Hot on the heels of part 1, Simon Bartold shares his thoughts on treatment of Chronic Plantar Heel Pain (CPHP aka Plantar Fasciitis). For more from Simon see his brilliant website and his previous articles on RunningPhysio. Follow him on Twitter via @bartoldbiomechanica.
So now the big question, in terms of treatment, what works for plantar heel pain?
The list of options for the treatment of CPHP is quite extraordinary, and includes:
- Extracorporeal Shock wave therapy (ECSWT)
- Low dye taping
- Tension night splints
- Myofascial Trigger point therapy MTrP
- Corticosteroid infiltration
- Custom orthoses and prefabs
- Infiltration of platelet-rich plasma
as an example of just a very few of the many in the literature!
Let us examine in detail the evidence from the literature in terms of the efficacy of the more common treatment options.
Extracorporeal Shock Wave Therapy (ESWT) involves the conversion of a sound wave into a shock wave that is applied repeatedly to a specific area of the body. The technique is similar to lithotripsy, which is used to treat kidney stones. In recent years the technique has become popular in the treatment of a number of recalcitrant musculoskeletal conditions including tennis elbow, achilles tendinopathy, plantar fasciitis, and tendinitis of the shoulder.
The results of the ESWT studies for plantar heel pain are equivocal, with Crawford et al (2008) reporting that ESWT is more effective than placebo but only reports a mean difference of 6% (reduction in heel pain).
Rompe and co workers found manual stretching of the plantar fascia superior to repetitive low energy radial shock-wave therapy for the initial management of acutely presenting plantar fasciopathy. (Rompe et al JBJS 2010 92:25 therapeutic level 1)
ESWT may be either high or low energy, and whilst I am unaware of any specific research quantifying the variants in CPHP, this study found no difference between high and low energy ESWT for rotator cuff tendinopathy.
However, a very recent Meta analysis by Dizon et al (2013) concluded moderate- and high intensity ESWT were effective in the treatment of chronic plantar fasciitis.
There is still considerable debate about which is better, and one such debate can be read here.
There remains no conclusive measurement method to differentiate low from high energy ESWT.
Despite the Crawford paper cited above, I believe there is now some compelling evidence for the efficacy of ESWT in CPHP, but only in chronic cases where conservative treatment has failed. For acute heel pain, there is little or no evidence to support the use of ESWT.
There are contraindications for this procedure and these include: neurological and vascular disease of the foot; history of rupture of the plantar fascial ligament; open bone growth plates; pregnancy, implanted metal in the area (bone screws and pins); and people on medication that interferes with blood clotting such as coumadin and prophylactic aspirin.
This image show ultrasound guided infiltration of steroid, however, the results from trials comparing steroid injections with placebo substances show;
- no advantage in the active substance
- only a short term improvement over placebo (Crawford and Thomson, 2008)
This seems logical given our understanding that there is most likely very limited inflammatory involvement in CPHP, with little or no evidence of inflammatory mediators in the condition.
So a very recent and well designed RCT by Ball, E. et al, which found steroid injection showed a clear benefit over placebo at 6 weeks and this difference was maintained at 12 weeks, is counter intuitive. I think it likely that steroid infiltration does help to reduce the pain of CPHP, but that the pathway is no anti inflammatory, and most likely is nociceptive. Time will tell.
LOW DYE TAPING A study by Radford et al (2006) was able to demonstrate that when used for the short-term treatment of plantar heel pain, low-Dye taping provides improvement in 'first-step' pain compared with a sham intervention after a one week.
This is what my variation of low dye taping looks like:-
for a complete description of how I apply tape for CPHP, watch this
According to Bekler et al (2007), patients without previous treatments for plantar fasciitis obtain significant relief of heel pain in the short term with the use of a night splint, however, this application does not have a significant effect on prevention of recurrences after a two-year follow-up. However, Attard and Singh (2012) compared the effectiveness of a posterior AFO (ankle –foot orthosis) , which dorsiflexes the foot, with an anterior AFO, which maintains the foot in a plantigrade position, and came to the conclusion that “Plantar fasciitis night AFOs are poorly tolerated orthoses but their use can be justified in that the pain levels are reduced. The anterior AFOs are more comfortable and more effective than posterior AFOs.”
CUSTOM FOOT ORTHOSES Custom foot orthoses have been shown to be effective in both the short-term and long-term treatment of pain. Parallel improvements in function, foot-related quality of life, and a better compliance suggest that a foot orthosis is the best choice for initial treatment plantar fasciitis (Roos et al 2006)
Calf muscle stretching is frequently prescribed for CPHP.
Radford et al found when used for the short-term treatment of plantar heel pain, a two-week stretching program provides no statistically significant benefit in 'first-step' pain, foot pain, foot function or general foot health compared to not stretching.
However, specific stretching the plantar fascia for CPHP has been shown to be superior to traditional weightbearing GSAT (gastrocnemius soleus Achilles tendon) stretching. Three randomised controlled trials have now shown the effectiveness of plantar fascial stretching (Rompe 2010, DiGiovanni 2006, DiGiovanni 2003). It must therefore now be concluded that specific stretching of the plantar fascia is an important part of treatment.
