The patient's unmet needs (PUNs)
A 50-year-old man hobbles into the surgery. He has had a painful heel for over six months. Despite using NSAIDs and heel pads, the symptoms are no better, and he's reached the ‘something must be done' stage. In particular, he's keen on an X-ray, as a friend with the same condition had one and this revealed a ‘spur'. He would also like an injection, as his friend said that had proved effective.
The doctor's educational needs (DENs)
What is the specific pathology in plantar fasciitis? Is the presence of a calcaneal spur of any relevance? Is an X-ray, or any other investigation, helpful?
Plantar fasciitis is localised inflammation of the fibrous band called the plantar aponeurosis. It affects the medial band at the heel insertion in 80% of cases, with middle to distal pathology in the remaining 20%.
The exact aetiology of plantar fasciitis is poorly understood, but it is usually thought to be due to overuse injury, secondary to prolonged weight bearing. It can occur in athletically active or in sedentary individuals.
It may be associated with autoimmune conditions as part of an enthesopathy, and these patients will often need assessment and treatment from a rheumatologist. It is more common and more resistant in patients with diabetes, but treatment is essentially
the same.
There isn't a general consensus on the gold-standard investigation for plantar fasciitis and diagnosis is usually made on the basis of history and clinical findings. Patients typically present with start-up heel pain that eases briefly, and returns on further weight-bearing activities. The patient is usually tender around the medial calcaneal tuberosity or central heel pad.
The presence of a calcaneal spur is usually a coincidental finding – they are seen in 20% of asymptomatic people – and its presence or absence is not helpful in making the diagnosis. Ultrasound scanning is the most commonly used investigation to aid diagnosis and treatment, with MRI and other investigations such as scintigraphy being reserved for difficult cases.
We often tell patients that plantar fasciitis can take some time to improve, but what is the precise prognosis? How often is it linked to an inherent abnormality of the foot or associated arthropathies, and how do these affect the outlook?
Overall, the prognosis for mechanical plantar fasciitis is very favourable – with 95% improvement or resolution. Most people have complete recovery within one to one and a half years, but it can take anywhere from three months to three years, leaving 5% of patients who may require surgery.
The condition can occur in a variety of foot shapes such as planus or cavus. It is most common in planus feet and if there is a significant abnormality patients may require additional biomechanical correction with functional foot orthotics.
Plantar fasciitis is often more resistant when associated with inflammatory arthropathies, diabetes or as part of an enthesopathy syndrome.
How effective are NSAIDs, heel pads and stretching exercises? Does rest help?
First-line treatment consists of NSAIDs, cushioned footwear with heel lifts, stretching the achilles and plantar fascia1 and using night splints. These strategies are very effective and are the main recommended treatment pathway. But if the injury is proving resistant or if it is severe, then second-line treatment with steroid injections followed by extracorporeal shockwave therapies can be recommended. These have a cumulative resolution rate of up to 95%.
Although prolonged immobilisation or resting is not proven to work, serial casting can be effective in resistant cases and can be used in combination with a steroid injection. And, in addition to the biomechanical treatment methods already mentioned, it is advantageous for patients to reduce the amount of time they spend on their feet – advise them to perch or sit at every opportunity, stop impact activities such as racquet sports and have shorter walks.
What is the evidence for steroid injections? If they are useful, what is the most effective approach?
Although the evidence for the use of steroid injections is very limited, they are widely accepted and used. A Cochrane database review2 did show improvement in symptoms at one month, but this was not maintained at six months.
The method of delivery is equally effective whether it is undertaken by injecting the most tender spot or targeted using ultrasound guidance. Again, it is best used and most likely to be effective as a supplement to the above biomechanical treatments.
What other treatments are available and how effective are they?
Recent randomised controlled trials have shown that extracorporeal shockwave therapy in conjunction with physiotherapy treatments is more effective than either method alone. This is reserved for patients with symptoms lasting over six months, and where steroid injection has not worked.3
Platelet-rich plasma is currently under evaluation. Early results show it to be as effective as steroids. The systems available for obtaining platelet-rich plasma vary and this means the quantity of platelets in the mixtures are different, making comparison studies difficult. The procedure is undertaken within trials or under strict audit – the techniques are evolving and may prove to be a promising adjunct.
A course of electroacupunture and transcutaneous electrical nerve stimulation can be used with chronic pain in resistant cases. They are equally effective, but the longevity of pain relief is not known.
Mr Rohit Madhav is a consultant in orthopaedic and trauma surgery at University College London Hospitals NHS Trust and the London Orthopaedic Clinic
References
1 Digiovanni B, Nawoczenski D, Malay D et al. Plantar fascial-specific stretching exercises improve outcomes in a patient with chronic plantar fasciitis. JBJS 2006;88:
1775-81
2 Crawford F and Thomson C. Interventions for treating plantar heel pain. Cochrane Database Syst Rev 2003;3:CD000416
3 NICE. Extra corporeal shockwave therapy for fracture pains and fasciitis. NICE Interventional procedure guidelines 2009;IPG311
Further reading
Clinical Knowledge Summaries. Plantar fasciitis.cks.nhs.uk (accessed 11 May 2012)
