Clinical Studies
Outcome Study of Subjects with Insertional Plantar Fasciitis
Robroy L. Martin, P.T., James J. Irrgang, M.S., P.T., A.T.C., and Stephen F. Conti, M.D.
Published in Foot & Ankle International, December 1998
The purpose of the study was to examine the effect of a standardized treatment regimen on a well-defined group of subjects with insertional plantar fasciitis and examine the effect of subject compliance with different aspects of the regimen on clinical outcome.
A total of 237 subjects were treated over almost a 4-year period. The subjects met the three criteria for inclusion in the study, which were: (1) they were personally seen and evaluated by the attending Orthopedic Surgeon at the University of Pittsburgh Medical Center Foot and Ankle Clinic (2) they had a history consistent with insertional plantar fasciitis and maximal tenderness at the medial calcaneal tubercle (3) they had no coexisting symptomatic foot or ankle problem.
The subjects followed a four-part, non-operative treatment program including the use of oral NSAIDs, one physical therapy session to learn Achilles tendon and plantar fascia stretching exercises, the use of a night splint, and the use of either a custom orthosis or heel cushion. The majority of the heel cushions used were Bauerfeind ViscoSpot heel cushions. If there was no improvement after 4 months of treatment, the subject was offered a steroid injection at the insertion of the plantar fascia and continued the program. If improvement was not seen after 6 months of treatment, surgery was considered.
A mailed survey was used to obtain information from the subjects treated. 157 surveys were returned and analyzed. The average age of the subjects who returned the survey was 45 years old, with 60% being men. The reported outcomes were 51% good (no pain), 33.8% fair (intermittent pain) and 14.6% poor (constant pain), with 87.6% satisfied with the treatment and 81.8% satisfied with the final outcome. 56 subjects were put in Group 1, as being compliant with the night splint, exercises and orthosis/heel cup. 15 Subjects were put in Group 2, which met the same criteria as Group 1 plus the additional criteria of taking the medication as prescribed. 88 subjects did not meet the compliance criteria to be included in either group.
Only a small number of subjects agreed to injection or surgery when offered, even if they had continued heel pain. Only 22.1% of subjects who still had symptoms after 6 months reported receiving an injection, and 10% of these consented to surgery. The authors concluded that most patients would rather deal with occasional discomfort than receive an invasive treatment, including injection or surgery.
The study concludes, in agreement with previous studies, that subjects with insertional plantar fasciitis can obtain good results with a nonsurgical treatment program. Compliance was low, but did not correlate to outcome, with one exception. Patients with chronic conditions who were compliant with the night splint had a better outcome. This study does not conclusively describe what is the most appropriate treatment for this condition. Patient perceptions suggest that stretching, night splints, and orthoses/heel pads are equally important parts of the treatment program.
As far as timing, the results suggest that early, aggressive, nonsurgical treatment within 12 months after the onset of symptoms offers the best chance of a good outcome. There is a lower chance of having a good outcome if subjects had symptoms more than 12 months prior to treatment. Also, subjects were less likely to have a good outcome if their symptoms persisted for more than 12 months after starting this treatment regimen. However, the authors concluded that even patients with prolonged symptoms benefited from a nonoperative treatment program.
The authors concluded that indications for surgery are limited. They recommend that physicians provide education and encouragement to patients with this condition because good results can be obtained, but improvement is slow.
