Treatments

Available Treatments for Plantar Fasciitis and Plantar

Fasciopathy (listed in alphabetical order):
ASTYM treatment:

Qualified, specially trained physical and occupational therapists

provide ASTYM treatment. ASTYM treatment is highly effective and was scientifically
developed to stimulate regeneration of the plantar fascia, tendons and other soft tissues. ASTYM
has its foundation in basic science research and is supported by clinical trials, case studies and
extensive outcomes collected from a large number of multiple treatment sites4-19. It is a noninvasive treatment (there are no needles involved, no surgery). Instruments are applied topically
(on top of the skin) to put light to moderate pressure on the underlying soft tissue and stimulate a
healing/regenerative response. On average, 88.7% of plantar fasciopathy patients resolve within
4-5 weeks, and ASTYM usually is covered by insurance. A directory of therapists who are
qualified to provide ASTYM treatment can be found at www.astym.com. Make sure to check
that directory to confirm your therapist is certified in the ASTYM rehabilitation process.
Certification is extremely important, otherwise you will not receive proper treatment.
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Autologous Blood Injections:

Podiatrists (DPMs) and Medical doctors (MDs) perform these injections. There is no certification
or special training required, however, there is some training available to doctors. Be sure to ask
about your doctors training and experience. For these injections, a doctor draws out some of
your own blood and then injects it back into you at the site of pain, in an attempt to cause a
physiological response that will ease pain and increase function. No controlled studies have been
published on these injections, and further study is needed to determine whether this approach
will be useful in the treatment of plantar fasciitis and plantar fasciopathy. Health insurance
companies generally consider this investigational and do not pay for these injections.
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Botulinum Toxin Injection:

These injections are performed by podiatrists (DPMs) and medical doctors (MDs). Botulinum
toxin is injected into the medial (inside) aspect of the heel close to the calcaneal tuberosity
(origin of the plantar fascia) or into the arch of the foot near the origin of the plantar fascia. The
purpose of the injection is to lessen the pain of plantar fasciitis. Botulinum toxin has been
regularly used to paralyze muscles with great success, so it would follow that botulinum toxin
could also paralyze or deaden sensory nerves and thereby relieve pain. However, there has been
no suggestion that botulinum toxin promotes actual healing of the plantar fascia. There has been
very little research conducted on this approach for plantar fasciitis. One well-designed pilot (very
small number of patients) study revealed that botulinum toxin resulted in short term
improvement in pain and overall foot function20. Since patients were not followed long term, we
do not know if they had lasting improvement. Further investigation with larger numbers is
needed before the role of this approach in the treatment of plantar fasciitis can be determined.
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Corticosteroid Injections:
Podiatrists (DPMs) and Medical doctors (MDs) may perform these injections. Corticosteroid
medication (an anti-inflammatory agent) is usually mixed with a local anesthetic agent and then
injected to reduce inflammation and ease pain. The use of corticosteroid injections (CSI) for
the treatment of plantar fasciitis is controversial. There can be side effects. Corticosteroid
injection into the superficial fat pad on the heel may cause fat pad necrosis (tissue death, loss of
tissue), which can lead to a painful, chronic (long-term) condition where you have little to no
padding on the bottom of your heel. To reduce this risk, injections should not be made directly
through the heel pad. Even if necrosis does not occur, an injection through the heel pad can be
quite painful. Usually the method of injection is on the inside (medial aspect) of your foot (not
the bottom) with the needle directed toward the area of maximal tenderness on the medial aspect
of the heel bone (calcaneus). After the proper approach is made, the injection should then avoid
the superficial layers of the subcutaneous tissue, because a corticosteroid injection into the
superficial fat pad can cause the fat necrosis that was mentioned previously.
In tendons, steroid injections may weaken a tendon, increasing the chance of a rupture or tear.
There have been a number of case reports of tendon rupture after corticosteroid injections21,22.
This may also be the case with the plantar fascia. Corticosteroid injections are associated with a
high rate of rupture of the plantar fascia23. If this happens, you could have great difficulty
walking for 6-8 weeks. The arch of your foot may collapse, leading to a flattening of your foot,
and how you walk (your gait) may be changed. This can lead to many other problems with
muscles and joints in that leg, and chronic disability in some people. On the other hand, some
people seem to have little to no ill effect from a rupture of the plantar fascia. Ultrasound
guidance may be used with corticosteroid injections to improve targeting and monitor soft tissue
changes, which may help minimize complications.24

Corticosteroid injections can reduce pain in the short term, but the benefits of this approach are
transient (short lived). Studies have consistently shown no long term benefits to this
approach25,26,27. Long term effectiveness for corticosteroid injections in the treatment of plantar
fasciitis has not been demonstrated, and in fact, poor long term results have been reported28.
Since the goal of these injections is to reduce inflammation, it is understandable why there may
be no long-term healing benefit to a degenerated plantar fascia. The true cause underlying most
chronic plantar fasciitis is degeneration, so addressing this problem with a treatment aimed at
stimulating regeneration would be more productive than trying to reduce inflammation that is
probably not present.
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Electrical Stimulation and Iontophoresis:

Usually, physical and occupational therapists provide

these treatments. Equipment is utilized to deliver electrical current into the plantar fascia. More
than one session is usually done. Sometimes a corticosteroid cream or patch, or other medication
is added and that medication is then pushed through the tissue with the electricity (this
combination is known as iontophoresis). There is little medical evidence that this approach
works for chronic plantar fasciitis. In a well designed study, investigators found that
iontophoresis had some benefit in pain relief for plantar fasciitis at two weeks, but at one month
there was no statistically significant benefit29. Further investigation and study is needed. Health
insurance carriers are becoming hesitant to pay for this treatment.
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Extracorporeal Shockwave Therapy (ESWT):

Podiatrists (DPMs) and medical doctors (MDs) may provide this treatment. Proponents of this
treatment also call it orthotripsy. ESWT is either classified high-energy or low-energy, based
upon the magnitude of the shock wave generated by the equipment. A doctor (for high-energy
application) or a doctors office assistant (for low-energy application) uses equipment to deliver
a series of acoustic shock waves directly over the plantar fascia. The high energy shockwaves
must be done under anesthesia or sedation, and therefore they are done in operating room
settings. They are also done with the assistance of imaging to make sure that the shock waves are

being delivered to the right area. The machines to perform high energy shockwaves are very
expensive, so the high energy shockwave therapy may not be available in all areas.
Even though this has been studied for over ten years, how ESWT may work is not clear. More
importantly, whether it works is not clear. The studies have conflicting results as to whether
ESWT is effective in treating plantar fasciitis. A recent review found that lower quality studies
seemed to favor ESWT in plantar fasciitis, but the high-quality, more reliable studies indicated
that ESWT may not be effective in the treatment of plantar fasciitis30. More study of this
approach is needed.
The application of ESWT can vary widely in the duration of the treatment, the intensity and
frequency of the shock waves, and the timing and number of treatments. These factors make it
hard to measure its overall effectiveness. ESWT can be very painful. The high energy waves are
usually more painful than the low energy waves, and that is why patients are required to be under
anesthesia or sedation in an operating room. The low energy waves can be delivered in an office,
but be aware that even low energy ESWT is usually quite uncomfortable and each session will
last approximately 15 minutes (multiple sessions are usually required). ESWT remains a
controversial treatment for plantar fasciitis and is rarely covered by health insurance.
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Ice:

