Clinically it depends whether you are treating a re-current enthesitis with bone oedema or a chronic fasciopathy associated with fibrosis and expansion of the fascia... Few RCTs have made this distinction hence mixed results in trials for steroid vs saline injections.

ESWT - There's one high quality RCT evidence for chronic plantar fasciitis... there is still no guidelines over the SWT treatment protocol and it is not routinely undertaken in the UK...

I think streamlining trial is needed to identify responders to conservative treatments... Non responders still tend to be overweight, sedentary with tight foot and ankle dorsiflexion...

Conservative in practice: kynesiotape to both cover plantar fascie and have foot in dorsal flexion, intermittent cold application 3 repeats of 3 minutes application and 6 minutes rest for 1-2 times a day/ 3-4 times a week, excentric and concentric daily stretch exercise, use of extra corporal shockwave therapy (ECSWT) twice a week, adding an extra sole of at least 0.5 mm in shoe, friction massage and eventually use overnight of so called Strassbourg sock. Have a look at calcaneus spur, the Hübscher test and hallux valgus. Sometimes we see these pathologies related.

Good explanation by Jill and Alexia.

Most of the patients of (PF) plantar fasciitis are expected better treatment which is clinically and costly effective. One study done by Tong & Furia, 2010 stated that for this condition which was based on PF treatment, it is costly and burden third-party payers in US.

As a practitioners,we might think about low-cost and clinically effective treatment.

Surgical is last procedure for those who failed conservative management, but there are complications. Same goes with injections which are non-invasive treatment also have negative side effects.

Reference:

http://www.amjorthopedics.com/PDF/039050227.pdf

I read some article about it. Thay compare Shoc-waves and clasic tretmant(Ultra sound and strechting). Result is same. Personaly I do not like shoc-wawes.I prefer ultra sound manual stretching, using night split for dorsi flextion and shouse with cca.2cm heel.

Dear amirul, before any treatment, you may do a good body examination mainly in the foot, ankle and knee becouse a flat foot is the main predictor for a PF. So you have to do a correction of this or these postural alterations. In my practice, I start with a postural assessment and in presence of any disfunction such as flat foot, knee valgus, hip anteversion, I do these corrections first and after, I use ultra-sound, stretching and myofascial technique and some times proprioceptives insoles

Brilliant Rodolfo.

Amirul, this is because often we don't have good results for certain treatments, for example PF. there are many biomechanics alterations that impair a good functioning, thus, we have to atempt to these impairments to a excellent results for our patients.

@ Amirul, Rodolfo Take, besides, pes palnus also hallux valgus en weight load in consideration. As well tight shoes and flat floors although the latter is hard for intervention. Walk bare feet on sand which I recommend though Dutch weather usually is often not in appropriate condition.

We recommend 'Strasbourg sock', check calf muscle lengths (tight?), have also used ultrasound to good effect. Look at pain producing activities (biomechanically).

Alexia, you're right, pes planus may lead to hallux valgus that can contribute to FP, besides, Louise, I usually use ultrasound phonophoresis, with topical non-steroidal antiinflamatory drugs. Also, I have used too kinesiotaping to mantain the plantar arch. with good results.

we do a computerized foot scan before the start of treatment with this guide and a custom made insole we unload the pressure . us with local steroid and high power laser give us good result

You must first consider the cause of PF in your patient. PF has been shown to be degeneration of the PF much like Achilles tendinopathy, so since it is a tendinosis type issue instead of tendinitis you need different treatments. Therefore onset is caused by persistent overload and the PF degenerates faster than it can repair. Foot position is key therefore corrective in- soles can help. Calf tightness also increases load through the PF (search some papers on this aspect) . There was also a study in manual therapy showing excellent benefit with trigger point release in the calf. Strengthening of the calf might also help then SSTM s to the PF.

Do a new literature search for an update on pathology and aetiology for more info.

I am a PT with chronic, intermittent plantar fasciitis for the last decade. I agree with all of the biomechanical corrections and interventions suggested above and have had much success with patients. Unfortunately, despite optimal care, my own pain still persists (intermittently). However, I recently started wearing the Strassburg sock, mentioned by Lousie, and have had excellent results, especially when compared to other night splints. If I wear it every night, or even every other night, I wake up pain free, but if I stop wearing it the pain slowly returns. It is well worth the 40 USD.

