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Heel Pain & Plantar Fasciitis

An Orthotic is frequently prescribed for plantar fasciitis, and is considered standard therapy for the condition. There are a number of customized forms of orthotics, and non-customized or prefabricated forms on the market. A recent study set out to determine whether orthotics offer any long-term benefit to the treatment of plantar fasciitis.

Researchers enrolled 136 patients with at least 4 weeks of plantar fasciitis symptoms in a participant-blinded study. They were randomized into custom orthotics, prefabricated orthotics and sham orthotics.

Although there was some reduction in pain early on in the orthotic groups, at 12 months there was no significant difference in pain or function in all three groups.

(From Landorf KB et al. Effectiveness of Foot Othoses to Treat Plantar Fasciitis. A randomized Trail. Arch Intern Med 2006, June 26;166;1305-10)

This study seems to suggest that there may not be any long-term benefit to orthotics in the treatment of plantar fasciitis. However, in my experience, I have seen clinical improvement in pain and function in some patients with the condition using orthotics, although this is empirical.

If we look a little closer at the condition, and the possible underlying causes of plantar fasciitis, we may derive other therapies or approaches.

plantar fasciitis is often associated with lower back pain, Achilles tendonitis, metatarsalgia and tight leg and calf muscles. Myofascial/neuropathic research points to some possible explanations to the condition.

It is probable that plantar fasciitis begins as a result of shortening of the muscle in the plantar fascia either from repeated use, injury or underlying radicular motor disease in the lower lumbar nerve roots. The latter is a good explanation for chronic recurrent, and treatment failure.

In all groups, the fascia will shorten and apply a traction phenomenon to the insertion of the plantar fascia at the heel. Over time, the tendon will become tender and swollen causing a tendonitis like pain. Eventually calcification of the tendon insertion will occur, possibly as a result of chronic traction. The idea is that overcompensation for the traction occurs by thickening the insertion to strengthen the insertion site. The result is a calcified spur.

Other muscles in the foot will often become contracted/shortened and apply abnormal forces around the foot. The metatarsals and toes may lift. The “normal” position of foot bone swill change slightly and presumably will place compression in areas of other joints in the foot. The person may walk with a limp, further aggravating the gait and affecting the low back and perhaps higher up.

The placement of an orthotic for any foot is to act much like a brace for the foot, so it can hopefully perform its duty of weight-baring. However, in plantar fasciitis, the orthotic acts to maintain what is known to be a “poor position” of the pedal bones. So in plantar fasciitis, are we propagating the problem with an orthotic by accommodating the abnormal foot.

Shock wave therapy is a treatment adapted from lithotripsy to treat plantar fasciitis. It has a remodeling effect on the soft-tissue of the foot, so as to break up muscle contractures and even spur deposits, although the spur is generally not a major source of pain, but a demonstration of longevity of the traction. It may also be used to break up soft tissue contracture in the forefoot in metatarsalgia.

Overall, shock wave has about a 60% recovery rate in plantar fasciitis over the course of about 1 year. This is because there is a healing phenomenon that must occur in the foot after the shock wave disrupts and breaks down the scarring in the soft tissue. Some get progressive relief, but this is not assured, and is more common in mild to moderate cases.

However, I mentioned that a number of plantar fasciitis sufferers have associated lower back and leg disorders. These individuals require that any radicular component be corrected, or the condition will reoccur despite the shock wave, or any other treatment that is chosen. It explains why a cortisone shot directly injected into the site can fail. For these people rotational stretching of the lumbar spine and stretching of the hamstrings, calves and feet are important in long-term recovery.

Dry-Needle Injections of the spine to relieve radicular causes and in the limb muscles for local muscle shortening can be very effective, and is also recommended in complicated plantar fasciitis cases. Even with a flurry of combinations of shock wave, stretching, NSAIDS, cortisone, orthotics and dry-needling, some patients can be resistant, but, in my experience, the odds of a partial or complete recovery are much higher with this combination.

Keep Long and Strong