Ice is often a front-line treatment right after intense activity to

help reduce inflammation and relieve pain that may occur in the plantar fascia from the activity.
Ice is well accepted and traditionally used for its analgesic, pain relieving effect and
inflammation reduction. However, in chronic, longer term cases of plantar fasciitis where
inflammation is not likely to be present, its effectiveness is questionable. Chronic cases of
plantar fasciitis are degenerative in nature and a treatment designed to stimulate healing and
regeneration would be more appropriate.
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Laser/Light Therapy:
This treatment is often delivered by chiropractors, physical therapists, and occupational
therapists. Laser or light energy is aimed over the plantar fascia, either through cold low level
laser therapy (LLLT) or through light emitting diodes (LED) or super luminous diodes (SLD).
The effectiveness of this approach for plantar fasciitis is not supported by the medical literature,

however, there is some evidence that it may have a positive effect on the healing of skin
ulcers/wounds. A randomized, controlled clinical trial studied low intensity laser treatment (30
mW continuous wave diode laser) in plantar fasciitis, and found that it was no more effective
than placebo30. This treatment is generally not covered by health insurance for the treatment of
plantar fasciitis.
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Massage and Friction Massage (both tooled and traditional):

Therapists often teach patients how to perform massage

on the plantar fascia at home. To perform this type of massage, use your thumbs or fingers
lengthwise along the plantar fascia. Friction massage is also something most people can do on
themselves. It is a deep massage that moves across muscles, tendons and other soft tissues, and
its purpose is to mechanically break down tissue. There is little to no medical evidence showing
that friction massage consistently works, however, there have been reports from individuals who
have had some positive benefit. The Cochrane Review, an official medical review evaluating
medical literature, concluded there was no benefit to friction massage over controls in the
treatment of tendinitis31. There are a variety of different tools that are used to do friction
massage. Some of the tools are: GSO, Intracell, Fuzion, Acuforce, Graston, Jacknobber,
Sastm, T-Bars, handles of reflex hammers and various kitchen utensils. Some tools promote a
type of friction massage approach called Instrument Assisted Cross-Fiber Massage or Instrument
Assisted Soft Tissue Mobilization, such as Graston and Sastm. The only published article on
Instrumented Cross-Friction Mobilization shows that it has minimal to no long-term benefit on
healing32.
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Needle/Percutaneous Fasciotomy:
Podiatrists (DPMs) and medical doctors (MDs) perform this procedure; it involves puncturing
the plantar fascia with a large bore (18 gauge) needle area multiple times (50-100 punctures
usually) per session. There is no standard protocol. Some place the punctures together or near
each other to make a larger hole, others make one puncture and move the needle back and forth
inside the plantar fascia, and others make a grid or fanning pattern of smaller holes. Local
anesthesia helps the patient tolerate the procedure and it is often done under the guidance of
ultrasound imaging. Usually, patients receive only one session. If the condition recurs or persists,

and good results were seen after the first procedure, then the patient could receive more sessions.
The local bleeding and trauma that is produced by the multiple punctures may cause a similar
physiological response to actually injecting a patients own blood around the affected area
(autologous blood injections). This may be how fenestration might help the plantar fascia to heal.
In addition to multiple punctures to the plantar fascia, the procedure can include mechanically
breaking up calcifications and abrading the adjacent bone. A small study on this treatment for
plantar fasciitis was not of high quality, and although it did produce a statistically significant
positive result for this approach, the results did not appear to be clinically relevant (have results
that would matter to patients in a real world situation)33. Preliminary research on this procedure
for chronic tendinopathy (which has similarities to chronic plantar fasciitis) indicates that this
procedure improves chronic tendinopathy in a notable number of patients34, 35. It is questionable
whether health insurance will pay for this procedure.
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Night Splints:
Night splints are used to keep the ankle in a neutral position during sleep, allowing for the calf
and the plantar fascia to be passively stretched during the overnight period. The goal is to allow
the plantar fascia to rest and hopefully heal while it is in the elongated position. The medical
evidence for this approach is minimal. Very little research has been done. There are some lower
quality studies that suggest this approach is helpful36-40, and the theory behind this approach
seems reasonable. However, a different study compared a group of patients with night splints,
NSAID medication and exercise to another group with no night splints and just NSAID
medication and exercise. It was found that the night splints had no beneficial effect41. The study
is limited by the fact that it was comparing multiple approaches, did not have a control group and
patients were only monitored for a short period. More quality research needs to be done.
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NSAIDs/Anti-inflammatory Drugs:

This medication comes in both prescription strength and overthe-counter versions. There does not seem to be any particular drug of choice for NSAIDs. Oral
NSAIDs (non-steroidal anti-inflammatory drugs), have been used to treat chronic plantar fasciitis
for decades. Recently, gels or patches with this medication in them have also been used. The
medical literature contains frequent references to the use of NSAIDs in the treatment of chronic
plantar fasciitis and other degenerative conditions such as common chronic tendinopathies,

however, there is surprisingly little quality evidence supporting this option42. The use of
these drugs in acute (sudden, short term) plantar fasciitis can be justified by the belief that
inflammation is present in short term cases, and a medication to reduce that inflammation is
appropriate. However, the use of anti-inflammatory medications in cases where inflammation is
not likely to be present (chronic cases usually having a duration of over 8 to 12 weeks) is more
controversial.
The research shows that although NSAIDs may provide short-term pain relief, there is little to no
evidence of a positive effect on long-term healing43. In fact, there is conflicting evidence in
animal models regarding the effect of NSAIDs, with a suggestion that NSAIDs may actually
inhibit healing44,45,46. The medical literature now consistently refers to chronic plantar
fasciitis/fasciopathy, plantar fasciosis and chronic tendinopathies as primarily degenerative in
nature, with little or no inflammation present, so it is easy to understand why a medication
designed to reduce inflammation has little to no effect on the underlying degenerative problem of
chronic plantar fasciitis/fasciopathy, and plantar fasciosis. Instead of trying to reduce
inflammation, the better goal would be to try and stimulate regeneration (and reverse the
degeneration, which is the real cause of the condition).
It is important for patients to know that long-term use of NSAIDs carries the risk of significant
side-effects, including increased risk of gastrointestinal bleeding, liver damage, renal failure, and
cardiovascular complications associated with this type of medicine43. Common names of some
NSAIDs include generic ibuprofen (and brands such as Advil and Motrin) and generic
naproxen sodium (brand name: Aleve) and prescription strength celecoxib (brand name:
Celebrex).
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Orthotics:
Arch supports are orthotics that support the arch of the foot and decrease excessive pronation
(rolling in of the foot while walking) in order to decrease stress on the plantar fascia and thereby
reduce symptoms. They are usually inserted into the shoe(s) of the patient. The arch supports can
either be custom made or casted to fit the patients foot exactly (this is the most costly option),
pre-fabricated (some fitting may be necessary, but pre-made to a good extent) or off-the-shelf
(available right away, and the least costly of the three). A long-term, well-designed,
comprehensive clinical study concluded that both custom and pre-fabricated orthotics had only
small short term benefit in function and perhaps pain, however, there was no long term benefit
(at 1 year). It also showed that pre-fabricated and custom orthotics were equally effective (one
was not better than the other)47.
Another form of orthotics is the simple heel pad or heel cup (a rubber or silicone heel pad that
contours to the heel). They are relatively inexpensive, and available at most drug stores or
surgical supply stores. Materials for the heel pads vary, but all try to absorb the shock on the heel
from activity. Heel pads can be made from silicone, rubber, felt, foam or gel. They are often used
as a front line treatment for plantar fasciitis, but there is little medical evidence to support their
use30. Studies have reviewed the force of the heel strike on patients who have plantar fasciitis in

