foot mechanics (low arches, for example), then orthotics may have a role to play in correcting the faults. Your practitioner can do several things with a custom orthotic than can help – supporting the arch, adding extra cushion to soften the impact of the foot landing on the ground, adding a heel cup which can aid in shock absorption, etc.
4. Night splints – these are worn in bed and allow the foot to remain in a neutral (unstressed) position while sleeping. I managed to find one study (Wapner KL, 1991) which reported significant relief of plantar fasciitis in 83% of patients who used night splints. Granted, some patients don’t like these -they find them annoying to wear, and others find them ineffective. But they are an option that seems to work for some.
5. Ice – as simple as this one sounds, it is not to be overlooked. Simply put – ice is an anti-inflammatory, and plantar fasciitis is an inflammatory condition.
6. Medication – your medical doctor may prescribe pain killers or non-steroidal anti-inflammatory medication. Medication will not provide a solution to the root problem – but it may provide some much needed temporary relief.
7. Therapeutic modalities – such as ultrasound. Such treatment would not be used as a stand-alone treatment – but in combination with other treatment can be quite useful.
Often your health care provider will use a combination of the above-mentioned treatment options…..and fortunately – often they will do the job, and your plantar fascia will heal, and pain will disappear.
Sometimes, however, these treatments will not be enough. Sometimes the pain is too severe, the problem has been present for too long, and the damage is too great for these treatments to be effective. People in this scenario present to the office in despair – they tell me that they’ve tried everything.
Are there any more options?
3 more options remain:
1. Extracorporeal shockwave therapy – this is a relatively new treatment in Canada, but has been used in Europe for years. This is quite an exciting therapeutic option – and scientific research is quite supportive if it. The Journal of Orthopedic Research (2005) found a 90% success rate, for example. That’s encouraging! Shockwave therapy works by sending acoustic shockwaves into the damaged tissue – effectively re-injuring the tissue (on a microscopic level) and stimulating the healing process to kick in. Generally 3-5 treatments are needed for this therapy to be effective. (And to put a personal plug in – we are one of a handful of clinics in Ontario to have this therapy on site)
2. Cortisone Injections – again, this is not to be used as an initial treatment (if at all) – but it is capable of providing significant relief in some (although not a cure). Note that your doctor will not recommend multiple injections because they can weaken your plantar fascia (which can lead to rupture). One study, for example, found 44 ruptures (out of 765 patients) occurred as a result of cortisone injections. (Avevedo and Beskin, 1998).
3. Surgery – clearly, not the option that you want. This is only to be used as a last resort. The procedure is called a “plantar fasciotomy” and involves an incision (usually 3-6 cm) into the plantar fascia to release it. If a calcaneal spur were also present, the surgeon may wish to remove it.
As for self-help options – well, there’s a few things that you can do:
1. Stay off of your feet! Yes, I know, easier said than done. It’s only worth mentioning, however, because each step that you take further aggravates the condition.
2. Apply ice – preferably several times a day for 15 minutes at a time.
3. Gentle massage – using a rolling pin, for example, to massage the plantar fascia can be of benefit (just don’t overdo it – when dealing with an inflamed condition, overdoing it will worsen your pain and only serve to further inflame the tissue.
4. Combine points 2 and 3. That is, try an ice massage. To do this, freeze a water-filled plastic bottle of water, or a water-filled paper cup, and roll it back and forth over the plantar fascia for 5-10 minutes.
5. Gently stretch the plantar fascia, calves, and hamstrings. (Again, the key here is to do this gently – anything more than gentle can cause pain and further inflammation.)
6. Choose proper foot wear. Sorry ladies – high heels are disastrous to the plantar fascia. Wear shoes with a low to moderate heel, good arch support and shock absorption.
Finally, and to re-iterate, the best advice that I can give is to have a health professional perform a full assessment of your painful condition. Let them determine the diagnosis and recommend a proper course of action. You should never feel forced into a treatment plan that you are not comfortable with, but you do deserve to know what your options are so that you can make an educated decision about your course of action.
If you have any questions about this topic, please feel free to e-mail me or contact me at the office. Of course, if you require an assessment and/or treatment, we are happy to serve you at Kawartha Therapeutic Centre.
In good health,
Dr. Michael Carney
