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Heel Pain Treatments at the Doctor's Office





For information, illustrations, diagnosis and basic treatment information for heel pain, see our Heel Pain Information Page.

Steroid Injections

These are not the type of steroids which build up muscle, but the type which decrease inflammation. The steroid is injected right into the area of the most inflammation, at the heel. A steroid injection does not heal the fascia, it decreases the inflammation. It is important to remember this. Steroid injections work the best when they are used in conjunction with all the conservative therapy mentioned above. Steroid injections may not be very helpful in chronic conditions of plantar fasciitis. As mentioned previously, in chronic cases there tends to be more thickening and degeneration of the plantar fascia than inflammation and the steroid injection may do more harm than good.

Does the injection hurt? The short answer is yes, it does. But, the good news is that the injections are quick and the pain you feel when you get out of bed in the morning is far worse. The side effects associated with steroid injections at the heel include fat pad atrophy (shrinking of the padding at the heel), hyperpigmentation (brown spots at the injection site) and plantar fascia rupture. All of these are rare, especially the plantar fascia rupture, but they can occur. Allergic reactions are also possible, but systemic effects from the injections are uncommon.

Taping

Taping for plantar fasciitis can be an effective way to reduce stress on the plantar fascia. One of the most common methods is called Low Dye Strapping. There are many variations on this method, but most involve using 1" and 2" sports tape and wrap 1" tape around the heel from the little toe joint to the big toe joint. The 2" straps go across the arch. The big toe joint is pressed down while the straps or applied. When applied correctly, the taping can last a week or two before needing to be reapplied. Taping can be difficult to perform on yourself, so many will have this treatment done at the doctor's office or by a physical therapist.

Custom made orthotics

Custom made orthotics are devices which are molded specifically to your feet. A plaster mold is taken while you are sitting or lying on your stomach. Another method for casting is placing the foot in a foam box and taking a mold. The most common type of foot needing an orthotic is a flatfoot. But, any foot with abnormal motion may benefit from a custom made orthotic. To know if you need an orthotic, you should visit a podiatrist and be evaluated.

Custom made orthotics are rigid devices, with a soft cover. The rigidity is necessary to hold the weight of the body and control the abnormal motion, generally pronation. A soft orthotic will collapse under the weight of the body and be no better than a cushion. Most individuals need a week or two to get used to the orthotics, but kids adapt very quickly. Adults may develop knee, hip or back achiness the first few weeks. But this should always work itself out.

Physical therapy

Physical therapists play an integral part in the treatment of plantar fasciitis. Most therapists are well trained in treatment of this condition because it is so common. Physical therapy may involve ice baths, contrast soaks, stretching, strengthening, ultrasound and iontophoresis. Some therapy can be done at home, other therapy may involve twice weekly visits to the therapist for a number of months for good results.

Hard casts and Cast Boots

A fiberglass cast and crutches or a walking cast boot can be used in severe cases of plantar fasciitis in the initial inflamed stage. It is only used in certain types of cases which have not responded to other treatments. The idea is to take all the pressure off of the heel and allow the plantar fascia to heal. This can take 4-6 weeks.

Acupuncture

It is difficult to truly present acupuncture as a therapy for plantar fasciitis when there are no solid studies showing the effectiveness of acupuncture on heel pain. The papers written on acupuncture and heel pain are for the most part anecdotal. You may want to discuss this treatment with your doctor. If you do seek this type of therapy, consider that you are not truly addressing the problems 1. inflammation and 2. abnormal motion (usually pronation). If acupuncture does help the pain, then consider other therapies, which address the problem in addition to acupuncture.

Shockwave therapy

The term shockwave therapy usually makes people jump. No, this is not electric shock therapy. It is extracorporeal shockwave therapy (ESWT). Shockwaves are sound waves that create vibrations. The theory is that the vibrations cause controlled injury to the tissue, in this case the plantar fascia and surrounding structures at the heel. The body responds by increasing it’s healing ability at that area, stimulating a repair process. The FDA approved ESWT for the treatment for plantar fasciitis in the year 2000, but it still remains under investigation and many insurance companies will not cover this treatment.

Patients need to try most of the conservative therapies listed above for 6-12 months before being considered for ESWT. The procedure is typically done at a surgery center and in most cases does involve using anesthesia or some sedation. Full healing time after the procedure can take 2-3 months.

There are very few complications associated with ESWT, but a few that have been reported include bruising, hematomas, skin erosion, swelling and paresthesias (abnormal nerve sensations).

A Study in the Journal of Foot & Ankle Surgery (Malay DS, et al. Extracorporeal Shockwave Therapy Versus Placebo for the Treatment of Chronic Proximal Plantar Fasciitis: Results of a Randomized, Placebo-Controlled, Double-Blinded, Multicenter Intervention Trial. J Foot Ankle Surg 45(4):196-209, 2006) compared ESWT versus a sham procedure in 172 patients. The researchers found a statistically significant benefit of ESWT over the sham treatment and the patients experienced no significant complications or side effects.