one heel, but not in the other. The force of the heel strike is similar in both the plantar fasciitis
heel and the unaffected heel. So it is concluded that the force of the heel strike should not be
causing plantar fasciitis48. In another study, heel pads were not proven useful in the treatment of
plantar fasciitis, but heel pads did help patients with localized pain from contusions (injury).49
More quality study of orthotics is needed to determine their role in the treatment of plantar
fasciitis and plantar fasciopathy.
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Platelet Rich Plasma (PRP) Injections:

These injections are done by podiatrists (DPMs) and medical doctors (MDs). The doctor draws
blood from a patient and then places it into a machine that spins the blood down and produces a
layer of platelet rich plasma (PRP). The doctor then injects the patient with this derivative of
their own blood, in an attempt to cause a physiological response that will increase function and
ease pain.
There are different brands of machines which produce different platelet layer concentrations.
This approach is similar to autologous blood injections. The major difference is that the platelet
rich portion of the blood is separated and only the platelet rich plasma is injected. Some believe
this may cause less local inflammation, however, it does require more blood to initially be drawn
out of the patient.
If a good PRP injection is performed under imaging guidance (ultrasound), it may possibly be
effective on a small area of degeneration (about inch square) if it is followed by proper
rehabilitation. The growth factors in the PRP injection only spread out so far, and after the
growth factors are in the tissue, they degrade rapidly that is why its potential effectiveness, like
most injection techniques, is limited to a very small area. If the PRP injection is not guided by
imaging (ultrasound) to target the area of degeneration, then the injection can easily miss the
optimal injection site and its potential to be effective is lost. This treatment can require multiple
injections (if there is not an immediate response) and most of the time the patient must limit
activity and training for a period of time (2-4 weeks) after each injection. The course of the
treatment may easily take up to 6 months. PRP injections usually require the use of a large bore
(thick) needle.
Previously, very limited research had been done on this approach for treating chronic plantar
fasciitis and other degenerative conditions, such as chronic tendinopathy50. There was hope that
this approach would be proved effective through research, however, a well-designed study was
recently published in the Journal of the American Medical Association (JAMA) and it clearly
shows that PRP is no more effective than placebo (ineffective or sham treatment)51. Some former
proponents of this method are now questioning its application in chronic tendinopathies and
other degenerative conditions such as chronic plantar fasciitis. It is generally considered
experimental or investigational by health insurance carriers and is not covered under health
insurance. Most patients have to pay cash for this service.

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Prolotherapy (Sclerotherapy):
Podiatrists (DPMs) and medical doctors (MDs) perform these injections. An injection of an
irritating substance is made into the affected area and it is believed that the area then scars down
as a result of this injection. The injection may destroy the nerve fibers that are transmitting pain.
Originally, prolotherapy was used to scar down an area of instability in a joint. If a joint was
loose, the creation of scar tissue could help tighten it up by adding dense scar tissue to the joint
capsule. Some more adventurous doctors have now applied this approach to the treatment of
chronic plantar fasiitis, plantar fasciopathy and other degenerative conditions such as chronic
tendinopathies. How prolotherapy works (the mechanism of action) in the treatment of chronic
plantar fasciitis and other degenerative conditions such as chronic tendinopathies is unclear52.
Some initial studies have been done on this approach, but so far the research has mostly been
underpowered not well designed/controlled42, so there is no solid support in the medical
literature for this procedure in the treatment of chronic plantar fasciitis and other degenerative
conditions such as chronic tendinopathies. However, there are some individual stories with
perceived positive results that have been published in the popular media. Proper, well-designed
research would necessarily have to include injecting patients consistently with the same
substance. In current practice, different doctors often inject very different substances for this
procedure. Another concern with this procedure is that scarring down in one area of the body
may lead to increased stress on structures in other areas of the body, with the potential for
injuries or pain in areas other than the original site of pain. Prolotherapy is generally considered
investigational or experimental by health insurance carriers, and not covered under their policies.
Most patients have to pay cash for this service.
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Relative Rest/Immobilization:
Podiatrists (DPMs), medical doctors (MDs), and physical and occupational therapists often
recommend this kind of treatment. This is a common recommendation for patients with plantar
fasciitis and other soft tissue dysfunctions, such as tendinopathies. However, once resting is over,
and immobilization (not moving) is stopped, plantar fasciitis often returns. Resting the area
rarely leads to healing or resolution of the underlying problem of chronic plantar fasciitis (the
degeneration of the plantar fascia). However, it may be helpful where plantar fasciitis is acute
(sudden, short-term) and the underlying problem is only inflammation.
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Stretching:
Often patients with plantar fasciitis are given exercises to stretch the plantar fascia and Achilles
tendon. Stretching is a mainstay treatment for plantar fasciitis, however there is no unanimously
accepted standardized stretching protocol. Large, well-controlled studies are needed to determine