We have used PRP (Platelet Rich Plasma) for the management of such a condition, the results were quiet satisfactory but not as good as the other overuse syndromes especially Tennis elbow. This method might be efficient in improving PF.

Ultrasound should work well along with modified footwear and correcting the ankle foot alignment. Stretches of the plantar fascia where necessary should be done

I can recommend reading more on the subject in the Open AccessJournal of Foot and Ankle Research.

http://www.jfootankleres.com/search/results?terms=plantar%20fasciitis

check the calcaneal position ,TA tightness,Mulligan taping helps if there is any change in the position of the heel,otherwise kinesiotaping helps other than ultrasound and stretching

I would recommend plantar fascia and calf muscle stretching in the clinic as well as in the home programme. This should be continued for long periods to prevent recurrence.

I found this resource on Plantar Fascia Release.

Endoscopic Plantar Fascia Release ( EPFR) provides considerably better patient outcomes. Patients with more severe symptoms before the procedure and those with symptoms for longer than 2 years had worse outcomes (Ferkel, 2007). Ferkel found that obesity did not have an influence on outcome. WC patients had poorer results compared to non-WC patients. Women achieved better results than men. This finding may be biased because most WC patients were men (2007).

I personally had an experience with plantar fasciitis surgery. It went well and I have not had any symptoms since.

Regards,

Susan

Reference

Ferkel, B.R. (2007), Results of endoscopic plantar fascia release. Foot Ankle Int. (5):549-56.Denver, CO:Western Orthopaedics

http://www.ncbi.nlm.nih.gov/pubmed/17559761?dopt=Abstract

In the first line you should find the cause of PF, to be able to choose theappropriate treatment .Following methods are, generally, successful: eccentric muscle training, ESWT and trigger point treatment (in combination).

If conservative treatment fails, then surgical treatment may help. It depends on the individual case. Fasciectomy (partial or total), desinsertion from tuber calcanei, subtraction arrthrodesis of the mediotarsal joints.etc.

I also agree with everything said above. However, I have verified in some subjects with chronic medial calcaneal pain that the tibial posterior nerve, specifically its terminal branch (medial plantar nerve) can be damaged in the a condition called tunnel tarsal syndrome. Thus, I suggest performing tensioning neural test to differentiate between neural and musculoeskeletal conditions.

Dear Dr. Baldon, of course tarsal tunnel syndrome could be misdiagnosed as far as the pain syndrome is concerned. However, here the question is about chronic plantar fasciitis.This condition is something different taking in consideration the local status,tension tests, sonographic imaging, etc.

Dear Dr. Tanchev., although the tarsal tunnel syndrome is a uncommon condition, I have noticed that several patients are misdiagnosed with chronic plantar fasciitis. Of course that the doctor should always investigate all the possible sources of pain by way of image exams. However, most of times they don't do that and the diagnostic is only based on the pain localization. Thus my comment is only a piece of advice for that cases that there aren't exams and the source of pain is not well defined.

Dr. Baldon, you are right. Unfortunately, it happens. However, the question here tackles the specific condition "chronic plantar fasciitits". So I presume that the diagnosis here is properly made. If we go over to the differntial diagnosis of pain localized around the foot and ankle, then we have to include many other conditions.

.

Seth O'neill has nailed the basics, the research that shows tendinosis is the basic problem and a persistent load on the tendon structure shreds the collagen that the tendon is made of. You need to eliminate/reduce the constant load on the Plantar Fasciitis which is basically a large tendon - then the body can restructure the collagen in the proper form. Often the tight calf also causes restless legs syndrome because the muscle stays tight 24/7. Sit in a chair, place the ankle of the right leg on the left knee. Gently massage the inside of the right leg immediately below the bone. If you have pain at a low pressure you need to massage the inside length of the lower leg daily until the pain is gone, this relaxes the overactive spindle cells that are keeping the muscle tight and putting tension on the PF. You should also do direct massage to the bottom of the foot, gently at first. Then work the left leg and foot. Ramping up pressure over a week or so and you can put 50-80 pounds on the area will give a long term relief, although if you walk or stand with little Quad involvement the problem will probably tend to recur.