A more recent study in the Journal of Foot & Ankle Surgery (Chuckpaiwong B et al. Extracorporeal shock wave for chronic proximal plantar fasciitis: 225 patients with results and outcome predictors. J Foot Ankle Surg. 2009 Mar-Apr;48(2):148-55) retrospectively evaluated 225 patients with chronic plantar fasciitis who underwent ESWT. Success rates were noted at 77% at 12 months. More information on this ESWT study.

Similar studies need to be performed to help further assess the true effectiveness and safety of ESWT in plantar fasciitis

Coblation Therapy

Coblation Therapy is a bipolar radiofrequency-based technology that uses low temperatures to stimulate the release of hydrogen, oxygen and growth factors from tissues and stimulate the formation of new blood vessels within the tissue. The idea is to jump start the body's own healing response. Coblation therapy is not a new therapy, but has recently emerged onto the scene for treating plantar fasciitis, or more appropriately termed plantar fasciosis.

Plantar Fasciosis

Many in the foot related health care field are pushing for "plantar fasciiitis" to be renamed "plantar fasciosis." "Itis" means inflammation and many studies have shown that after the first few weeks following injury and development of plantar fasciitis, the inflammation decreases. After a few months, the blood flow which was increasing the inflammation initially, has disappeared and the fascial band starts to thicken and lose blood supply. The exact point of this transition is unique to each individual and still up for some debate. The idea of plantar fasciosis is important in that much of our treatment efforts in the past have focused on decreasing inflammation. Although decreasing inflammation is important in the first few weeks and possibly for the first few months of the development of heel pain, treatment of chronic plantar fasciitis (plantar fasciosis) should not focus on anti-inflammatory measures. More on plantar fasciosis. Detailed discussion of the breakdown of the plantar fascia.


The results from Coblation Therapy are promising with patients back into regular shoe gear within 2 weeks and a low risk of complications. There have been reports of infections and small wound dehiscences, but this is expected with any surgical procedure. More information on coblation therapy. 

Platelet Rich Plasma Injections

Platelet rich plasma injections work in a similar way to radiofrequency lesioning. The injections stimulate the healing response and repair process by releasing growth factors and stimulating the inflammatory cascade. The goal is also to jump start the natural healing process. A cast boot or heel lift may be used after the injection and addressing any mechanical causes of the plantar fasciitis are still necessary. There have not been many controlled clinical trials with the use of platelet rich plasma injections for the treatment of chronic musculoskeletal conditions, including plantar fasciosis, but what little research has been done is encouraging. See our blog post on platelet rich plasma injections.

Cryosurgery

Cryosurgery is a minimally invasive surgical technique using extremely low temperatures to destroy sensory nerves supplying the heel. This procedure has been a popular treatment for decades for the destruction of both benign and malignant lesions. Cryotherapy is also used to destroy sensory nerves in the management of pain, but is a fairly new treatment for chronic heel pain. Some suggest the most appropriate use of cryosurgery for heel pain is when nerve entrapment is also involved. More research is necessary to establish the efficacy of cryosurgery in the treatment of plantar fasciitis. Blog post on recent research on cryosurgery and heel pain.

Botox

Botulinum toxin injections are the heel are a promising treatment for chronic plantar fasciitis. Long term studies are still needed, but results are promising. More information and research on botox and plantar fasciitis.

Dry Needling

Repeated needle punctures using ultrasound as a guide in an attempt to cause localized injury and stimulate a healing response in chronic cases. More on dry needling.

EPF: Endoscopic Plantar Fasciotomy

EPF is a minimally invasive surgical treatment for chronic plantar fasciitis. The procedure involves making a small incision on the inside and outside of the heel. A small camera is inserted into the heel which allows the surgeon to visualize the plantar fascia. The success rate with this procedure ranges from 80-90% good to excellent results and the complications are reduced in comparison to an open heel surgery. More discussion on ultrasound guided plantar fascia release.

Open Heel Surgery

Over 90% of patients will improve without surgery. Surgery is the last resort and very few people will need to have surgery. Usually 6-12 months of conservative care is attempted before surgery is considered. A small incision is made at the heel, cutting the fascia and sometimes removing the bone spur, if there is a large spur (remember that the bone spur is rarely a cause of pain). This type of surgery usually involves a walking cast, a cast boot or sometimes crutches for 4-6 weeks.

No surgery is free of complications. Complications from either the EPF of the open heel surgery include nerve problems, infection, slow healing, pain on the outside of the foot (cuboid syndrome & lateral column overload), tendon rupture (posterior tibial tendon) and recurrence of the problem and instability of the foot associated with a collapsing arch. Although these problems are relatively rare, they need to be taken into consideration when undergoing the procedure.

The success of the surgery depends on many things: the time the patient has had the problem, how much scar tissue has developed (difficult to assess), the type and area of pain, the type of surgery performed, the healing ability of the patient and the compliance of the patient. Considering all these factors it is no surprise that the success rate reported has ranged from 60-95%.

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This page was last updated 07/15/10

Disclaimer: The advice on this website is not intended to substitute for a visit to your health care provider. We will not be held liable for any diagnosis made or treatment recommended. Consult your doctor if you feel you have a medical problem.