the best stretching program for plantar fasciitis and plantar fasciopathy. Recent medical evidence
does not give much guidance on effective stretching. One well-designed study showed calf
stretching to be ineffective for plantar fasciitis at two weeks. There was no data collected after
that period, so it is unknown whether stretching would have had some benefit if patients
continued to be monitored after two weeks53. Another study compared stretching of the Achilles
tendon to a plantar fascia specific stretching technique, and found that in the short term (8
weeks) the patients stretching their plantar fascia specifically fared better, however, over the long
term, neither stretching approach was superior54,55. Stretching may help guide the healing of the
body, and also may help align tissue properly. However, stretching alone rarely provides enough
stimulation to cause significant healing of chronic plantar fasciitis and other degenerative
conditions such as chronic tendinopathies. Stretching is one of the most common
recommendations in treating plantar fasciitis and also one of the most common recommendations
generally as part of rehabilitation and pain management programs, yet relatively little is known
about its effectiveness. Much of the research done to date on stretching the plantar fascia has
been underpowered or has had flaws in the design or execution. More quality study on stretching
is needed.
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Surgery:
These procedures are performed by podiatrists (DPMs) and medical doctors (MDs), usually
orthopedic surgeons specializing in foot and ankle. Surgery is usually only recommended as a
last resort and only to a small number of patients. Surgical procedures should be considered only
for patients with persistent, severe symptoms that do not respond to more conservative
treatments for at least 6 to 12 months.56 There is no high quality evidence from randomized,
controlled clinical trials to show the effectiveness of surgery. Since the outcome can be
unpredictable, the vast majority of patients opt for more conservative treatments and decline
surgery. It is also important to note that low patient satisfaction after surgery has been reported
(less than 50%), and it is possible for patients to have some continued functional limitations after
surgery57.
Isolated partial or complete release of the plantar fascia (fascial release), which can be
combined with the removal of a heel spur, removal of abnormal tissue, and nerve decompression
are surgical options. These procedures may be open (large incision) or endoscopic (small
instruments used through a tiny incision). Although the surgical procedure involving the
complete release (severing) of the plantar fascia (plantar fasciotomy) was done routinely years
ago, it has since fallen out of favor somewhat, due primarily to successful management of
chronic plantar fasciitis in other ways and the fact that a complete fasciotomy results in a
profoundly weakened arch and a certain degree of disability for most patients. Basically, the
complication can be that the arch of your foot collapses and for several weeks you could have
great difficulty walking. Following the arch collapse, how you walk (your gait) may be changed.
Without proper arch support, this can lead to many other problems with muscles and joints in
that leg, and chronic disability in some people. If surgery is necessary, it is recommended that a
partial release of less than 40% of the plantar fascia be done in order to minimize the effect on
arch instability and maintain normal foot biomechanics58. All surgery has risks. Those associated

with the surgery for plantar fasciitis/plantar fasciopathy include: infection, rupture of the plantar
fascia, transient swelling of the heel pad, calcaneal fracture, nerve injury (of the posterior tibial
nerve or its branches), and flattening of the longitudinal arch with resultant midtarsal pain.
A fairly new and uncommon type of surgery for plantar fasciitis/plantar fasciopathy is
radiofrequency microtenotomy. It can be minimally invasive. Basically, a hot microwave (which
is a high frequency radio wave) tip is inserted into the plantar fascia to burn the tissue and relieve
symptoms. How and why this approach would work is unclear. This approach does induce
sensory nerve fiber degeneration, and any pain that was being transmitted to the brain by these
fibers could be eliminated since those fibers are eliminated59. The concern with this method is
that the procedure may result in tissue that is not as strong or elastic as normal tissue,
predisposing patients to further injury in the treated area at a future time. Research and study is
needed on this method to determine its role in the treatment of plantar fasciitis and plantar
fasciopathy.
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Taping:
Applying athletic taping to support the bottom of the foot is frequently used in the treatment of
plantar fasciitis. The purpose of the taping is to distribute forces away from the plantar fascia and
decrease the stress that activity or weight may put on it. In a recent systematic review of
controlled trials on taping, it was found that although there was some limited evidence that
taping could reduce pain in the short term, no results could be drawn on whether taping could
affect the disability (function) of a patient with plantar fasciitis60. Where low-dye taping (a
technique designed to support the foot and limit pronation) was studied, it helped patients with
the pain of the first step in standing or getting out of bed61, but not much other benefit was
noted. A few patients complained of the taping being too tight or having an allergic reaction to
the tape, so be aware of these possible temporary drawbacks A small study reviewed calcaneal
taping (tape specifically encompassing the heel only) for just a week and found there was some
benefit in pain during that short period62. No reliable, long term studies on this method could be
found, so additional research is needed to determine whether taping is an effective way to treat
plantar fasciitis.
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Ultrasound and Phonophoresis:

These procedures are provided most often by physical and occupational therapists. They use
ultrasound equipment to deliver high frequency sound waves into the affected area, which heats
the targeted tissue. Multiple sessions are usually done. A corticosteroid cream or other
medication can be applied to the skin over the affected area and then ultrasound waves can be
used to push the medication through the tissue (this combination is known as phonophoresis). A
study comparing therapeutic ultrasound to sham ultrasound was conducted, and it was found that
therapeutic ultrasound was no more effective than placebo (the sham ultrasound)63. This study

did not have an ideal design, so further research should be done in this area before we can draw a
firm conclusion. Sometimes ultrasound is covered by insurance, but now certain health insurance
companies are beginning to deny payment for this form of treatment.

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A Patients Guide to Heel Pain

A Patients Guide to Heel Pain

What You Need To Know

By:
Michael Zapf, D.P.M.

Diplomate, American Board of Podiatric Surgery

Diplomate, American Board of Podiatric Orthopedics
Fellow, American College of Foot and Ankle Surgery
Fellow, American College of Foot and Ankle Orthopedics
Selected Best Podiatrist by Two Daily News Readers Poll
Former Assistant Professor, CA College of Podiatric Medicine
Past Assistant Clinical Faculty, L.A. County / U.S.C. Medical Center
Revised 6-1-2011

What are the symptoms of heel pain?

The typical symptoms of heel pain are pain on the inside of the heel when you stand or walk
after periods of rest or inactivity; especially pain with the first step in the morning. The pain
lessens after walking for a while. Typically in the afternoon the heel hurts whether you rest or
walk on it. The pain can vary from mild to debilitating and can last from a few weeks to many
years. The pain can be centered just under the heel or it can extend across the arch of the foot.
The pain can appear to be cured, at times, only to return months or years later. You may have
noted that shoes with a bit of an elevated heel or walking with your feet turned inward helps to
relieve the pain. Plantar fasciitis is uncommon, but not unheard of, in anyone younger than 30.
What is going on here?

To understand heel pain you first need a quick

lesson in anatomy. There is a thick band or belt of tissue that extends from your toes to your heel
and is just under the skin. The band is called the plantar fascia or PF. At the front of the foot it
attaches to all five toes and at back it attaches to the heel bone, the calcaneus, with a 1 inch wide
attachment. The purpose of the plantar fascia is to provide stability to the foot when you lift your
heel for walking, running and climbing. It is possible to do more of these activities then your
plantar fascia can handle in any given time period in pain results. So the first and simplest cause
of heel pain is overuse were the plantar fascia hurts at its weakest point, the attachment site on
the heel bone. We can easily see this visually in the office with the diagnostic ultrasound
machine which allows us to measure the thickness of the plantar fascia at the heel attachment
site. A normal plantar fascia is 3-4 mm thick and the thickness of a painful plantar fascia is
typically six or more millimeters thick.
If the overuse and over-pull of the plantar fascia goes on for a long period of time, some say 18
months or more, a spur can develop on the heel bone which you can visualize with an x-ray.
Most authorities believe that the heel spur is not the cause of heel pain. People can have a huge
heel spur with no pain while others can have tremendous pain without a heel spur. I believe that
the heel spur is a marker to indicate that the process has been going on for almost 2 years or
more. These people will probably require more treatment than just a cortisone injection.
Fasciitis vs. Fasciosis
The terms fasciitis and fasciosis look suspiciously similar but they refer to very different things.
The -itis ending of fasciitis gives a clue to its meaning: inflammation. During the early stages
of this condition where the over-pull or overuse of the plantar fascia is in its beginning stages the
condition is inflammatory. Anti-inflammatory pills and cortisone injections are very useful in this
stage. As time passes the condition morphs into a chronic pain phase where we refer to it as
fasciosis. Anti-inflammatory pills and cortisone injections are not effective during the fasciosis
phase. If you have had a cortisone injection for your plantar fasciitis that only lasted for a few
days you are probably in the fasciosis stage.

