Comfort Shoe Specialists

11693 Manchester Rd

St. Louis, MO 63131

314-822-3300

Pedorthic Management of Plantar Fasciitis

Plantar fasciitis is the most common foot injury that is encountered by the pedorthic profession.  In searching our current database of patients with diagnosed foot ailments and gait disturbances, 2350 were diagnosed with planter fasciitis by their referring physicians, approximately 20%.  The plantar fascia is a thick fibrous tissue on the plantar aspect of the foot.  It originates from the calcaneus and passes anteriorly, splitting at each metatarsophalangeal joint to permit passage of the flexor tendons.  The plantar fascia acts as bowstring that helps maintain the longitudinal arch of the foot.  The problem occurs when the fascia is overused and micro tears within the fascia become inflamed resulting in pain.  Pronation is the most common repetitive traction stress that pulls the fascia from the calcaneal periosteum.  Additionally, when the metatarsophalangeal joints are dorsiflexed, a tightening of the plantar fascia occurs, adding to the micro tears of the fascia. 

    Plantar fascia injury may also occur at the   midsole or near the toes.  Planter fasciitis is   an  ongoing re-injury process since it is difficult to rest the foot.  When sleeping, or at rest, the foot is plantar flexed and the plantar fascia becomes shortened and tight, as do the calf muscles.  Thus, upon rising after rest, a painful re-injury occurs.  Other contributing factors include: a supinated rigid foot, poor shoe support, short shoes, uphill and toe running, bare feet on soft terrain, sudden weight increases, and sudden increases in activity. 

In a study published by the American Orthopaedic Foot and Ankle Society, 100 patients were followed for an average of a 47-month period.  A subjective rating showed the treatments that worked best in order:

1.     Achilles/plantar fascia stretching            click here for stretches

2.     Time passing/rest

3.     Custom cushioned orthoses

4.     Shoe change

5.     Non steroidal anti-inflammatory drugs

6.     Hard orthoses

7.     Injections

8.     Plantar strapping

9.     Ice/heat

10. Night splinting

The survey indicated 82% recovered completely from their symptoms.  For most patients, the time period to resolution of symptoms was approximately the time symptoms occurred before they sought medical attention.[1]  However, most patients find significant relief 4 to 6 weeks after the start of the treatment plan.

          Based on published studies regarding plantar fasciitis and experience our method of treatment is as follows:

1.     Educate the patient regarding the etiology of the problem.

2.     Encourage the patient to buy shoes with more room in the toe areas to allow the flexor tendons to become relaxed to reduce tension upon the fascia.  (This is the reason shoes rated highly in the study mentioned above)

3.     Custom orthoses: Three different types of orthoses are constructed for the patient dependent upon the amount of pronation control, cushioning needed, and the recommendation of the physician.  One type is made of different densities of Plastazote reinforced with Poron for the ultimate cushioning with slight pronation control.  The second type is made of Tri-laminated materials (Poron, Puff, and thermo cork for control) for equal pronation control and cushioning.  The third is a semi-rigid device for maximum pronation control with cushioned Spenco top covers to reduce shock and shear.  Hard orthoses are avoided with the exception of obesity, but a cushioned cover is used.

4.     Strong recommendations are made for the patients to stretch the gastrocnemius, soleus and posterior tibialis muscles.  Most patients report a significant improvement when compliant.   Click here for stretches

5.     Advise the patient to avoid going barefoot while symptoms are present.  Supportive sandals are an option to wear, such as Birkenstock and others, when the patient does not want to wear the orthoses in an enclosed shoe in the home.  We also suggest the patient to avoid rising from bed without orthoses or a supportive sandal.

6.     If the patient walks or uses a treadmill for exercise, it is best to avoid any inclines.

7.     For chronic cases a dorsiflexion night splint is used.  An 88% success rate was shown in a study in the Foot and Ankle International January 1998.[2]

In other studies, corticosteroid injections to the heel can cause the plantar fascia to rupture, which causes abnormal loads to the forefoot, collapse of the medial arch, leading to other foot pathologies.[3],[4],[5],[6] Pedorthic conservative treatment is a valuable modality for prescribing physicians.  In a recent survey sent to our patient database, we were pleased to discover that 94% of the patients that responded were satisfied with our treatment modalities.  Insurance often will cover a portion of the cost of the prescribed orthoses.  Stretching, rest, custom cushioned orthoses, roomy supportive footwear, medication, and ice therapy have proven to be an effective conservative treatment for the treatment of plantar fasciitis to our referring physicians’ patients.

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