Plantar Fasciosis - What Works Best

he Indian Journal of Orthopaedics recently published a first-of-its-kind study comparing four proven treatment approaches to plantar fasciosis (previously referred to as plantar fasciitis).

Modern healthcare offers a broad variety of treatments for this common condition. Scientific research has proven many of them to be at least partially effective.2 Interestingly, no peer-reviewed study has compared the effectiveness of common treatments in isolation, until now. 

Eighty percent of heel pain cases presented to orthopaedic practices turn out to be simple plantar fasciosis.1 This refers to the heel pain occurring at the plantar fascia’s point of origin on the calcaneus. Histopathological studies reveal that this pain, historically referred to as plantar fasciitis, does not involve inflammation. Rather, the pain stems from a chronic degenerative process and an overloaded healing response.4

This aetiology gives insight as to why plantar fasciosis tends toward chronicity and recurrence. Authors sometimes refer to plantar fasciosis as self-limiting, leading to a wait-and -see approach. However, one in five cases is still symptomatic after a year, and high recurrence rates have been reported.4,5

Moreover, patients may average as much as eight months of symptoms before seeking medical attention. Prescribing wait-and-see on top of that is connected with lesser clinical outcomes and patients harbouring the mistaken belief that healthcare has little to offer.6 Patients and clinicians, of course, also want the most cost effective approach with minimum effort for maximum results.

Therefore, Ravi Gupta (Department of Orthopaedics, Government Medical College Hospital, Chandigarh) and colleagues started the work of defining what works best. They performed a randomised, double-blind, controlled study with 140 patients. Patients were middleaged and had plantar fasciitis for an average of six to seven months (range one month to four years).

Researchers divided the patients into four groups of 35 individuals. Each group received one and only one treatment: (1) analgesics (2) hot-water fomentation & silicon heel pads (3) plantar fascia stretching or (4) calf stretching. At one-year follow-up, all four groups showed statistically significant improvements in pain and disability. However, analgesics, proved to be the least effective treatment in terms of pain reduction. Plantar fascia stretching stood out as the most effective treatment for reducing disability. In terms of pain and disability, the four treatments ranked as follows:

Most effective: plantar fascia stretching More effective: heat & silicone heel pad Effective: calf stretching Least effective: analgesics There is clearly much more work to be done in terms of defining the most efficient treatment plan. Previous research has found other treatments effective, but we still do not know how they compare or the most effective combinations: night splints,7 foot orthotics,7 shoe rotation,8 dorsiflexion modalities,7 and adjunctive therapeutic ultrasound.9 One thing we do know is that programs supervised by a physiotherapist achieve better results than programs that patients conduct independently after initial consultation.10 Conservative treatment for plantar fasciosis has a good foundation in the scientific literature, but much is still left to experience and clinical decision-making.

References

1. Gupta R, Malhotra A, Masih GD, Khanna T, Kaur H, Gupta P, Kashyap S. Comparing the role of different treatment modalities for plantar fasciitis: a double blind randomized controlled trial. Indian Journal of Orthopaedics. 2020 Feb;54(1):31-7.

2. Grieve R, Palmer S. Physiotherapy for plantar fasciitis: a UK-wide survey of current practice. Physiotherapy. 2017 Jun 1;103(2):193-200.

3. Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treatment. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2008 Jun 1;16(6):338-46.

4. Ramamoorthy EN, Daniels JM, Kukkar N. Challenges in Diagnosis of Plantar Fasciosis (Fasciitis). Ann Sports Med Res. 2016;3(7):1086.

5. Carcia CR, Martin RL, Houck J, Wukich DK, Altman RD, Curwin S, Delitto A, DeWitt J, Fearon H, Ferland A, MacDermid J. Achilles pain, stiffness, and muscle power deficits: achilles tendinitis: clinical practice guidelines linked to the international classification of functioning, disability, and health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2010 Sep;40(9):A1-26.

6. Orchard J. Plantar fasciitis. BMJ. 2012; 345: e6603.

7. Saxena A, Fournier M, Gerdesmeyer L, Gollwitzer H. Comparison between extracorporeal shockwave therapy, placebo ESWT and endoscopic plantar fasciotomy for the treatment of chronic plantar heel pain in the athlete. Muscles Ligaments Tendons J. 2012 Oct. 2(4):312-6.

8. Werner R, Gell N, Hartigan A, et al. Risk factors for plantar fasciitis among assembly plant workers. PM R. 2010; 2: 110-116.

9. Heigh E, Bohman L, Briskin G, et al. Intense Therapeutic Ultrasound for Treatment of Chronic Plantar Fasciitis: A Pivotal Study Exploring Efficacy, Safety, and Patient Tolerance. J Foot Ankle Surg. 2019 May. 58 (3):519-27.

10. Almubarak AA, Foster N. Exercise therapy for plantar heel pain: A systematic review. International Journal of Exercise Science. 2012;5(3):9. 

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