If you treat feet, patients come in wave after wave with plantar heel pain. We start with an historical review of the problem to attempt to analyze variants of our most successful treatment of plantar fasciitis. We know how to treat plantar fasciitis with our taping, stretching, icing, orthotic devices, and activity modifications. We are great at that, and proud of it. Our podiatric formula works in the black and white of medicine, much as the surgical realm of podiatry. Do this, and that will happen, and all is well. However, what truly distinguishes us is our ability to see the gray areas of this problem, and perhaps see it faster than most. Patients, of course, want their problem to be black and white, but hunting the gray will bring you the most joy.
If you have a rushed practice, you must have protocols for everything. And, you must have a working diagnosis for the patient when you leave the office that is accurate 80% of the time, by which your protocol sparks a treatment course. The gray area is the 20% of patients that are not plantar fasciitis. But, if you follow the patient, and they are not improving on your plantar fascia protocol, you should switch to Plan B based on your second best diagnosis (aka common differential diagnosis).
What helps us know more than just statistically that the plantar heel pain is plantar fasciitis? On historical review, the plantar fascia identifiers are the worst pain when getting out of bed in the morning, the most painful spot in the bottom of the heel where the plantar fascia attaches, there is no swelling, no limping, and the pain comes on gradually over weeks and months.
Therefore, any limping you see, any swelling in the tissue, side to side heel bone pain, absence of pain when getting out of bed, or any nerve symptoms, it is not plantar fasciitis. Typically, pain at the plantar aspect of the foot, if it is not at the medial calcaneal tubercle, is not plantar fasciitis. Also, side to side bone compression pain of the calcaneus is a sign of deep bone swelling, and is not associated with plantar fasciitis. The patient typically has no pain when walking only on their heels on examination.
Let’s briefly talk about x-rays brought up to me by Dr. Stefan Feldman. It is not standard of care to take an x-ray, especially the lateral weight bearing foot, for all patients with plantar heel pain. However, I do believe it is good medicine. The patient can have the x-ray sometime between when you leave them and the next appointment to review. It is a good visual for the patient and you can find a few zebras from time to time.
Here is my office protocol for plantar fasciitis to get the ball rolling on a good treatment course. Since there are over 50 common treatments out there in the podiatry universe, this could just be the start of getting your patient better.
The top 10 common treatments for plantar fasciitis are:
- Plantar fascial wall stretch for 30 seconds 5-10 times/day.
- Rolling ice massage for five minutes 2-3 times/day.
- No negative heel stretches.
- Avoid barefoot walking (something like Dansko or Oofos sandals at home).
- OTC or custom orthotic devices to transfer weight into the arch (you must feel that the heel is protected and weight is in the arch).
- Physical therapy or acupuncture (two times/week for four weeks and then re-evaluate).
- Posterior sleeping splints when morning soreness lasts over five minutes (these can be used at any time as rest splints when you are going to sit for 30 minutes or more). DeHeer Equinus bracing best for gastroc equinus.
- Low dye/arch taping daily initially and then with strenuous activity.
- Activity modification to avoid “bad pain,” as you quickly want to achieve 0-2 pain levels consistently.
- Calf stretches (straight and bent knee) two times/day.
We are trying to, at each visit, successfully treat the plantar heel pain mechanically, ease the “itis” or inflammation, and add flexibility in the sagittal plane (plantar fascia, achilles, and sometimes hamstrings). Next week we will continue this discussion into what is and is not plantar fasciitis. The week after I will describe several orthotic devices we can design.
