What advice should I give to a person with plantar fasciitis? Advise that most people with plantar fasciitis will make a complete recovery within 1 year. Advise conservative measures, which may improve healing and reduce the frequency of attacks: Wear shoes with good arch support and cushioned heels (such as laced sports shoes) and avoid walking barefoot. Insoles and heel pads to insert in the shoe can be purchased, with the aim of correcting foot pronation (however 'magnetic' devices should be avoided). Rest the foot (that is, avoid standing or walking for long periods) where possible. However, specific stretching exercises may be tried to relieve symptoms and improve healing. Lose weight (if overweight) to prevent future episodes. For symptomatic relief, advise applying an icepack (covered with a towel) to the foot for 15 20 minutes, and use appropriate analgesia. Prognosis The longer-term clinical course of plantar fasciitis is good. One prospective survey found that over 80% of people achieved complete resolution of their symptoms after a mean of about 2 years of follow-up [Wolgin et al, 1994]. Other studies with shorter follow-up times have indicated that most people recover fully within 1 year [McPoil et al, 2008]. Self-care measures to improve healing and reduce recurrence Foot rest, and the use of shoes with good support, are recommended as pragmatic measures to relieve foot pain and promote healing of the fascia [ARC, 2004a]. CKS identified no controlled trials to verify the effectiveness of good footwear, but such footwear has received positive feedback from a user survey [Wolgin et al, 1994]. Walking barefoot is also likely to aggravate foot pain. Stretching exercises are generally recommended by most experts as the mainstay of conservative treatment for plantar fasciitis. However, there is a lack of quality evidence from randomized controlled trials (RCTs) to support the use of exercise, with one short-term placebo-controlled trial finding no benefit [Radford et al, 2007]. 1
Despite this, stretching exercises are perceived to be the intervention of most benefit by people with plantar fasciitis [Wolgin et al, 1994]. Orthoses are widely recommended on the basis they benefit foot posture and aid fascia healing. Although there is limited evidence from RCTs that prefabricated orthoses are equivalent to custom-made orthoses, a lack of placebo-controlled trials means their overall effectiveness is uncertain. Evidence from one RCT (n = 101) suggests magnetic insoles are no more effective than ordinary insoles, so these should be avoided on a cost basis [Winemiller et al, 2003]. Obesity (body mass index greater than 30 kg/m2) has been associated with poor prognosis of plantar fasciitis, possibly by causing more pressure on the plantar fascia [Wearing et al, 2006]. Therefore it is recommended that overweight people with plantar fasciitis should lose weight, which is also likely to have other health benefits [McPoil et al, 2008]. Additional information The following stretching exercises and cross-frictional massage can be used at home or at work (where suitable). They may help stretch the fascia and relieve symptoms. Achilles tendon and plantar fascia stretch Advise the person to keep a long towel (or tubigrip) beside their bed. Before they get out of bed, they should loop the towel around their foot, and pull it with the knees straight, causing dorsiflexion. Repeat three times for each foot. Wall push-ups or stretches for Achilles tendon In order to stretch both parts of the Achilles tendon, both these exercises should be carried out twice a day: Advise the person to place both hands (at shoulder height) on a wall, with staggered feet (one foot in front of the other). The front foot should be approximately 30 cm (12 inches) from the wall. With the front knee bent and the back knee straight, the person should lean towards the wall, until a tightening is felt in the calf of the back leg, and then ease off. Repeat ten times. The exercise above is repeated, but the back foot is brought forward a little so that the back knee is slightly bent. Repeat ten times. Advise the person to stand facing upstairs using the stair-rail for support. The feet should be positioned so that both heels are off the end of the step, with the legs slightly apart. The heels are lowered, keeping the knees straight, until a tightening is felt in the calf. The position is held for 20 60 seconds, and then the heels are raised back to neutral. The process should be repeated six times, at least twice a day. 2
While seated, the person should be advised to roll the arch of their foot over a rolling pin, a drinks can, or a tennis ball. The foot and ankle should be moved in all directions over the object. This can be done for a few minutes or until there is some discomfort. The exercise should be repeated at least twice a day. The discomfort can be relieved by rolling the foot on a cool drinks can from the fridge. [ARC, 2004; Foye and Stitik, 2008] Basis for recommendation The recommendations for information and advice for people with plantar fasciitis are consistent with an American evidence-based guideline [McPoil et al, 2008], and a UK guideline [ARC, 2004a]. Symptomatic relief Ice is believed to cool the fascia and causes vasoconstriction, reducing inflammatory processes. Analgesics are recommended on the basis of limited evidence. See Management for more information. How should I manage a person with plantar heel pain? Advise conservative measures. Consider prescribing analgesia on an 'as required' basis to relieve