Doctors' Preferred Methods of Treatment


Most of the following comments were taken (with permission) from Podiatry Online's Forum (which is no longer active).

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Over 70% of my podiatric practice has heel pain. 90% of those patients do get better without surgery. For all those who suffer, you know the spectrum of treatment.NSAIDs(motrin,naprosyn,etc.),cortisone shots, tapings, rest, physical therapy(including iontophoresis, ultrasound, frictional massage),orthotics. The custom made orthotics DO work better than over the counter, when in the right treating hands. 386 patients receiving orthotics in my practice, 87% improved with the devices. Night splints- a splint that is made to wear at night or periods of rest that keeps your foot maximumly dorsiflexed (up towards you leg) are very beneficial as well. Other treatments: adult recommended doses of calcium taken at bedtime, so that your body can absorb it better. Take for 2-3 mo. Fasciitis sufferers should NEVER go barefoot. Constant support is needed. Lastly, watch your shoes carefully. Even the namebrand shoes slip in cheap models. The shoe should only bend where the foot is supposed to bend, and that is at the ball of the foot. Be aware of the shoes with an indentation of the outersole in the midfoot region. If it allows your foot to bend, it's only going to pull on the fascia. And, ask for "ethyl chloride" to be used if you must get a cortisone shot. This will 


Day 1: radiograph. Discussion of heel pain. Arthritis is the cause not the spur if present. Therapy discussed with pt. Inject heel from medial aspect with 27g long needle with decadron LA. Antiinflammatory as needed. Reappoint 1wk Day 7: Cast for orthotic. Inject if necessary. 70% do not need it. Day 14: Dispense TWO PAIR orthotics..... one for dress shoes and the other larger pair for everyday shoes. Day 28: Exam for heel pain and ck orthotic fit. Inject if necessary. Week 6: Reexamine. Inject if necessary. Most don't need it. Week 12: 95% are asymptomatic by now. Remainder will be soon. 


A response to the above: "...arthritis is the cause..."???????? What is your basis for this conclusion? Which joint(s) in particular are affected? 


 

Calcaneal pain/tendernes @ the plantar medial tubercle (medial slip insertion of the plantar fascia) is most likely caused by excessive pronation causing excessive "pull" or traction @ the tubercle(a stress riser in engineering terms)The fascia tears itself off the calcaneal periosteum (Sharpies fibers)& may cause cortical thinning or micro fractures. This causes inflammation & PAIN. Treat the faulty biomechanics w/ an appropriate functional orthosis & heel lifts if gastroc equinus is present & the traction decreases along w/ the symptoms. Obese pt's. may be much tougher & I don't haave any great answers for obesity.

 


The first question that must be answered is whether there is such a condition as heel spur syndrome? Or is it just an incidental finding? From my experience it is the later, as others have suggested here. After the first session I will send the patient off with an regime of ] stretching, icing and heat therapy. After 3 weeks we determine how beneficial this has been to the patient. Usually pts will say that they have benefitted greatly. If that is not the case strapping (coplands) will be included into the program. If there is benefit gained from this then I will consider orthotic therapy. I use to place pts strait into orthotics, however I am less likely to do this now unless there is a glaring biomechanical problem. Surgery and injections are rarely entered into as virtually all my patients respond well to this regime. 


As with any disorder I always approach from the most consevative option to more aggressive and radical ones as needed. Consevatively, I will offer strappings, paddings, and injections. Oral NSAIDS, and orthoses also are considered. If the patient responds to the strappings and paddings then these modaliities have identified ,in all probability a mechanical etiology. The patient would then benefit from an orthotic device or shoe modification. Injections, although they can effectively ameilorate the condition are usually only addresing the symptomology. No more than 2-3 a year is the rule for me. Surgical intervention is considered when all coservative measures have been exausted and the condition is recalcitrant(e.g.- exostectomies, steinler strippings, MIS etc.). Magneto-therapy has recently titillated my interest as much discussion is occuring concerning it's apparant anti-inflammatory and pain relieving,(amoung other) qualities. Other modalities I use with varying results are U/S, Whirlpool, stetching exercises etc. Strething is usually recommended in all cases along with strengthening exercises etc. 