What causes the spur?

The cause of the spur has been an intriguing

question that does not have a clear answer. The best explanation I have heard is that the spur
forms as a reaction to an accumulation of micro-fractures to the heel bone. These micro fractures,
like all fractures, heal by having the tissue covering the bone, the periosteum, produce more bone
which will, in effect, glue the bones together. With chronic plantar fasciitis, or fasciosis, there are
tens of thousands or hundreds of thousands of little fascial tugs on the heel bone that produce
tens of thousands or hundreds of thousands of microscopic heel bone fractures. The extra bone
produced to heal the microscopic heel bone fractures is visualized as the spur. Although it may
feel like it, the spur does not point downward towards the ground
When do you suspect that there might be a stress fracture?
Long standing over-pull and overuse of the plantar fascia can also lead to a stress fracture of the
heel bone. This is not common but it can occur. I am suspicious of a stress fracture if squeezing
the heel bone between the palms of my hand produces pain on the affected side but not the
unaffected side. Regular x-rays taken in the office can give a clue that you might have a stress
fracture. Confirmatory tests for a stress fracture often need a bone scan or an MRI both of which
are done at a radiology center.
Bone scans are very useful tools. A radioactive dye is injected in the arm and an x-ray scan is
taken of the heel bone three hours later. A hot scan which shows a lot of activity in the heel
bone is diagnostic for a stress fracture. An example of a hot scan is attached the right heel has a
very hot spot indicating that something is going wrong. It could either be cancer, an infection or

a heel stress fracture, depending on the symptoms of the patient. In this case, it was a heel stress

fracture.
As useful as bone scans are, they are being replaced with MRIs as the cost of the MRIs have
decreased. MRIs can also get useful information about the plantar fascia and the surrounding
tendons that you cannot get with a bone scan. I cannot remember the last time I ordered a bone
scan to evaluate the possibility of a stress fracture in the heel. If the MRI shows you have a stress
fracture expect to be in a walking cast for 3-6 weeks to allow the foot to heal.
Quick summary so far
1)

Plantar fasciitis produces pain with the first step after resting

2)

The most common cause of pain is inflammation of the fascia at the heel insertion

3)
Long standing plantar fasciitis leads to a non-inflammatory chronic pain we call plantar
fasciosis
4)

Untreated plantar fasciitis/fasciosis can lead to a stress fracture of the heel

5) The heel spur that forms is not the cause of pain but is a marker that the process has been
going on for 18 months or more
Factors that Contribute to Plantar Fasciitis/Fasciosis/Stress Fracture
Here is a non-exhaustive list of the factors that can lead to plantar fasciitis which leads to plantar
fasciosis and calcaneal stress fractures:
1. activity level
2. weight
3. pronation or flattening of the foot
4. floor surface

5. shoe type
6. foot type and ligamentous laxity

What is pronation and what does it have to do with my foot pain?

Our feet are the product of a Master Designer. They have to do two very opposite things every
walking step we take. First the foot hits the ground and pronates. In pronation the foot collapses
and becomes very flexible. This flexibility allows the foot to adapt to changes in terrain. As the
opposite foot swings by the planted foot the foot begins to supinate into a foot rigid enough to
support push-off. A supinated foot is very stable and not prone to plantar fasciitis. A pronated
foot elongates and allows for a potentially painful stretch of the plantar fascia. Some pronation
and supination is normal in every walking step. Pronation beyond the normal amount is one of
the most common causes of over-stretching of the plantar fascia and, thus, pronation.
What role does my weight have on heel pain? Pregnancy?
Any force causing the foot to elongate, or flatten, can contribute to the pain of plantar fasciitis.
This includes weight, which is implicated in as many as 70% of the cases of heel pain. Excess
weight also seems to be the one common thread connecting those few people who end up having
heel pain surgery. While difficult or impossible for many people to achieve, weight loss can help
their foot pain considerably.
Plantar fasciitis is common in pregnancy because of weight gain and the presence of the
hormone Relaxin. Relaxin is produced in the latter stages of pregnancy to allow the pelvic
ligaments to stretch. There is a ligament in the foot that also responds to this hormone and causes
the foot to stretch putting strain on the plantar fascia. Usually pregnancy related plantar fasciitis
goes away after birth, but not always.
Activity Level
Being an overuse injury, plantar fasciitis is aggravated by increased activity that causes the
plantar fascia to repeatedly pull on the heel bone. The worst activity I can think of to aggravate a
plantar fascia is one where the foot is repeatedly struck on the ground with a great ballistic force
running on an inclined treadmill. The best activity I can think of would be swimming. Here is a
list of activities in decreasing order of their impact on plantar fasciitis:
Running on an inclined treadmill
Running on a flat treadmill

Stairmaster
Walking
Elliptical machine
Health writer
Rowing machine
Swimming

There may come a time when you need to increase your activity levels to master your plantar
fasciitis but I do not like to start there. I refer to keep you performing your favorite athletic and
fitness endeavors if at all possible. Certainly, if you have a stress fracture and need to wear a
walking cast, something has to give.

Floor Surface
This may at first seem like an unlikely candidate for modification by hard floor surfaces are
certainly worse on the feet been something softer. Running on a track, for instance, is easier on
your heels and running on the blacktop which, in turn, is easier than running on concrete
sidewalks. At home if you spend a lot of time standing at a workbench or a kitchen counter you
might want to add a soft floor mat for that purpose. Similarly, a cashier may also want to add a
soft floor mat or, if possible, a stool on which to sit.

Shoe Type Elevate That Heel

It is a simple anatomical fact that the plantar fascia relaxes as the heel is raised. We can use this
fact to modify the stresses of daily activity by, if it is possible, raising the heel height of the shoes
you wear. For women, it is easy to find work shoes, dress shoes and casual shoes with a bit of a
heel. Doing this for men is more difficult unless youre fond of Western boots. Conversely,
walking in bare feet, socks only or shoes with no heel at all can aggravate pain of plantar
fasciitis. If you need to wear shoes without a bit of a heel, consider purchasing and using some
heel lifts that fit in the shoes under your heels. Sorbothane is a good brand of heel lift, if you can
find them. Look for them at sporting goods stores. A warning here, heel cups are not the same

thing as a heel lift. Heel cups are usually not thick enough to act as heel elevators. They may be
helpful for attenuating the impact force of the heel on the ground but they are not very effective
at raising the heel.

