Plantar Fasciopathy: When Orthotics and Night Splints Aren't Enough

Plantar FasciitisPlantar fasciitis (more accurately called plantar fasciopathy) is a painful thickening of the plantar fascia or the thick band of connective tissue on the bottom of the foot.  It is estimated to be the most common cause of heel pain among runners and results from overuse.  Runners regularly stress the plantar fascia with several times their body weight during the push-off phase.  Most runners encounter plantar fasciitis at some point in their career.

Overuse, not always related to running, is the common cause. Tight calf muscles and hamstrings, changes in weight, improper or ill-fitting footwear, and prolonged standing can all increase the load through the plantar fascia and precipitate overuse.

Symptoms of plantar fasciopathy

include stabbing pain in the bottom of your foot near the inside of the heel. Typically, the discomfort is worst with the first few steps in the morning; though, it can also be activated by long periods of standing or getting up from a seated position. It tends to get better with exercise and activity only to worsen the next day.

Traditional Treatments

Plantar fasciopathy can be a nagging, recurring condition though fortunately surgery is rarely indicated.  Most patients suffer through the pain or stop doing activities that hurt until the pain goes away.  Improvement does usually occur, though the time course can be prolonged and recurrences are extremely common.

The most common treatments are physical therapy, orthotics and night splints. Intrinsic foot muscle strengthening and calf and plantar fascia stretching is the mainstay of all treatment plans.  Physical therapy can asses and address underlying biomechanics deficits as well as use modalities to help with pain and function.

Heel pads are cheap, easy and do help absorb shock that is normally distributed through the plantar fascia.  Custom orthotics are a more expensive next step.  Night splints are used to gently stretch the plantar fascia and Achilles tendon so the transition to bearing weight in the morning isn’t so abrupt.  NSAIDs are often used but research shows plantar fasciitis is not an acute inflammation issue.  Cortisone injections are often the next step.  While cortisone injections may provide short term pain relief, new studies suggest relief comes at the expense of long term recurrence and dysfunction.

Plantar fasciitis does not need to mean an end to running nd other activities.

Innovations

Platelet-rich plasma (PRP) provides an alternative to surgery when traditional therapies have failed. The use of orthobiologics (growth factors and proteins used to help bone and soft tissues heal) in the treatment of foot and ankle injuries is gaining traction. The clinician and the surgeon continue to seek better ways to accelerate and mediate healing of bone and soft tissue while incorporating less invasive techniques.

For PRP, a patient donates his or her own blood via a traditional blood draw, the platelets are centrifuged (or spun) out while the patient waits.  Typically this process takes 30 minutes.  PRP contains healing growth factors that can be injected under ultrasound guidance directly into the area of damage.

With plantar fasciopathy, there is a dysfunctional healing response that is painful. According to Podiatry Today, “platelet rich plasma injections are very useful in chronic injury cases as they restart and stimulate the inflammatory cascade, which enhances the healing process.”  Often, a “bone spur” or osteophyte develops in reaction to an overloaded plantar fascia.  This becomes a structural problem that PRP may not completely relieve.  Procedures such as Tenex that can be done in office can help remove the bone spur, creating essentially a vacuum that generates blood flow and triggers the body’s normal healing response.

The Assistant Clinical Professor at the UCLA School of Medicine, Chief of Foot and Ankle Surgery at the Santa Monica UCLA Medical Center and Orthopedic Hospital, and the Director of the University Foot and Ankle Institute in Los Angeles, Dr. Baravarian, found 70 percent of his PRP patients with plantar fasciosis “improve to the point of having minimal to no pain following the PRP treatment.” They do not go on to have surgery. “Thirty percent of patients … needed a second injection in the two-month period after the first injection for full recovery.”

PRP shows all the signs of being an effective, safe, non-surgical treatment to the pain of plantar fasciitis and it works.