Day 1: radiograph followed by discussion with pt about cause of heel pain. Primarily arthritis and not spur causes the pain. Decadron LA injection from MEDIAL side with long 27g needle. Rx Feldene or other antiinflammatory. Orthotic discussion. Reappoint 1wk Day 7: Cast for orthotic. May inject again if still sore. 80% fell better and do not need injection at this visit. Day 14: Dispense TWO PAIR of orthotics.....one for dress shoes (smaller) and the other for jogging or other shoes (larger). Reappoint 2wks 2wks later: ck orthotic fit and asses pain level. Inject if sore. 6wks later: 70% are symptom-free. Reappoint as needed. 


Plantar fasciitis is usually secondary to increased tension on the plantar fascia due to jamming of the windlass mechanism and the inability of the first ray to plantar flex during toe-off. This usually results from increased reactive forces under the medial column of the foot. This information was first described by Hicks in his classic articles in the 1950's. 

The foot types which result in this are either the foot with the everted rearfoot (rearfoot everts and jams medial column into the ground) or the foot with the everted forefoot - either a ff valgus or a plantarflexed first ray. 

To treat, first evaulate the foot type. If a rearfoot problem control with an orthosis that controls the rearfoot - for example, an inverted device, a medial heel skive, a wide device or a combination depending on the biomechanics of the foot. 

If a forefoot problem, than support the valgus. Both with intrinsic posting, and if necessary consider a Reverse Morton's Extension (under met heads 2-5) 


1 xray reveals plantar heel spur 

2 conservative treatment A. cortisone injection B. nsaids C.ultrasound D.functional orthotics 

When this fails surgery is the answer. 


Conservative treatments as listed, plus... -Plantar fascial night splints-They work well in those cases where a.m. pain is resolving slowly even with the use of orthotics. Can easily/inexpensively be made in your office, i.e.fiberglass casting material, similiar to a posterior splint and secured at night with an ace wrap. -Stretching-Usually have the pt. do gastroc. & soleus stretching exercises (helps with treatment and prevention) 


In most cases, it is my understanding that the pain and "inflammation" associated with a diagnosis of plantar fascitis or heel spur syndrome is from mostly the effects of seveerley strething or, in some cases tearing of the plantar fascia resulting in plantar fascial neuralgia usually very near the insertion of the medial band at the medial calcaneal tuberosity. The exostosis itself usually is not the origin of pain except in cases where so-called "micro fractures" and perostitis occur from the trama and pull of the insertion of the fascia or intrinsics. As you know, although heel pain can result from a variety of etiologies(e.g. stress fractures, bursitis, bone cysts, etc) the majority result from mechanial causes(80%). Although x-rays should be taken to rule out other osseous pathology that might be causative, again the presence or absence of a spur is, in my view not that significant. There really is no need to distinquish between heel spur or fascitis-the treatment is the same or approached very similarly in both.The spur is usually a rsponse to the tension on the instrinsics and fascial structures-Wolf's Law. So their occurance is interrelated and the main pathology and clinical symptoms are arising from the soft tissues being stressed. I am aware that seperate ICD codes exist for both conditions and perhaps a differentiation may be stategic from a billing standpoint-I do not know. 


I have had bone spurs for 4 years and been through cortizone, ultrasonic, and two sets of marathotic orthodics in this time and still suffer pain about 50% of time especially while working. I am considering surgery..I would like to know how it is done? Do both feet get done if both effected? How long would I be off my feet? How long out of work, I am a machinist and on cement floors 8 hr's per day? What complications go with this type of surgery? Is there any lazer surgery available? Would you know anyone, preferably someone in a similar trade that has had this done I could call or E-mail? Will the area be weeker? Will they come (spurs) back or form elsewhere ? Thank you for your comments...hurting but scared of surgery....