Foot Type and Ligament Flexibility

People who have flat feet put a lot more stress on their plantar fascia that people with a high
arched foot and consequently have more plantar fasciitis. Nominally there is nothing you can do
about her foot flatness type or your foot ligament flexibility. A flexible flat foot, however, usually
responds very well to functional orthotics, a topic which we will discuss later.

Self-help for Plantar Fasciitis

There were several things you can do on your own before seeking professional help. Start by
wearing well-made shoes that have a bit of a heel. Try making your floor surface a little softer.
Over-the-counter arch supports may help, a good brand here is Superfeet which can be found at
most athletic shoe stores and sporting goods stores. Stretch your foot ligaments before you
exercise or work and apply an ice pack to your heel when hurts and after activities. In the
morning for you get out of bed beside her heel on a tennis ball or a bottle.

Who should you go to for your heel pain?

It is probably no surprise that I think that heel pain patients should see a podiatrist. Podiatrists
know the biomechanics of heel pain and how to treat it with taping and orthotics. We have the
medical ability to take and interpret x-rays and diagnostic ultrasound and to administer oral antiinflammatory medication and cortisone injections. We have the surgical ability to treat the
plantar fascia with noninvasive means like shockwave therapy, minimally invasive procedures
like radiofrequency ablation and fully invasive procedures which include either minimal incision
or endoscopic plantar fasciotomy. Although we are trained as surgeons very few cases of plantar
fascia and out in the surgery suite: maybe one in 50.

What else could it be?

There are several medical conditions that could mimic plantar fasciitis. No matter whom you end
up seeing for plantar fasciitis, he or she should be able to distinguish it from tarsal tunnel
syndrome, medial calcaneal nerve syndrome, calcaneal bone infection, calcaneal cysts or tumors,
Reiters syndrome, infracalcaneal bursitis and posterior tibial tendinitis, among other conditions.
Again, I think that podiatrists are in the best position to evaluate this list of possible other causes
of your heel pain.

What to expect at your first visit

A typical heel pain visit starts with a complete lower extremity history and physical examination.
The examination should include blood flow and neurological tests as well as it dermatological
and biomechanical examination. Ranges of motion of the lower extremity joints and muscle
strength should both be part of the examination. Usually to radiographs of each foot are taken at
this visit and, in our office at least, the plantar fascia is visualized and its thickness measured
with a diagnostic ultrasound machine.

Next your doctor should discuss the possible causes of your heel pain which, in medical speak, is
called the differential diagnosis. Each diagnosis has some reasons for its inclusion and there are
usually tests you can do to evaluate or eliminate each possible cause.

Low-Dye strapping
In our office we will usually place a low-Dye strapping on your foot. If you notice, the word

Dye is capitalized
because its named after a
podiatrist, Dr. Dye, who first described it in the literature. He had a high strapping which was
used for ankle sprains and a low strapping which is used for plantar fasciitis. This taping

method is, sometimes, magical. There have been many cases where people have had heel pain
for many months and have seen more than one doctor and did not have any relief from the heel
pain until the moment the low-Dye strapping was placed on their foot. A positive response to the
low-Dye strapping usually indicates that a biomechanical approach (i.e. orthotics) will probably
work. Since the strapping is used to predict the effectiveness of biomechanical therapy, doing a
cortisone injection at the first visit when the taping is applied is not advised. With both taping
and a cortisone injection at the first visit, the variables are confounded and we do not know
which one actually worked. Even if I plan to use a cortisone injection as an early therapy I will
have the patient come back a day or two after the strapping so I can know if the strapping
actually worked.

Diagnostic Ultrasound What is Your Number?

Both our Agoura Hills and Thousand Oaks office have diagnostic ultrasound machines. These are

the same ultrasound

machines that ob/gyns use to
look at babies in the womb. We use them to measure the thickness of the plantar fascia word
inserts on the heel bone, the calcaneus. Ultrasound images appear upside down that asked shaped
structure going across from left to right on the ultrasound image is the bottom of the heel bone. If
you look carefully on the account being photographed see two lines moving from left to right on
the bottom of the heel bone. Those two lines are the margins of the plantar fascia. The dotted line
you see towards the left in the photograph is actually the measurement of the thickness of the
plantar fascia. In this case the plantar fascia is measuring 2.3 mm in thickness. It has been my
experience that you can determine the severity of the plantar fasciitis and make some predictions
about the eventual treatment of plantar fasciitis by looking and measuring at the plantar fascia
with the ultrasound. Here are my general guidelines regarding plantar fascia thickness is
determined by the ultrasound:

Thickness
Less than 4mm thick

Meaning
Normal thickness

4-6 mm thick

Moderately thick-mild or early case

6-9mm thick

Significantly thick chronic case

Over 9 mm thick

Severe long standing and probably resistant case

Other facts can be determined with the ultrasound image. Often times an area where the plantar
fascia has been injured shows up as a large dark circle in the plantar fascia. Infracalcaneal
bursitis can also be seen with this modality. If you are looking for a doctor to diagnose and treat
your plantar fasciitis, you might want to ask if he or she has a diagnostic ultrasound machine on
the premises.

X-rays is there a spur?

X-rays are almost routinely taken during your first visit for plantar fasciitis but, in reality, theyre
not as useful as the

ultrasound image. Yes, you may have a heel spur

but, as I stated above, the heel spur is not responsible for the pain. The heel spur is just a marker
that you have had the plantar fascia pulling hard on the heel bone for a long time. With the
radiograph we can look and see if you have evidence of a stress fracture or a cyst in the bone.
Stress fractures are actually difficult to see with an x-ray and cysts in the heel bone are
exceedingly rare. When we take heel pain x-rays we usually limit ourselves to just two views.
Three views, to me, seem like overkill.

Mechanical vs. Medical Treatment

Plantar fasciitis can be successfully treated with both medical and chemical methods and a
combination of both. Let me explain.

Mechanical:
Since plantar fasciitis is an overuse injury of the plantar fascia on the heel bone, we can
successfully treat it, in most cases, by lessening the pull of the fascia on heel bone. Proof of this,
as I stated above, can be ascertained by the response to a low-Dye strapping. Simply stated, if the
taping worked, so will orthotics (in most cases). If the strapping was wildly successful at the first
visit we will then make a cast impression of the foot at the second visit to make orthotics. Since
it will take 2-3 weeks to get orthotics back we will frequently retake the patient once or twice a
week until the orthotics, come in. It can be as simple as that.

Another mechanical method is the stretching of both

the plantar fascia and the Achilles tendon. Simple wall stretching can be done by the patient two
or three times a day. In the illustration the right leg is being stretched. The right knee is locked
straight in a heel remains legally on the ground. The left leg, in this case, should the flexed green
they have down towards the junction of the wall with the floor. This will cause a dramatic
burning pull at the upper calf.

A second strategy involves stretching the plantar fascia, itself.

