What is the best treatment for plantar fasciitis?

Journal of Family Practice, Sept, 2003 by Teresa S. Stadler, E. Diane Johnson

* EVIDENCE-BASED ANSWER

Mechanical therapies--such as taping, tension night splinting, and rigid arch support--are the most effective treatment for plantar fasciitis (strength of recommendation: A, based on randomized controlled trials). If limited or no improvement is observed after 6 months of mechanical therapy, extracorporeal shock wave therapy (Orthotripsy) is the next treatment of choice (strength of recommendation [SOR]: A, based on meta-analysis of randomized controlled trials). When mechanical therapies and extracorporeal shock wave therapy have failed for more than 1 year, surgical treatment may be considered (SOR: C, based on a case-series study).

* EVIDENCE SUMMARY

In a prospective, observer-blinded study, 103 subjects were randomized to 1 of 3 treatment categories: anti-inflammatory (etodolac plus corticosteroid injections); accommodative (viscoelastic heel cup); or mechanical (low-dye tapping for 1 month followed by rigid custom orthosis for 2 months). (1) After 3 months of treatment, 70% of patients in the mechanical treatment group rated their functional outcome as excellent, compared with only 33% of the anti-inflammatory group and 30% of the accommodative group (P=.005). Additionally, the mechanically treated group was less likely to terminate treatment early because of treatment failure (P<.001).

Several of the same researchers then went a step further to find out which specific mechanical treatment is best. They found no statistically significant difference among treatment with tension night splinting (Figure 1), custom rigid orthosis, and over-the-counter arch supports. (2) A retrospective study of 237 subjects also concluded that mechanical treatment is better than anti-inflammatory or accommodative treatments. (3)

[FIGURE 1 OMITTED]

Another prospective, observer-blinded study randomized 116 patients to 1 of 2 groups for 3 months. (4) The first group of patients were treated with a nonsteroidal anti-inflammatory drug (piroxicam) and Achilles tendon stretching 3 times a day. The second group received the same treatment but also wore plastic tension night splints in 5 [degrees] of dorsiflexion. After 3 months, in an intention-to-treat analysis, no statistically significant difference was detected in subjective pain between the 2 groups. In this study, patient compliance with the tension night splinting was poor, and this likely affected the outcome.

From 1993-1995 an observer-blinded randomized controlled trial of 112 patients compared standard with sham extracorporeal shock wave therapy. (5) The main outcome measure was patient satisfaction on a 4-step score at 6 months and 5 years. At 6 months, the treatment group had a significantly better 4-step score than the placebo group (P<.0001). In fact, 51% of treatment-group patients were pain-free, while none of the 48 placebo-group patients were pain-free. After 5 years, the 4-step score only demonstrated a trend in favor of the treatment group (P<.071) because of a high rate of good results from subsequent surgery in the placebo group. Thirteen percent of the treatment-group patients had undergone a heel operation, compared with 58% of placebo-group patients.

A controlled and observer-blinded study of 302 patients with plantar fasciitis compared standard extracorporeal shock wave therapy with sham treatment. (6) The treated patients had significantly lower pain scores (as measured on a visual analog scale) than the placebo group (1.9 vs 4.7). Three months post-treatment, half as many treated patients were taking pain medication when compared with placebo patients. After 1 year of follow-up, 94% of the treatment group patients were still pain-free, with a pain score of <2.

One randomized controlled study of 166 patients found no evidence to support a beneficial effect on pain, function, and quality of life of extracorporeal shock wave therapy over a sham treatment. (7) Of note, this study enrolled patients who had a minimum of 6 weeks of symptoms. All recommendations in the US are to reserve extracorporeal shock wave therapy for patients with more than 6 months of symptoms.

A meta-analysis of 8 published studies involving 840 patients whose condition was not improved after conservative therapy for at least 6 months showed that up to 88% of patients experienced good to excellent outcomes with extracorporeal shock wave therapy and were satisfied with the result. (6)

As for surgical treatment, in a prospective study of 43 patients with 47 painful heels followed for an average of 31 months, only 49% of the patients were satisfied with their outcome. (8) Patient expectations should be considered in preoperative counseling. In contrast to surgery, either open or endoscopic, extracorporeal shock wave therapy does not require the patient avoid weight-bearing or a prolonged time for return to work.

* RECOMMENDATIONS FROM OTHERS

Figure 2 has been modified from a clinical practice guideline on the treatment of plantar fasciitis published by the American College of Foot and Ankle Surgeons. (9)