The tx protocol that I use has a documented 85% success rate, in eliminating symptoms within 3 weeks. I give injections into the subcalcaneal bursa at weekly intervals, of 2cc 1% lido/0.5% marcaine 50:50 mixture and 1 1/2 cc dexamethasone acetate. Subsequent injections are given if more than 20% of the original sx remain. I measure for the location of the bursa on a non-wt bearing xray. I do PT, consisting of EMS, WP, US and deep heat every 2 days. Finally, you must reduce the excessive pronation in these patients. I use a lowdye strapping or premade orthotics until I can get a posted custom orthotic for them. The 15% that don't repond have the choice of having a EPF. 


I am interested to hear your thoughts regarding which is your preferred procedure (instep fasciotomy vs EPF). Personally I have performed about 10 in-step procedures since late 1995. Overall the results have been very satisfying, with dramatic advantage for both doctor and patient when compared to the traditional plantar fascial release. I have performed most of these procedures in-office, again adding to the cost-effectiveness over the EPF approach. From my present point of view, I see the EPF as a step toward complexity in performing a plantar fasciotomy. The in-step approach is a step toward simplicity. Another thought--I have seen several failed EPF procedures by other docs. These were cases in which, from my perspective, the surgeon was likely at an early stage in the learning curve for this procedure, and simply "got lost" during surgery. Another advantage of the in-step procedure is the excellent visualization it provides. I am happy to report that the procedure is close to "idiot-proof". I certainly have never seen the plantar fascia so clearly during the traditional heel spur approach. 


Your Plantar Fasciitis page is a remarkable piece of work, scott. I really admire you for pursuing a solution to your foot problem in this manner. I have to tell you, though, that despite the comments that you have received via the Internet, their [painful experiences with shots] have not been typical, in my experience. My guess is that your survey method has selected out the 15% of people that have tried the common forms of treatment and for whom it has failed. 


I've practiced Podiatry for 15 years and have treated over 1000 cases of Plantar Fasciitis with and without subcalcaneal bursitis and osseus heel spurs. My experience has been that, if a rigid protocol of cortisone injections and mechanical support to stop the constant re-injury from walking is adhered to, ~85% of patients get better and stay better. The remaining 15% usually opt to have Endoscopic Plantar Fasciectomy, which helps 80-90% of that 15%. 

The protocol involves 1,2 or 3 injections of repository steroid (Dex Acetate or equiv.) into the subcalcaneal bursa, from the side of the heel, after topical freezing. Physical therapy is done every 2 days. If that's all that's done, it doesn't work. The over pronation of the foot must be limited by an Orthotic or a tape strapping or certain running shoes. Otherwise, the re-injury from walking outweighs the anti-inflammatory effects of the steroid and Physical Therapy. Long term control of over pronation is achieved with Orthotics. 

As you can see, this isn't rocket science; it's good common sense. I must admit that I see a lot of heel pain patients in my office that started treatment at other doctor's offices and didn't "see it through" long enough to get better. It takes between 1 and 3 weeks, but 85% do get better. And many receive piecemeal treatment, instead of a complete plan that has a good chance of success. 

Stretching RECREATES THE MECHANISM OF INJURY, causing injury by pulling more on the plantar fascia. I know a lot of doctors, particularly orthopedic surgeons advocate it. It just doesn't make sense. If a gastrocnemius or soleus equinus (tight calf muscle) is present, that must be stretched, but only while protecting the plantar fascia with tape or an Orthotic, to prevent further injury. 

I hope this has been helpful, scott. Again, thanks for the work that you've done informing peole about this conditon via your web site. I believe there are some other discussions about heel pain far down the content list below. 


Perhaps there is another cause for your heel pain other than mechanical. These causes could include nerve entrapment, bursitis, stress fracture. Heel pain can also result from systemic conditions such as Rheumatoid Arthritis. A detailed examination should be performed by your podiatrist to determine the cause. If the heel pain is mechanical in nature, then perhaps steroid injections or orthotic modifications could alleviate your symptoms. Endoscopic heel spur surgery can also be performed on an outpatient basis for severe cases of heel pain that simply do not respond to conservative treatment. Ask your local podiatrist about these additional treatment options.