In the accompanying illustration a towel is placed around the forefoot and pulled back towards
the body while keeping the knee locked. Both of these stretches need to be held for 20 seconds at
a time with no bouncing.
More aggressive stretching can be accomplished using a night splints stretches both the Achilles
tendon in the plantar fascia for three or more hours at a time, sometimes all night long.
Ice therapy can reduce the inflammation or two or three hours at a time. I find that the easiest

method to apply ice to

the heel is to feel a 20 ounce plastic Coke bottle
with water and freeze it in the freezer without the cap. Remove the bottle and put the cap back on
and roll the midfoot and heel over the depression at the bottom of the Coke bottle. Roll the heel
on bottle for 10 min. at a time three times a day. More often is never wrong. You could get in
trouble if you apply unclothed skin to ice without motion. The Coke bottle works very well
because you roll your heel back and forth on the bottle and never keep the ice in one spot for
very long.

Physical therapy:
Physical therapy can often do wonders to control the pain of plantar fasciitis. They will use
national level of stretching and taping techniques as well as ultrasound treatments and electrical
stimulation to bring the pain under control. They have a technique called electrophoresis and
phonophoresis where cortisone preparations are painlessly push through the skin using either
gentle electric current or the wand of an ultrasound machine. If you visit either of our physical

therapist, Amy or Beth, be prepared to go home with a list of exercises and activities to do on
your own to control plantar fascial pain.

Medical:
Pills: The early stages of plantar fasciitis are inflammatory conditions. As such, antiinflammatory agents can often make life much more bearable. Oral agents like Motrin, Celebrex,
Naprosyn and Voltarin can stop the inflammatory process in its tracks. While over-the-counter
Motrin can achieve anti-inflammation levels of medication you need to take 2400mg 3200 mg
per day to do that. At 200mg per tablet that is a whopping 12 to 16 tablets a day in divided doses
and taken with meals. Few people feel comfortable taking that many tablets so I write for other
medications that need to be taken as infrequently as once or twice a day.

Injections: injections of cortisone mixed with a local anesthetic can often be the Holy Grail of
heel pain treatment. I cannot tell you the number of patients who have been permanently and
forever cured of their heel pain with a single cortisone injection. This fact combined with the
near absence of any injection complications makes it the singular best treatment you can have for
plantar fasciitis. I have developed a technique to place the cortisone injection needle in a little
pocket between the plantar fascia and the heel bone that, many times, causes no pain whatsoever.
Many is the time that patient has asked me after the heel cortisone injection Doc, have you done
it? So, if you come to me for a heel spur injection, expect not to even feel it, especially if its
your left foot. Honestly, Im better at the left feet.

Orthotics

As I stated above, if you had a positive response to the low dye strapping you will probably have

a positive response to
functional orthotics. The
orthotics that podiatrist make our oftentimes much better than the ones made by physical
therapists or chiropractors. It is a little frustrating to have a patient who has an ineffective pair of
orthotics from another practitioner say to us that they already have orthotics when we can see
from the inserts in their shoes they are nothing like the kinds we make. So let me repeat to be
perfectly clear, even if you have so-called orthotics from other practitioners, if our low dye
strapping make sure foot stop hurting so will our functional orthotics in most cases. This is
providing, of course, that youre able to wear the kinds of shoes in which and orthotic is
appropriate. Orthotics cannot be worn in most sandals or flip-flops. They also cannot be worn in
most high heels but, as I mentioned above, the mere fact of elevating the heel will probably make
your heel stop hurting.
To make orthotics in our office we will take either a fiberglass or a plaster mold of your foot held
in what we call the neutral position and, and this is important, in a non-weight bearing
position. Orthotics made from an outline of your foot or from stepping into foam are not usually
considered legitimate orthotics. Once we have your non-weight bearing impression we will send
them off to the laboratory along with an order form for one of any number of these signs or
styles of orthotic that will hold your foot in this neutral position as you go about your daily
activities. Again, I cannot tell you the number of patients who have been, in essence, cured of
their plantar fasciitis by wearing a well-made and proper fitting functional orthotics.

Do they really work? Ask David P who said, I had heel pain for a long time and the tape
helped right away and gave immediate relief. I got orthotics and broke them in gradually; they
worked perfect. I could wear them full-time after four or five days. My arch feels good and I am
not having any [heel] pain. I am happy with them.

Or ask Carol S: Case of Carol S.: Carol was a 52-year-old woman, 5-5 and 170 pounds. She
worked as a librarian and could wear a variety of shoes to work. Her left heel hurt her for three
years before she limped into my office. Prior to her visit with me she received a course of Lodine
from her internist and a course of Voltaren from an orthopedic surgeon. In addition the
orthopedist gave her a heel cup and three times injected her with cortisone. She continued to
have heel pain, especially the first step in the morning. She tried two kinds of arch supports,
changing shoes and chondroitin + glucosamine complex from her chiropractor. She saw me on
referral from a fellow librarian. An x-ray of her foot revealed a 3-4 mm long heel spur but no
other pathology. When I rubbed her foot I could reproduce the pain by touching the spot where
the plantar fascia attaches to the foot on the inside of her heel. I made a diagnosis of plantar
fasciitis and made my usual recommendations to avoid flat shoes, bare feet, sandals, slippers
and socks without shoes. I told her to ice her heels three times a day and then I applied a lowDye strapping to the left foot. She felt more immediate relief of pain then she did with her
cortisone injections. I retaped her twice a week for three weeks. During this time I made a
plaster impression of her feet and made a pair of functional orthotics. Wearing the orthotics kept
her virtually pain free from that day to now

Insurance coverage for orthotics

Functional orthotics works so well that it is a shame that Medicare, and some private insurance
plans do not cover them. If you want to know if your insurance plan covers functional orthotics
we ask that you call them. The phone number should be on the back of your insurance card. Ask
them specifically if they cover functional orthotics and give them the code number L3000 which
is the medical code number for functional orthotics. Be sure you write down carefully what they
say and who you talk to. Also ask if they need any preauthorization prior to paying for functional
orthotics. If orthotics are not covered by your insurance, we have a reasonable cash fee.
For more information about orthotics, including the insurance coverage aspect, please call our
office and ask for a copy of our Orthotic Brochure.

Why do you keep referring to your orthotics as FUNCTIONAL?

From the podiatric point of view orthotics are either functional or accommodative.
Accommodative orthotics, often called soft orthotics, are designed just to pad your foot and give
it a cushier landing. Arch supports, spine levelers and just about anything made of leather or
rubber fit into this category. A functional orthotic changes the way your foot functions. It will
hold your foot in a pre-designed position. A functional orthotic is made from a plaster or

computer impression of your foot, not just measuring the size or having you step into a foam
box. Originally accommodative orthotics were made of leather and were designed for patients
who needed a more cushioned insole in their shoes. Insurance companies that do cover orthotics
require that they be functional to be eligible for coverage.
Who Needs Surgery?
The overwhelming number of cases of plantar fasciitis are brought under control with
nonsurgical means. For my patients I recommend surgery only if ALL of the following are true:

1)

The pain has been present for six months

2)

Two or three cortisone injections have been tried

3)

Orthotics have been tried

4)

Physical therapy or a night split have been tried

In our office we offer three types of surgery for resistant plantar fasciitis: 1) shockwave therapy
2) radiofrequency ablation and 3) plantar fasciotomy or cutting the plantar fascia.