Maintenance can keep the problem at bay. Arnica Gel ( Boiron brand ) will help in this process - it's about $11 for 2.5 OZ - don't get the homeopathic pills, they are worthless.

A little work will take care of the problem.

I'm curious what diagnostic test(s) Dr. Tanchev would consider to be the "gold standard" for diagnosis of chronic plantar fasciitis. Assuming that this diagnosis is "properly made" is speculative based on the current evidence.

My clinical experience is consistent with what Dr. Baldon has described above, which is that plantar fasciitis is frequently mis-diagnosed in patients with medial ankle/heel pain, and often includes entrapment of the medial plantar nerve at that tarsal tunnel. Also, frank damage of the nerve is not necessary to create a nociceptive input. The nervi nervorum can depolarize due to accumulation of metabolities from transient and recurrent ischemia, then peripheral sensitization of the sensory receptors can occur resulting in a "cranky" nerve. Neurodynamic testing of the tibial nerve per Shacklock can be performed to differentially dx this condition versus true plantar fasciitis.

I've seen many post-surgical disasters over the years from plantar fasciectomies.

Dear Dr. Ware, as far as the diagnostics of CPF is concerned I would recommend you to throw a glance on some propedeutical textbooks, i.e. Essential Orthopaedics and Trauma (D. Dandy and D. Edwards). Furthermore, it is well known that exact diagnosis is not always possible. So misdiagnosing happens with many pathologies.

As far as the "post-surgical disasters" are concerned you are right. In my 40 years long surgical practice I have seen a lot. Unfortunately, surgery is loaded with complications and failures. Nevertheless, surgery has never lost its place in the arsenal of medicine. In cases with chronic plantar fasciitis not responding favorably to the conservative methods mentioned by the colleagues, surgical treatment remains an important option.

Do no harm is the basic concept. In the case of surgery a statistical rate of !% disastrous result is really 100% for the individual patient. The time to exhaust non-invasive treatment is at the beginning - leaving options open.

Patients owe it to themselves to consider the risk of any procedure - and what options may or may not be available should an outcome be less than optimal.

In my personal case an injured shoulder could have surgically treated to reconstruct the bursa, - the explanation of the shoulder pain. The prognosis of successful treatment at the time was 1%. Years later in the Philippines a barber/massage therapist worked on it for 10 minutes using high pressure - deep tissue work. After 24 hours I had a "brand new shoulder" that no longer hurt.

Was I lucky to forego surgery? No, I was fortunate - the risk verses reward at the time was near zero - I had no incentive to take those odds. I had tried pain killers, herbs, massage, acupuncture, hands on healing, Ice, Heat, hot and cold combined, tiger balm, and whatever else available at the time. Purely out of luck I was back to normal. PF seems to be amenable to the same therapy.

Dear Gregory,

the story of the miracles of alternative medicine is well known. I would like to underline that the patients in whom it failed (there are a lot of such cases) do not like to share their adverse experience. I have no explanation for this fact. Anyway, in this forum we are discussing the problems from the point view of the official medicine. In the best case with data and results obtained and confirmed by the evidence-based medicine.

Dear Panayot - please see:

http://www.nytimes.com/2012/01/17/health/for-intrigue-malaria-drug-artemisinin-gets-the-prize.html?pagewanted=all

Wishing you well.

Dear Panayot - again, an example.

The Chinese and East Indians have been doing evidence based medicine for quite a while. Example: There are many types of Astragalus. One type is one of the 3 top tonic herbs in Chinese medicine - the other two are Ginsing and Cordyceps.

Astragalus Membranaceus is used as a component in many Chinese herbal tea medications. Recent research shows compounds in Astragalus Membranaceus that stimulate the body to produce telomerase - which rebuilds the telomeres which keep cells functional.

http://www.nobelprize.org/nobel_prizes/medicine/laureates/2009/advanced-medicineprize2009.pdf

http://www.esciencecentral.org/journals/malleability-of-short-telomeres-by-telomerase-activators-a-mini-review-2329-8847.1000108.pdf

Alternative medicine is in the eye of the beholder. Effectiveness recognized by Chinese medicine simply had not previously been witnessed or tested by conventional medicine.