I agree with the exception of his comment on endoscopic heel surgery. First, you should not consider heel spur surgery without 1 year of conservative treatment. If conservative treatment fails, then surgery could be considered. Be advised that conservative treatment (ie: cortisone injections, padding, strapping, orthoses, shoe modifications, etc...) works in 90-95% of cases of heel pain. Second, I have yet to see a great result with endoscopic heel surgery. Why, perhaps it is not the appropriate procedure or a particular patient or poor surgical technique, but the results I have seen are terrible. I do not do this type of surgery for this reason. Third, any heel pain which has gotten worse during conservative treatment must be re-evaluated to rule out stress fracture, nerve entrapment or neuroma, arthritis, or even in rare, rare, rare instance, bone tumor. Therefore, further x-rays, and blood tests should be performed to rule out any of these problems. Perhaps a bone scan is needed to see about stress fractures of the heel or spur. Fourth, you should go to your podiatrist with these recommendations. Hopefully, he or she will do a complete exam. If he or she is unwilling to rethink his diagnosis, then it is time to find another doctor.


I agree with MOST of the reply. I also agree that conservative care should be performed for at least six months, and that 90-95% of patients DO NOT require surgery. I also agree that other causes such as stress/occult fracture, entrapment of a nerve, arthritic condition, etc. must be considered. Lab tests, bone scans or MRI's should also be considered. Although many podiatrists perform bone scans to rule out stress fractures, I prefer MRI's. A bone scan is not specific, and other disorders can also make a scan "hot". Additionally, IF the radiologist is specially trained in musculoskeletal MRI, he/she will be able to determine if a stress/occult fracture exists, AND can determine if there may be an injury to the plantar fascia or muscles of the foot. A major teaching hospital in Philadelphia (Jefferson University Hosp) advocates MRI vs bone scan, but this is doctor preference. Additionally, although I feel that endoscopic plantar fasciotomy has been abused and used too frequently, I have seen excellent results with my patients and patients of my colleagues, when the procedure was performed correctly and when indicated. I do not feel that the endoscope has any advantage over a simple "open" surgical release of the plantar fascia. I DO NOT BELIEVE in removal of the "spur", since I do not believe it is the cause of the pain. Regardless, I would NOT recommend surgery until you have had at least some of the additional tests I and Dr. Knudson have discussed, and have tried a longer course of conservative treatment. Additionally, you should consider asking your doctor for referral to a physical therapist for therapy and stretching exercises. Best of luck.


Unfortunately for you, there are many different ways of treating plantar fascitis. These include injections, strapping, taping, orthotics, non-steroidal anti-inflammatory drugs, night splints, and good old rest of the part. Your posting does not specify your foot abnormality. Plantar fascitis is there for a reason, and the reason needs to be treated (sort of treating the cold and not the cough). As Vernon stated, any good podiatrist will be able to figure out what to do about the cause of your fascitis. Orthotics need to be made to your foot and therefore, it is difficult to give you specifics regarding your feet in a fourm like this one.


re: endoscopic "neuroma surgery" I've been using a plantar approach for over 16 years, and do not believe that one can merely "release" the neuroma, and expect to achieve consistently good results. e.g., there are many anatomical variants that one may overlook via a dorsal approach, like encasement of the intermetatarsal nerve in the deep fascial slips, binding it to the mtpj capsule. Plus, there is an atrophic variant of the neuroma, which is more symptomatic than the hypertrophic variety; if you don't excise this lesion, you're asking for an increase in your malpractice insurance rates!


I like to visualize the fascia as i am cutting it. This also allows me to capture photographs of the fascia before, during, and after cutting. A copy of these photos are kept for the chart.


In reply to your question, I've been working on some professional soccer players who presented with the classical S+S of calc heel spurs and do certainly agree that FF Varus is commonly found. I must however add that some of my stubborn cases have been reassessed pedobarometrically and I have noticed that 1st ray dysfunction is certainly something to bear in mind when clinically evaluating your patient. Another important factor in the unsuccessful treatment of the heel pain is the miss diagnosis of the condition which very often occurs amongst the medical profession. In acute cases I have had great success with low-dye strapping and this has helped with everyday training programmes.