Shockwave therapy ESWT.

Sound waves contain energy as anybody who has had their windows rattled by a sonic boom can
testify. Shockwave therapy machines gather a very loud shock explosion and concentrated on
one tiny little point about 2 inches from the head of the machine. For almost 30 years
shockwaves have been used to break apart kidney stones without the need for surgery. For 15
years these little waves have been directed at the insertion site of the plantar fascia on the heel.
Unlike what you might expect, attacking a heel spur with sound waves does not break them up.
The disappointment at the lack of destruction of the heel spur is offset by the fact this machine
has chronic, long-standing plantar fasciitis. The treatment takes about 25 min. and its usually
done under local anesthesia. After this treatment fully one third of the shockwave patients no
longer have any heel pain at all, one third have enough of a reduction that traditional surgery is
not needed and one third do not receive much help at all. Surprisingly, there are no known
complications from this surgical procedure. Either it helps or it doesnt but nobody has been
made worse. We are one of the only offices in the Southern California area to have a high-energy

shockwave therapy machine in our office. We use it for many of the resistant heel cases and it is
very effective. The only real complication is financial: many insurances refuse to pay for
shockwave therapy. For those of you for whom shockwave therapy is not a covered service we
have a very reasonable cash fee structure of $1000 or 1 foot and $1500 if we do both feet. We
have another section of our website entirely devoted to shockwave therapy and we ask that you
refer to it. http://conejofeet.com/shockwave-therapy

A final note on shockwave therapy, do not confuse the high-energy shockwave therapy that we
can offer in our office with the low energy shockwave machines that are found in many other
podiatry offices and, especially the entire package and physical therapy offices. High-energy
shockwave needs some kind of anesthesia, in most cases. Low energy does not. All of the results
we are talking about are based upon high-energy shockwave not low energy. You can suspect that
your Dr. is dealing with low energy shockwave if he or she offers you a series of four or six
treatments for a fixed fee like $400 or $600. High-energy shockwave therapy is, unfortunately,
more expensive than this.

RFA- Radiofrequency ablation.

There is a new method of performing surgery for plantar fasciitis. This new method was
discussed in the June 2011 issue of the Journal of Foot and Ankle Surgery, which is the official
publication of the American College of Foot and Ankle Surgeons. The article was written by
doctors Hormozi, Lee and Hong who are all residents in the Los Angeles area, one at Tarzana
Medical Center any other to add Kaiser Permanente Medical Centers. The method uses
radiofrequency ablation. In this method a small needlelike probe is placed through the skin into
the plantar fascia at 24 locations in the heel. With each placement of the needle a small electric
charge is generated at the tip of the needle which causes a little spark or shock. The 24 total
sparks or shocks create a little scarring in the plantar fascia which can result in healing. This is a
very exciting alternative for plantar fascia surgery. In our office Dr. Benson and I have use this
technique for Achilles tendonitis and it would take only a small modification in the technique to
do it for plantar fasciitis. The authors conclude that this technique is an effective and minimally
invasive and save surgical option for the treatment of recalcitrant plantar fasciitis and fasciosis in
adults. Under anesthesia there are 24 spots where the electrode needle is placed into the skin.
This is, of course, done with significant local anesthesia of the area. For the squeamish we could
even do this at the surgery center under a little sedation.

Plantar Fasciotomy
The most direct and the oldest method for doing surgery on plantar fasciitis is to cut the plantar
fascia. 25 years ago, during my residency, the technique involved making a 2-3 inch incision on
the medial aspect of the heel and dissecting down to the plantar fascia which was cut the very
large and thick scissors. Since the foot was so open and we would always saw the heel spur at the
same time. The theory here he was that if a patient did not receive relief from the surgery and
saw a heel spur on the x-ray they would point to it and say that is why they still had pain. In
reality the heel spur does not need to be removed as I have discussed previously. For this reason
there are two lesser dramatic plantar fascial surgery procedures: the minimal incision one that I
do and the endoscopic one performed by Dr. Benson and Dr. Payne of my office.

Minimal incisional plantar fasciotomy

The technique that I use involves cutting one third of the plantar fascia to a small, 1/4 inch,
incision on the bottom of the heel. This can be performed either in the office or at the surgery
Center under local anesthesia with or without a little sedation. The incision takes just one little
suture stitches to close and the patient can return to regular shoes in three or four days. This has a
remarkable success rate in my hands. One of the feared complications of performing a plantar
fasciotomy is the possibility of transferring pain to the outside of the foot-the middle of the foot
behind the baby toe. I have performed more than 50 of these little surgeries and nobody has ever
complained of this outside of the foot pain although it is always a risk and always acknowledged
on the consent form.

Does plantar fasciotomy really work? Well ask Diane S. from Camarillo wrote to me and said: I
cannot believe how [good] my right foot feels now. After my fall I started to feel the terrible pain
in my right heel. This fall was in 1996 and Ive had to live with this every day until Dr. Zapf
operated on it within an office plantar fasciotomy in October 2000. I can now walk without pain
in my right foot. This operation consisted of a small incision to the right heel area and I was able
to walk within days. I would recommend Dr. Zapf to anyone who needs this kind of foot surgery.
I cannot believe it! Its so great now.

Endoscopic plantar fasciotomy

I feel comparable cutting the plantar fascia through a small incision on the foot. I admit that the
cut is blind and then I do it by touch and not by sight. I have seen enough plantar fascia

surgeries in my career that I am comparable feeling where it is and cutting it blindly. I

understand that this does not make most foot surgeons comfortable. Dr. Payne and Dr. Benson
prefer cutting the plantar fascia only when they can visualize it. They do this surgery using an
endoscope which is a small straw like to which is placed into the heel with a small incision on
the inside of the heel. A small, very tiny, camera is placed into the wound and they can actually
visualize the plantar fascia as they cut it. This is very elegant. Because this is done at the surgery
center under local anesthesia it cannot be done in the office.

Who should do the surgery?

There are only two categories of doctors who commonly and routinely perform plantar
fasciotomy and heel spur surgeries: podiatrist and orthopedic surgeons. In your area you should
use the professional who does the most plantar fascial surgeries and has the most experience.
While that could be an orthopedic surgeon in most areas very few orthopedic surgeries do very
many foot surgeries. If you are bidding surgeon says he or she does a lot of heel surgeries then
you are probably in good hands. More than likely, however, you will be getting surgery from a
local podiatrist. And if you do choose the podiatrist, I recommend that you pick one that is Board
Certified by the American Board of Podiatric Surgery. You can usually identify these surgeons
because they are also Fellows of the American College of Foot and Ankle Surgeons which means
they have the initials FACFAS after their name. In our office all three doctors are Fellows of the
American College of Foot and Ankle Surgeons

Thank you for reading this far. If you have questions that I could answer, feel free to leave them
on http://conejofeet.com

Michael Zapf, DPM

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May 31, 2011

Michael Zapf

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