What's Your Routine for heel spur/fasciitis?

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Heel pain (of the plantar fasciitis variety) is the most common chief complaint in my office, as I'm sure it is in most of your practices.

Given this very common CC and the subsequent commonality of the ensuing medical history and physical findings, what is your routine for treating these patients?

What do you do on the initial visit? When do you have them return? What do you did if they are no better with you initial treatment? What do you think your success rate is?

Steve

 

So if we take general general.

- Triceps surea stretching
- Icing
-Tennis ball massage
- modified Low dye taping
-NSIADS
- rest if possible
- Ive added the dorsiflexion of the toes foot stretch in morning from a paper that was put on here a couple of weeks ago to see the results.
- if FF Eq heel lifts

Come back 7 days later, give patient options for orthotic treatment or continue with soft tissue program for a lttle longer, if so retape review 1 month.

I have beleive that the low dye tape has a very high success, but pain returns often very quickly when its taken off. If tape successful usually indicates good success with device for me.

 

Mike,

I know you like your articles so here's one from the latest edition of JAPMA

Ian

 

Hi Steve

Assuming Dx correct I:

determine area of PF the pain is in
determine if it is more painful when I massage across the the PF or along the PF. Which ever it is I work along the painful line on a 70/30 ratio

Technique
pt prone knee flexed to 90.
plantarflex and invert the foot so I have as soft a foot as possible
I then apply a soft tissue mobs (massage) along the PF in the area of pain to start with and then extend the massage further out (assuming longitudinal pain is worse).
By the end of the first session I have the foot at plantar grade and reasonably neutralish but the knee still flexed.
Massage pressure grade is 1 or 2

Session two would see me start in the same way but maybe work across the PF more as well. This session would move into a grade 2 massage pressure increasing it if possible to 3 and I would also start to extend the knee

By session three the massage is deeper, the knee is more extended.

Usually between 3-5 sessions is enough and by the last one the knee is fully extended, the foot maximally pronated and dorsiflexed and dorsiflexion applied to the toes whilst massage pressure may reach 2

It is uncomfortable for the pt but ususally by the first session there is noticeale and beneficial improvement for them.

Massage pressure for me will go from 1-5 but in the case of PF usually a maximum of 4 only is occassionaly done.

Ian

 

I tend to categorise PF heel pain into one of two flavours. You get the pain caused by local inflammation, shock and impact and the pain caused directly on traction on the PF.

The first type probably contains a lot of misdiagnosed heel bruising, simple soft tissue trauma, bursitis etc etc. Its always worth remembering that heel pain is no more synonymous with PF than forefoot pain is with Mortons neuroma. There's a lot more which can go wrong under a heel than the PF.

I get the patient to walk up and down on a hard floor for a bit and notice WHEN it hurts. At heel impact there is little tension in the pf but plenty of impact and pressure, at heel lift there is lots of tension, but no direct pressure.

So if they tell me it primarily hurts on impact, I initially go down the cushioning and NSAID route. If they tell me it primarily hurts on heel LIFT I go down the support route. If both to equal degree I'll try to incorporate both elements into an orthotic.

And In almost all cases I recommend the usual set of homecare. Cold squash ball under the PF, Gastroc stretches, etc.

Regards
Robert

 

Look for myofascial trigger points in the abductor hallucis. Not all heel pain is plantar fasciitis/osis.

Scott

 

I try and locate the main etiology of the pain by their symptoms, insertion of the PF, primarily heel (atypical) or individual muscle insult through manual testing with resistance (as Scott points out many complaints are myofascial).

In typical PF they are given ultrasound diathermy with good old Epsom Salts subaqueous , interferential current muscle stim, manipulation low-dye taping, ice and myofascial release. I may recommend they have a cortisone injection and refer them out for this, or a OTC NSAID short-term. If they have equinus a dorsal night splint is recommended and off weight-bearing stretches and exercises early. I also believe that methylsulfonylmethane and good amounts of vitamin C are of value in healing PF.

I have found a shotgun and team approach is beneficial early on. Control the inflammation and control the foot.

They are then afforded either an OTC insert or casted for a CFO depending on their exam, gait and length and severity of symptoms. I see them 2-3 week for 4 weeks then re-evaluate and an follow-up at two weeks if they are fitted with a CFO. Footwear advice.modification is afforded on the first visit.

To date a very small percentage require care beyond 2-3 months. I routinely have them see a podiatrist or orthopedic foot specialist for co-management.