The technique is incredibly simple, and involves pulling the hallux toward the head for a stretch count of 30. it is demonstrated in this photo.
for a description of the science behind the stretch, click here; stretch
TRIGGER POINT DRY NEEDLING A single randomised controlled trial by Cotchett et al (2011) provide evidence for the effectiveness of dry needling for the relief of CPHP.
PLATELET RICH PLASMA INFILTRATION
Once considered an experimental therapy for CPHP, platelet rich plasma (PRP) infiltration is gaining traction as a real treatment option. It remains, however, extremely cotroversial, and clinicians are divided in opinion as to efficacy.
Very recently Ragab and Othman (2012), injected 25 symptomatic CPHP sufferers with PRP. They found, using a visual analogue pain scale, the average pre-injection pain in patients of was 9.1 (range 8–10). Prior to injection, 72 % of patients had severe limitation of activities, and 28 % of patients had moderate limitation of activities. Average post-injection pain decreased to 1.6. Twenty-two patients (88 %) were completely satisfied, two patients (8 %) were satisfied with reservations, and one patient (4 %) was unsatisfied. Fifteen patients (60 %) had no functional limitations post-injection and eight patients (32 %) had minimal functional limitations. Two patients (8 %) had moderate functional limitations post-injection. Ultrasonography, demonstrated significant changes not only in thickness but also in the signal intensity of the plantar fascia after PRP injection. None of the subjects experienced any complications from PRP injection at the end of follow-up period. The study concluded that “injection of PRP is safe and doesn’t affect the biomechanical function of the foot. The successful early findings with injection of PRP indicate that this may become a very commonly used modality in treating this difficult condition.”
However, if we assume (and admittedly this is dangerous!), that the plantar fascia behaves at least partially like the achilles tendon, the following study by Ball et al should throw up some red flags. They found “The administration of two unguided peritendinous autologous blood injections one month apart, provides no additional benefit in the treatment of mid-portion Achilles tendinopathy.”
Perhaps the final word should go to revered Australian tendon researcher Professor Jill Cook, who very recently tweeted “Yet again blood products show no benefit in tendinopathy, when are clinicians going to follow research evidence? # @ProfJillCook.
Whether PRP is a fad or a saviour remains to be seen, but for the moment I would advise proceeding with extreme caution around the plantar fascia.
HOT OFF THE PRESS! Some very recent and interesting findings include the thought that morphological features of the fascial enthesis are related to regional loading and the static shape of arch in individuals with enthesopathy, (Wearing et al 2007). Interestingly, entheseal thickening in diabetes correlates with increased pressures beneath the foot during walking (D’Ambrogi 2005) and it is therefore believed that the energy dissipation ratio (EDR) is significantly less for plantar fat pad of the symptomatic limb than that of asymptomatic and control. Thicker fascial entheses are associated with reduced energy dissipation of the plantar fat pad in the symptomatic population. The EDR is a measure of energy lost by viscous friction and it is an important indicator of the role and efficacy of the plantar fat pad in dampening high-frequency vibrations. Decreased energy dissipation leads to increased vibration loading of deeper tissues which in turn leads to adaption of stress-dissipating fibrocartilagenous enthesis. The net result of this is that a 12% decrease in EDR equates to a 1mm increase in thickness of the enthesis. Another important finding is that the fat pad thickness remains unchanged with enthesopathy.
Currently it is unknown if thickening of enthesis precedes, occurs with, or follows change in plantar fad pad properties (Wearing, 2010).
So, that’s us up to date with plantar fasciitis, which we shall now call Chronic Plantar Heel Pain or CPHP. Based on the evidence, if I had to make treatment recommendations, they would be as follows:
- Institute the earliest intervention possible, do not wait for the pain to worsen.
- Use low dye taping as an immediate, short term management protocol.
- Use diagnostic ultrasound to identify fascial thickening
- Immediately incorporate a stretching program focussing on the triceps surae (calf) complex, and more specifically of the plantar fascia
- Consider using a lateral forefoot wedge of approximately 5 degrees to “unload” the fascia
- Especially consider a padded non rigid orthotic device. If a rigid orthosis is truly necessary, it must be covered with a suitable shock attenuating material, e.g. spenco, to ensure the shock dissipation ratio is not interfered with.
- Change treatment appropriately for more a chronic condition. There is some reasonable evidence for the use of ECSWT in plantar heel pain six months old or older.
- For the athlete, and especially the runner, shoe selection will become very important. It seems recommending minimalist footwear (let’s for the sake of the argument call this a drop of 4mm or less), may be counterproductive given the increased ankle joint moment and eccentric load on the Achilles tendon. Some arch support may be beneficial, and it seems clear cushioning will be important in this condition.
For those keen on barefoot and minimalist running, very careful transition back to this style of running after complete symptom resolution is recommended. Some product, is specifically designed with a type of cradle built into the shoe that may help to distribute the load through the plantar fascia, especially at take off, is more effective. Hope this helps!
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