Keeping an open scientific mind is of the greatest benefit.

Dear Gregory,

I agree entirely with your last sentence about " ... open scientific mind..." That is what I do. We discuss here the treatment of chronic plantar fasciitis. Please, redirect me to RCTs in which Astragalus membranaceus is effective in treating chronic plantar fasciitis. Thank you for your efforts in advance.

I'm interested in studies demonstrating the validity of the medical diagnosis of chronic plantar fasciitis. It seems illogical and perhaps unprudent to me to develop RCTs (a decent one costs about $500k to implement) to examine the effectiveness of interventions for a condition that hasn't been shown to validity exist.

Dear Panayot - My digression as to the Astragalus and the Artemisinin URLs was only in response to your assertion "the story of the miracles of alternative medicine is well known." The assertion that alternative medicine has no worth is neither scientific, fair, nor correct. Astragalus and Artemisinin are but 2 examples of alternative medicine becoming mainstream.

Early Alternative medicine, - Willow bark - folk remedy, + scientific investigation = 40,000 tons of aspirin used world wide each year.

The use of the scientific method is to understand the world to the benefit of humankind. If we reject out of hand, - never question current "knowledge", and take the narrow view that science is settled, it's back to the dark ages.

Asking questions is basic to my personality. I would expect that we ask questions about everything - including "established" science. I would hope the negative attitude about alternative medicine would also find some understanding.

Microbes on the skin cause disease. Fortunately we can agree the alternative medicine of swabbing the skin with alcohol is a good idea, - now endorsed by science.

As a surgeon, I am sure you agree.

Chronic Plantar Fasciitis post to follow.

Dear John,

Dear Gregory,

Although this discussion got deviated a lot from the primary question, it was useful for me in the following issue. I will continue to try conservative treatment in cases with chronic plantar fasciitis (incl. Chinese medicine) and if it does not work I will go over to surgery.

I just want to mention that I'm dubious of the term "alternative medicine". Something I heard from the medical skeptics at Science-Based Medicine is that "alternative medicine is just another word for conventional medicine that hasn't undergone rigorous scientific scrutiny." This is not to say that traditional, ancient remedies should be dismissed out of hand, to the contrary. Rather, this means that they should, if they possess a plausible mechanism of action, be subjected to the same rigors of scientific discovery that what we call "conventional medicine" has undergone.

Unfortunately, particularly in many areas of surgery, what is considered mainstream or conventional treatment interventions have NOT undergone adequate scientific investigation. It's very difficult to design good RCTs to investigate the efficacy of surgical procedures, but the current science of placebo (see Benedetti's work on placebo and the placebo knee arthroscopy trial by Moseley) in my opinion has reached the level that we need to radically reconsider the paradigm under which the clinical decision to perform surgical interventions is made, including plantar fasciectomies. I think this paradigm is seriously flawed and resulting in far too much iatrogenesis and expense to modern health care systems.

The diagnosis of "chronic plantar fasciitis" may be not as clear-cut as the textbooks suggest:

http://www.podiatrytoday.com/print/814

To John Ware: Thanks for the opportunity to view the nerve release from podiatry today, the chain of logic and detailed SOP was a beautiful demonstration of science done right.

I would hope at some point we will see more enthusiasm for scientifically testing what have been termed alternative medicine. In the case of high pressure - deep tissue work there is the potential for huge savings in the cost of treatment, a potential to limit unwanted complications to the patient, and the hope of returning millions to healthy function.

Finally thanks John, it is encouraging to hear from a scientific mind with a foot in both worlds - I think this is how change is made. Thanks for your perspective.

Best regards.

Greg Zurbay

You're welcome, Gregory.

After 20 years I think bkz you never be sure just experience that the best way to treat plantar fasciitis is a custom made insole with ice application every morning before you step down. Also stretching helps for tight gastrosoleus or extra help only from laser or shock wave it is very beneficial. For my opinion , start with the insole with a lot of fitting trials until you find the position of the foot that relief or sweeten the pain during toe off without any symptomatic therapy. And after start the symptomatic therapy such as ice, stretching, physio. This is bkz if you start symptomatic therapy you don't know which one helps insole or therapy. As the most important think is to relax the plantar fascia or what ever better use this protocol and when you find that the insole work then start after two days the other therapy.