As you know, I've made a detailed study of treatment efficacy in patients with Plantar Fasciitis/Subcalcaneal Bursitis/Heel Spur Syndrome. A number of clear patterns have emerged. There is clear pattern of FF Varus foot types in this group. Other risk factors include obesity or recent weight gain, recent increase in activity, underlying rheumatic disease, and a recent change to less structured shoes. Of any of the uses that I put forefoot posted functional orthotics to, use in these patients has been the most successful. Approx. 85% of them remain pain free for long periods of time. Best regards, Alan Sherman, D.P.M.


At the Scholl College of Pod Med, class of '78 we were taught to apply the low or high dye tape splint. When applying the medial leg of the heel lock, the forefoot was manipulated from whatever into FF Valgus to relax the medial band of the plantar fascia. Since then, a few plantar fasciitis pts, resistant to conventional posting of Rx orthotics, have responded to mild RF varus post or vertical with a mild FF Valgus post, which was ground off to neutral when the pt's plantar fasciitis cooled or healed. Then permanant posting in neutral for that pt. was done. What do you think of this approach.


My experience of 76 unilateral heel pain patients suggests that there is no convincing biomechanical difference between the painful and non-painful foot. Most had a FF Varus deformity and follow up over a 6 month period using soft Orthoses with a 4degree rearfoot post led to remission of pain. Although "pronation" is always quoted as an aetiological factor I have yet to see any concrete data to support this. My study also looked at a variety of tests including X ray interpretation and I found no difference between painful and non painful feet. Most people have FF Varus so it is not suprising that most heel pain suffereres have FF Varus


I feel that the emphasis on looking for a common or specific structural type that pre- dominates is leading us around the bend. Each person has their own combination of structural faults and muscle imbalances, and as a consequence will have their own pain manifestations. I find generally that the one common denominator lies in lack of calf flexibility, thrown in with all the other structural, be it FFV, RFV, Tibial Varum etc. The foot will compensate depending on the range of motion in the ankle joint, mid-tarsal joint and this will put stress on the plantar fascia leading to micro tears and consequently a chronic/ heel spur problem.


MIPF is our facilities preferred procedure due to its ease and the exposure it affords. One caveat is the potential for some serious bleeding. Therefore, some form of cautery needs to be available to you if you are doing these in the office. Also, we have gone back to releasing the entire fascia. We had less favorable results when we only released 2/3 to 3/4 of the fascia. Enjoy!


YOU PROBABLY SHOULD SPEAK WITH FRAN LYNCH, DPM IN NEW HAVEN, CT. MOST LIKELY HAS THE MOST EXPERIENCE AND EXPERTISE WITH MIPF. HE IS AN EXCELLENT RESOURSE AND HAS A LARGE PATIENT POOL.


MIPF is an easy, excellent procedure for chronic plantar fasciitis, 3 weeks nwb with a posterior splint. much better visualization than an epf...there was a good article about it in jfs around 1-2 years ago


since only a third of the fascia is cut(medially),what is the point of going all the way laterally and piercing lateral skin?Is it an overkill?Is it a good idea to snip fascia via medial small incision using ultrasound or just feeling the fascia? e-mail me at vlmed2@webtv.net


Dr. V: The HMO you work for leaves you too much time in front of the TV.' What ifs' don't work is sugrery....only personal experience and the literature count. Cost, "overkill", etc. are tertiary decisions, but what work best in a particular surgeons hands is the most important.


Dear Mr.FOOTMAN: Thank you for your response.You made a valid point,but some of the greatest inventions were made in the absence of(and often despite) either experience or literature.What works best for you may be not the best for the patient. Also,I do not work for any HMO. Judging by the multitude of your responses,your HMO allows you to spend no less time in front of computer than "my HMO allows me" I was only trying to understand the rationale for certain elements of the procedure


At the expense of the flesh of a human being- ta da- you get a photograph. Gosh. You really are an altruistic sort of doctor who I'd want to send my kids to. Gimme a break- the same technology and a fifteen blade. Primus non nocere- that was the expression used MD school- but I guess for a photo op- document doc- DPMSs don't really care about that sort of thing. I understand Mister big shot- unfortunately, although you may be chuckling all the way to the bank with that wondrfully fandangled procedure- its BS. You know and so does everyone else in the world who does surgery on feet. I'm scrolling this because it ticks me off. It ticks off a lot of people-


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