Barrett and O'Malley (1999) recommend a conservative treatment that addresses the inflammatory element causing the discomfort and the biomechanical factors producing the disorder. To complement the treatment, the patient should be adequately educated on the etiology of their pain, the biochemical factors that produce the symptoms, home therapy that can relieve some of the discomforts and changes that must be introduced to their daily activities, such as wearing suitable athletic shoes with enough medial arch while walking. If the patient has had an increase in exercise or activity associated with the symptoms, he or she should adopt a less straining regimen until the plantar fasciitis condition resolves (Barrett and O'Malley).

1. A removable longitudinal metatarsal pad fitted from the distal part of the medial calcaneal tubercle to the five metatarsal heads. It should serve as a temporary arch support to decrease pronation during midstance of the gait cycle (Barrett and O'Malley 1999). It may also be placed directly against the patient's skin and taped from a plantar medial to a plantar lateral direction. These can provide greater biochemical support than over-the-counter heel cups or pads.

2. stretching the Achilles tendon as adjunctive therapy for 2 minutes 3 to 5 times a day for 6 to 8 weeks, followed by a re-evaluation (Barrett and O'Malley 1999, Thomas et al. 2001). The patient should face a wall with one foot 6 inches from the wall and the other 2 feet from the wall and then lean towards the wall while keeping both heels on the floor. Other doctors (Singh et al. 1997) recommend doing the stretches at least 10 times five or six times daily. Stretching will not only help in the recovery but also in preventing recurrence (Olson 2003). It should be done gently and not strenuously and on a consistent basis.

3. orthotic devices to counteract pronation and disperse heel strike forces (Barrett and O'Malley 1999, Thomas et al. 2001). These can be heel pads and arch supports (Singh et al1997) made up of softer materials that can cushion and reduce the shock on walking up to 42%. Two randomized trials of orthosis showed that patients had the highest level of improvement in using silicone heel inserts and rubber heel cups after 8 weeks, with prefabricated inserts outperforming stretching alone and customized orthoses (Shea and Fields 2002). Patients should replace worn or worn-out running shoes with new ones with firm arch support and firm heel cup to buffer forces at impact (Miller 2004).

4. ice pack on the plantar part 15 to 20 minutes before going to bed at night for 10 to 14 days or massaging the plantar fascia with an ice block 15 minutes daily for 2 weeks.

5. night splints to keep the foot an angle of 90 degrees or more to the ankle as an adjunctive therapy to prevent contraction while the patient sleeps. A study showed that 83% of patients treated with these splints showed relief from stubborn plantar fasciitis (Barrett and O'Malley 1999). Wapner and Sharkey reported a 79% cure after patients used the splint for an average of four months (Singh et al. 1997). Another study found improvement in all patients using night splints at an average treatment time of 12.5 weeks (Batt et al. As qtd in Shea and Fields 2002). Still another study found that 88% of the involved feet improved at the end of 6 months after using night splints (Powell et al. As qtd in Shea and Fields).

6. short-leg walking cast for several weeks as a final conservative measure. It was found effective for chronic plantar heel pain when worn for a minimum of three weeks (Barrett and O'Malley 1999). Below knee casts for three to four weeks provides relative rest, reduces pressure on the heel, provides arch support and prevents the tightening of the Achilles tendon (Singh et al. 1997).

7. ice massage, stretching, inserts like orthoses for boots (Edwards 2003) and "relative rest" of the affected area (Singh et al. 1997). Icing is the best management for inflammation by using an ice pack of bags of frozen vegetables ideally several times a day (Olson 2003).

8. extra-corporeal shock wave treatment is a non-invasive and safe alternative to surgery in treating chronic plantar fasciitis when conservative modes do not work (Langerman 2004). The technology was approved by the Food and Drug Administration or FDA for the condition. Besides its efficacy, it enables the patient to return to normal activities the following day and the capacity of wearing comfortable shoes instead of a walker boot or cast shoes (Langerman).

A study conducted and published by the American Orthopaedic Foot...

The plan consisted of Achielles stretching, rest, wearing custom-cushioned orthoses, shoe change, taking of non-steroidal inflammatory drugs, hard orthoses, some injections, plantar strapping, ice or heat and night splinting and educating the patient about the etiology of his or her condition.
CASE STUDY female emergency physician at a level II trauma center, 32 years old, 5"2' and 125 pounds, presented a 10-year history of chronic plantar fasciitis (Langerman 2004). Her work requires standing or walking for most of her shift. She reported progressing pain since college when she worked as a medical assistant. The pain was consistent throughout medical school and her residency. She tried treating the condition with oral anti-inflammatory medicines, orthotics, stretching and massage. She bought multiple brands and different types of shoe gear, but without improvement. She then had to restrict activities, such as horseback riding, jogging and running. Her everyday pain level ranged from 7 to 10 in a scale of 1 to 10 with 10 as the most severe. Without relief from these conservative modalities, she opted for high energy ESW treatment for bilateral heels. She was given plain bupivacaine anesthesia before the administering of the ESW for each heel. Throughout the operative time, the patient's heel was maintained on the OssaTron head with good gel interface. After the procedure and on discharge, she was instructed to stretch, wear shoe gear and discontinue using anti-inflammatory and ice. During her postoperative visits every 10 days, the pain progressively decreased, so that at the sixth month, she did not experience pain in either heel. She continued to be pain-free more than a year following the procedure. She went back to full activity level of horseback riding, jogging, kickboxing and work, does not take pain medication or anti-inflammatory medicines and does not wear orthotics. This case study provides excellent example of the benefits of the ESW procedure in restoring activity and the quality of life (Langerman).

Pharmacological Management of Plantar Fasciitis

An adequate conservative therapy must be pursued for several months before considering medications or surgery (Barret and O'Malley 1999, Edwards 2003). The use of anti-inflammatory medications has been under a lot of controversy lately because there is no real inflammation in plantar fasciitis, but a kind of collagen degeneration. Non-steroidal anti-inflammatory drugs can only control pain and should be limited to 3 to 5 days.

A steroid injection as the option after at least 6-9 months, as the steroids cause atrophy (Edwards 2003). Steroid injections account for 10% of successful management of plantar fasciitis, with 80% from traditional therapy and surgery for the rest. Corticosteroid injections are reserved for those who want faster pain relief or faster return to training. Ionophoresis is costly and offers only brief pain relief. Local steroid injection can relieve pain in an extremely tender area and best given from the medial rather than the inferior aspect of the heel (Singh et al. 1997). It involves a series of minor withdrawals and reinsertions to infiltrate the entire reach of the inflamed fascia and avoiding the inferior surface so as not to cause fat pad atrophy. Steroidal injections may lead to osteomyelitis of the calcaneous or iatrogenic rupture of the plantar fascia. The use of steroidal injections are now advocated only occasionally for patients with refractory symptoms (Singh et al.)

Non-steroidal anti-inflammatory drugs to play a limited role and offered primarily for short-term pain relief (Shea and Fields 2002). They should be withdrawn as soon as the pain subsides.

Lithotripsy as a possible alternative to surgery for patients with chronic plantar fasciitis. Trials conducted produced good to excellent results in reducing pain in 70-75% of the enrolled patients. More than 70% of the patients who opted this mode were pain-free after 6 weeks but the pain resolution decreased significantly at 36.9 months (Shea and Fields2002).

Endoscopic plantar fasciotomy as a minimally invasive intervention, it is less traumatic than the traditional open heel-spur surgery and allows earlier weight-bearing after surgery (Barrett and O'Malley 1999). It has been considered a controversial technique but a recent study showed that it has a high 97% success

Surgery should be considered only for intractable pain that…