 

I use almost the identical routine to Michael's (below).
At the discussion of orthoses, I also suggest physiotherapy as an alternative, or additional treatment option.

 

Our routine is similar to Michael's also...

Following gait analysis... will also discuss possible need for night splint/brace during first visit and orthotic therapy. Will only use the brace if really needed. Will also recommend x-rays &/or scans if tape fails to help. This is rarely needed. Success rate with conservative treatment is over 95%.

 

OK, I'll throw in my 2 pence worth because no one yet has mentioned checking for joint hypomobility that often causes the soft tissues to compensate resulting in trigger points, myofascial tension, tissue inflammation and all the soft tissue pathologies that have all been listed.

These modalities are useful in providing symptomatic relief but long term resolution needs to address the etiology/ies; most often hypomobility or hypermobility of related joint function. Treatment choices would then typically be mobilisation, physical therapy and/or orthotic control or combination of these modalities.

Our latest audit revealed a 92% success result of 'significant improvement in pain' or better.

Ted.

 

Just another heretic to make a comment.

Firstly, I thought that we'd been convinced that in the vast majority of cases that the fascia is not inflammed.
I also think that one study showed that about 7% of enthesopathies aligned with the the fascial attachments and the vast majority align with the attachments for the plantar intrinsic muscles. I'll also grant that there is also very specific heel pain associated with myofscial triggers in soleus.
For heel pain I like to find out exactly where it is to detirmine which of the muscles is iinvolved and treat them. The pain referral patterns are quite standard in myofascial trigger point books such as Travell and Simons.
The longer the problem the more liklihood that more than one muscle and often all of the likely culprits ahve become involved.
Whilst you think you are treating, massaging and stretching the fascia you are fortunately also applying those forces and pressures to the intrinsic muscles. Great!
If you mobilise any joints in the feet that require it you get even better/faster results.
Mechanical intervention appropriate for the foot type presenting is the other ingredient that can improve the course of resolution.
I also find that when existing orthoses are removed that the foot often improves quickly as well. I would like to have overcorrected orthoses are a common cause of this condition which I will call heel and arch pain.

 

Sorry, I pressed the wrong key and submitted.
In reality, that was probably enough for one post anyway and could ramble on a lot more.
Just because there is an association between heel/arch pain and increased fascial thickness does not at all mean that the fascia is the problem.
I personally regard the fascia as providing protection and support to the functional units which are the intrinsic muscles. The first layer is totally connected to the fasci through the arch. The fascia is not like a ligtament that functions independently.
It's not much of a leap of focus to see the intrinsics being there for some reson rather than being more or less dismissed as having no importance whatsover. That seems to be the general impression that I get as the podiatric consensus.
Enough from me.

Cheers
Shane

 

There is no question that plantar fasciitis is the most common complaint in our office. I am usually not the first person to see this individuals condition. They have tried family doctors, physios etc. before I get to them.

I also see that they often already have orthotics and not surprisingly, they don't help. That is usually again because of non-podiatric suppliers out there are dispensing redundant and under corrective devices. Starting with a functional orthoses that has been casted in hind-foot supination with plantar flexion of the first ray is a good beginning. The we establish a timeline. If it is still in the acute or even sub-acute stage then we will proceed with the icing, massge NSAIDS and ultrasound. Traditional and conservative methods, although can be effective on an acute case may be effective, they are wasted on a chronic condition. For this reason, after confirming it to be chronic, we start them on extracorporeal shockwave therapy.

Our results are favourable.

 

X-ray about 60% of the time. If they've had previous xrays I usually won't repeat them.
Evaluation for LLD, FnHL, AJ ROM, evaluate for FF/Anterior Equinus, Watch patient walk - brief gait exam.
Manipulation of the proximal fibula, AJ and lateral cuneiform plantarly.
Modified Low-Dye Taping, modified metatarsal pad, accomodate for LLD unilaterally and anterior equinus bilaterally in most instances.

Patient to keep tape on 2-4 days. Return to office in one week.
On return if they did well, cast them for orthotic devices with similar prescription as was used with taping plus digital pad / cluffy wedge 1-5, 1st ray cutout w/ ppt backfill and FF valgus posting in most cases along with Medial heel skive.

If not successful, consider traditional injections, physical therapy and / or NSAID's or a combination of the aforementioned.

I think my success rate is 90% or greater with this treatment plan.

Cheers
bruce