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CLINICAL CARE: PODIATRY
from CCC- April/May 2022
by ensembleiq
Plantar Fasciitis: Diagnosis and Treatment
At a Glance
• Plantar fasciitis is the most common cause of heel pain.
• The majority of patients can find relief with over-the-counter (OTC) analgesics and stretching.
• Night-time splinting is no longer recommended.
• Recovery takes about two to three months for most patients.
Each year, millions of people in the United States are treated for plantar fasciitis (PF), the most common cause of heel pain. Fortunately, the majority of them can find relief with conservative treatments and over-the-counter (OTC) remedies, making retail health clinics one-stop solutions for PF care.
Causes and Consequences
Plantar fasciitis is caused by inflammation of the plantar fascia, the thick and fibrous tissue that runs from the heel to the toes and supports the arch of the foot. Repeated and excessive strain on the tissue can produce many small tears, resulting in irritation and inflammation. Left untreated, PF can turn into chronic heel pain that significantly impairs everyday activities like walking. Changes in a patient’s gait can cause additional ailments in the foot over time, as well as in related regions like the knee or hip.
Clear Signs
The hallmark symptom of PF is stabbing pain in the heel when a patient first gets out of bed in the morning.
A clinical exam is usually sufficient to diagnose plantar fasciitis, says Shanna Chapman, DNP, APRN, FNP-BC, a retail health clinician and the region 7 director of the American Association of Nurse Practitioners. X-rays and other confirmatory imaging tests are needed only when a patient might have another source of heel pain, such as a fracture or arthritis.
During the exam, watch for tenderness while pressing on the bottom of the patient’s foot, just in front of the heel bone. Applying pressure there will “send [the patient] through the roof,” says Nathan Miracle, MS, an assistant professor in the department of physician assistant studies at Missouri State University. Pressing the patient’s foot and toes toward the shin will produce that pain as well. Conversely, the pain will decrease when the patient points their toes down.
Gold Standard Approaches
The gold standard for treating PF consists of nonsteroidal anti-inflammatory drugs and regular foot stretches.
Directing the patient to take OTC ibuprofen or naproxen is usually a good first step, but tailor the dosage and duration to reduce the risk of side effects, such as heartburn, nausea and, less commonly, high blood pressure, liver and kidney damage, and gastrointestinal ulcers.
The second half of the treatment regimen is regular stretching of the arch of the foot and the Achilles tendon. Dr. Chapman suggests instructing patients with PF to roll their affected foot over a cold or frozen water bottle for 20 minutes three to four times per day. The American Academy of Orthopaedic Surgeons (AAOS) offers three additional stretches to share with PF patients:1 • Lean forward against a wall with one leg in front of the other.
Straighten the back leg and press the heel into the floor. Bend the front knee. Hold the stretch for 15 to 30 seconds. Repeat with the other foot—even if only one foot is affected. • Place the ball of one foot on the edge of a step, with the other foot solidly on the same step. Slowly drop your weight into the heel of your foot and push the heel down. Hold for 15 to 30 seconds and repeat with the other foot. • Sit on the floor and place both legs in front of you. Wrap a towel around the ball of the affected foot and pull it toward your body. Hold for 15 to 30 seconds and repeat with the other foot. The AAOS recommends performing each of these stretches three times daily.
Supplemental Pain Management
To further reduce pain, especially in patients with flat or high arches, Dr. Chapman suggests recommending shoe inserts like soft rubber heel lifts, cups, and wedges. She adds that many pharmacies offer patients machines to measure their arches, allowing them to find inserts that suit their feet.
Since carrying extra pounds can exacerbate plantar fasciitis,
Approaches to Avoid
Not all OTC products are created equal when it comes to treating PF. Miracle advises skipping topical analgesics such as diclofenac sodium creams and gels. “They’re not likely to produce any benefit because of the deep structural placement of the plantar fascia,” he explains. Similarly, having patients use devices like night splints to stretch the plantar fascia and Achilles tendon while sleeping is no longer recommended. Though formerly a favored treatment, Dr. Chapman says that recent indepth studies conclude that night splints are “not as helpful as originally thought.”
REFERENCE
Dr. Chapman recommends gently suggesting that overweight patients attempt to lose weight. She finds that guiding patients to conceptualize excess weight as a household item, like a gallon of milk, can help motivate patients to begin and persevere in weight-loss regimens.
Follow-Ups and Further Treatment
When using conservative treatments and OTC remedies, you can expect about nine out of 10 patients to show improvement within two to three months.1
“I would follow up with patients within a few weeks to a month to see if there’s improvement, but they need to understand it will probably take two to three months to see dramatic results,” says Miracle. Make sure patients’ expectations are realistic.
If patients are still experiencing significant heel pain after three months, they might benefit from corticosteroid injections into the plantar fascia. However, Dr. Chapman and Miracle agree that, at this point, it’s prudent to refer patients to a podiatrist or other specialist experienced with such a course of treatment.
Miracle explains that “this injection is one of the most painful done in orthopedics, so having a skilled clinician is important.” What’s more, “Corticosteroids can start breaking down the heel bone if they’re done too much,” Dr. Chapman adds. A podiatrist can also discuss with the patient if and when surgery may be indicated. C