pain. Options are: Paracetamol alone, or with the addition of codeine (if paracetamol alone is inadequate and a nonsteroidal anti-inflammatory drug [NSAID] is not suitable). An NSAID: ibuprofen is the preferred. Refer to a podiatrist (or physiotherapist) if, after 3 months, symptoms have not improved with conservative measures. Injection with a corticosteroid (with a local anaesthetic) may be an effective option if the expertise is available. However there is little consensus from specialists regarding optimal use of corticosteroid injections for plantar fasciitis. Discuss the benefits and possible harms with the person before administration. Usually this should only be considered when conservative measures and interventions provided by a podiatrist or physiotherapist have proved inadequate. However, a corticosteroid injection can be considered sooner if symptoms are severe, or are having a significant impact on quality of life, or for people in particular 3
occupations (such as athletes, or people whose job entails standing or walking for prolonged periods). Consider repeating the treatment if symptoms return only if initial treatment was clearly beneficial: Do not repeat if symptoms do not improve initially with the first dose (consider an alternative diagnosis). Wait a minimum of 6 weeks before repeating administration. If the person requires three or more doses, consider referral. Basis for recommendation Analgesia and injected corticosteroids are recommended by an American evidencebased guideline [McPoil et al, 2008], an electronic guideline [Foye and Stitik, 2008], and a narrative review [Neufeld, 2008]. Analgesia and NSAIDs CKS found no evidence from randomized controlled trials to verify the efficacy of analgesics or NSAIDs in the treatment of plantar fasciitis, although they have a plausible mechanism of action to relieve symptoms (but not the cause). Paracetamol, with the optional addition of codeine, is the standard treatment for pain. Ibuprofen is recommended as the NSAID of choice in the absence of trial data. It is generally accepted as having a relatively good safety profile, is widely used, and is available over-the-counter. Injected corticosteroids There is little consensus from specialists (e.g. orthopaedic and podiatric consultants) on the optimal use of injected corticosteroids for plantar fasciitis. CKS recommendations are based on historical practice, bearing in mind that clinical judgement should always be used on an individual basis. The available trial evidence to support the use of injected corticosteroids in plantar fasciitis is generally poor, as a prevailing presumption of its efficacy means that placebo-controlled trials have not been conducted. In the absence of direct evidence, knowledge of pharmacological effects, together with extrapolated data from other conditions, strongly supports the effectiveness of injected corticosteroids, and they are almost universally recommended by experts. Potential harms of injected corticosteroids include plantar fat-pad degeneration or plantar fascia rupture. 4
Administration of an injected corticosteroid can be painful and there are risks involved, so it is generally recommended that all suitable and available conservative measures should have been tried before injections are considered. However, CKS recognizes that in practice more immediate and effective treatment may be required for some individuals, especially for people who are required to be 'on their feet' as part of their occupation. When should I refer a person with plantar heel pain? Refer to a podiatrist (or physiotherapist) if lifestyle advice and stretching exercises do not have an adequate effect after a reasonable time period (e.g. 3 months). Consider referral to podiatrist or orthopaedic surgeon if: The diagnosis is uncertain. Pain persists despite maximal treatment in primary care, for example three courses of injected corticosteroids have failed to produce an adequate effect (this will probably be at least a year after diagnosis). Basis for recommendation CKS identified no guidelines or reviews that gave comprehensive advice on referral; referral recommendations are therefore based on what CKS considers to be good clinical practice. Referral to a podiatrist or physiotherapist is recommended after about 3 months if initial advice and treatment is ineffective; this is in line with a UK guideline which recommends referral after 3 6 months of non-response [ARC, 2004a]. A podiatrist can give expert advice on exercise and prescribe custom-made orthoses, although evidence from randomized controlled trials that these are superior to prefabricated orthoses is lacking. Other conservative options that may be available in a secondary care environment (e.g. physiotherapy) include taping, night splints, and manual therapy, but overall trial evidence for these is lacking or absent. If the diagnosis is uncertain, referral to a podiatrist or orthopaedic surgeon for further investigation (depending on the suspicion of the cause) is necessary. If the pain persists and affects quality of life after maximal treatment in primary care (i.e. several injections of corticosteroid have been tried), referral to an orthopaedic or podiatric surgeon may be considered. 5
One electronic guideline suggests this should be 6 9 months after the last course of treatment, although this is probably based on opinion rather than evidence [Foye and Stitik, 2008]. A surgeon may attempt fascia release, although there is no evidence available on the benefits and harms of this [ARC, 2004a]. 6