Hi all,

Thanks for the interesting debate on alternative medicine, food for thoughts indeed. Very good point also is differential diagnostic and eithiopathology of PF. My input here to offer an answer to the question is to maybe remove ourselves from the exact diagnostic and go back to the mechanism of such overload injuries - as suggested by Seth and Louise: biomechanical factors. Tight calves yes, but also

Tight biceps fem vs underactive semi mem (ten?), overactive VLO vs underactive VMO, underactive gluts max vs overactive TFL and tight rec fem? Lumbo pelvic control, running technique, jump-landing mechanics? Enough strength endurance? Power? I personally view PF as a teaching opportunity for athletes / sport amateurs who do not necessarily undestand the requirements of their own bodies to perform safely and effectively. Short term solutions or immediate appliances of orthotics can definitely have a role to play but I personally treat patients with PF functionally like people who are 5-6 months post ACL reconstruction and have done poor / little rehab...

You have right everything is a chain and PF or Calcaneal spur or Heel pad Syndrome has related with leg length discrepancy or poor biomechanics or tight HS or Gastro/Soleus. But long term PF treatment is the use of right orthotics as IT SOLVES ALL THESE POOR MECHANICS, it is not short term treatment. Pain relief therapy is short term treatment

Hi Christos, thanks for your reply however I have to disagree with your point that orthotics solve all biomechanical issues, this is simply not true and such a blunt statement is just erroneous. There is no large RCT that could even attempt to corroborate that hypothesis! I do believe however that orthotics have a role to play in PF treatment but not all patients suffering from it actually require long term orthotics to sort their symptoms out; some don't even need any. Many other treatment modalities have shown to be effective: shock wave therapy, injections, acupuncture / dry needling, corrective exercises... Even though all present advantages and disadvantages, the reality behind PF treatment is that all patients are different and can benefit from many different approaches.

Hi Xavier, I agree entirely with you. One should decide individually from case to case. Orthotics is an important adjuvant means but not a panacea treatment.

Hello, I didn't say that orthotics is panacea just 70 percent from my patients with PF independently the cause or the reason of it, with excemption of arthritic one I found that ice application with the proper insole and with or without complimentary shock wave or laser or acupuncture treatment is the best treatment before you go to cortisone injection. And this is in terms of eonomical way to treat the patients, otherwise I agree with this what you said. Just I speak in terms of eonomical way to treat a patient......

And in terms of orthotics you don't need expensive ones or custom made. During my experience even an anti shear material at the top of a prefabricated insole helped better than a custom made one. Meaning as you said every patient is individual and every case different. Just I learn in Glasgow foot clinic from my mentor, the orthopedic surgeon that I worked, Mr. Eric Anderson, the first foot clinic in UK after 30 years experience that : The simple treatment is the best if you know what you do and after do more complicate things

Activity modification and flexibility of ankle (in particular dorsiflexion and Foot Intrinsic activation ) may yield better results

My personal experience shows that the lipid deposition in plantar is the main cause of PF, and can be cured by natural weight loss. Please see:

Re: Plantar heel pain - Plantar Fasciitis (Fasciosis) can be cured by Natural Weight Loss

https://www.bmj.com/content/353/bmj.i2175/rr-0

Yes but some times is because of the weight loss. if it is not due to arthritis most of the time is due to add or lose weight or bkz of the shoe interaction. The best treatment is proper insoles with ice and hallux stretching. An i f you make cortisone injection the fat pad loss is getting more meaning more pain if this is the cause of PF

Mechanical constraint against the foots will not cause plantar fasciitis. The deposition of ectopic fat in the plantar fascia over time, which stiffens the plantar fascia, and makes it lost its flexibility; is most likely the cause of plantar fasciitis. So lifestyle change may help to get rid of heel pain.

Eat moderately in the day, and stop eating 5 hours before going to bed, and then sleep for 7 to 8 hours. In this way, by fasting for around 12 to 13 hours, our body will be forced to use the ectopic fat as energy source. Over a long period of time like half or one year the plantar fascia will be very clean without any ectopic fat. And then the heel pain will be greatly relieved.

About mechanical properties and PF read thesis by Walker ,1991 (PhD thesis, university of Strathclyde)