New practice guidelines for the diagnosis and treatment of heel pain, published on April 30 by the American College of Foot and Ankle Surgeons (ACFAS), continued the trend of basing treatment recommendations on evidence-based medicine.1 But the guidelines also provoked controversy among those most likely to rely on them for clinical decision making. Heel pain—most commonly plantar fasciitis—is a serious matter for podiatrists, physical therapists, and other lower extremity clinicians.
Despite the condition’s prevalence, practitioners disagree about the best treatments for it. Of course, the whole point of guidelines is to delineate the evidence for different approaches and help all practitioners make better decisions. The new ACFAS guidelines, which evolved from a previous version in 2001,4 classify heel pain in several categories and provide both text and graphic pathways for diagnosing, evaluating, and treating it.
Although Thomas emphasized the importance of examining the guidelines’ text rather than going just by the flowcharts, in fact the text provides no further clarification of the authors’ intent in this matter. Clough also expressed concern that the guidelines did not clarify which aspects of orthotic intervention were most likely to affect fasciitis. Clough has not had to resort to plantar fascia surgery for fasciitis in his past 15 years of practice, and he is troubled at how often some of his colleagues do. However, Clough noted a scarcity of studies assessing long-term outcomes following plantar fasciotomy. The authors of the APTA guidelines, not surprisingly, found significant evidence to support the use of physical therapy in treating heel pain and fasciitis (though it should be noted that an MD was among the authors). A recent randomized clinical trial further bolstered the efficacy of manual therapy, however;2 and Michael Gross explained why stretching the calf actually works.
New studies make it important to update the guidelines every four or five years if possible, McPoil said; the 2008 guidelines are the first set issued by the APTA. I read this article and finally felt like there was an article written with some really logical persperspective on treatment of plantar fascitis. Some practitioners find plantar fasciitis patients respond to corticosteroid injection when other treatments have failed, but concerns about complications make others cautious. A seemingly never-ending question continues to exist among practitioners who treat patients with plantar fasciitis: whether to use corticosteroid injections to relieve pain and inflammation, or rely on more conservative nonsurgical modalities.
The American College of Foot and Ankle Surgeons (ACFAS) did include corticosteroid injection among first- and second-line treatments for heel pain in its 2010 revised guidelines,2 based on what the authors called “fair” evidence.
In a 2013 review article in the Journal of the American Podiatric Medical Association,3 researchers wrote that core literature has wide-ranging outcomes that are largely supportive of short- and long-term benefits of corticosteroid injections for plantar fasciopathy, and cited the ACFAS guidelines including it as a first-line therapy. For this article, LER interviewed practitioners across a spectrum of specialists to gain a sense of the status quo in the US for use of corticosteroids to treat patients with plantar fasciitis. Leslie Campbell, DPM, who practices at the Presbyterian Hospital in Plano and Allen, TX, said she is “fairly conservative” in her use of injections. He advises stretches, heel cups, and three months of conservative treatment before considering injections, and he often sends patients to physical therapy to learn proper stretching techniques. James Jastifer, MD, an orthopedic surgeon at the Coughlin Clinic in Boise, ID, counsels patients not to expect their symptoms to resolve completely after a month.

He uses mostly over-the-counter soft orthotic devices such as arch supports, and sometimes heel cups.
Alan MacGill, DPM, a foot and ankle surgeon in Boynton Beach, FL, sometimes uses corticosteroid injection as a first-line treatment for plantar fasciitis. Perhaps even more dividing a question than whether to use corticosteroid injections for patients with plantar fasciitis, is how many times to inject over what period of time. To avoid directly injecting into the substance of the plantar fascia or injuring the plantar nerves around the heel, he recommends injecting from the medial side, rather than from the bottom of the heel, and placing the corticosteroid near, not in, the plantar fascia. Plantar fasciitis is one of the most common causes of heel pain in runners and many various patient populations. SUMMARY: This course evidence based course which involves orthopedic rehabilitation of plantar heel pain. Plantar Fasciitis is one of the most common heel problems seen by Canadian Certified Pedorthists, effecting one in ten people at some point in their life. The common symptom of plantar fasciitis is pain at the bottom of the heel or through the arch, but most commonly noted in the centre of the heel pad. Proper footwear plays an important role in treating and preventing plantar fasciitis by reducing motion that may put pressure on the fascia. If you think you have plantar fasciitis, talk to your local Canadian Certified Pedorthist to find out what treatment is right for you. But evidence has its limitations, and clinical experience is still essential to the therapeutic process.
Some of this has to do with scope of practice; physical therapists can’t give cortisone injections or perform surgery, of course, and podiatrists are usually less familiar with physical therapy approaches than with the techniques in which they’ve been trained.
And although there is significant confluence of ideas about best practices, the differences can be telling.
The clinician’s first step is to determine the cause of the problem, whether it be neurologic, arthritic, traumatic, or mechanical. For example, corticosteroid injections are given an evidence grade of B in the guidelines’ text and listed as an initial treatment option; by contrast, physical therapy is not listed in any of the protocol’s three tiers (physical therapy received a grade of “I”—insufficient evidence to recommend—from ACFAS). In 2009, researchers reviewed 22 years’ worth of studies, then reported in the Journal of the American Podiatric Medical Association that research in cadaver feet suggested that plantar fasciotomy led to loss of integrity of the medial longitudinal arch. Interventions include activity limitation, dexamethasone delivered via iontophoresis, manual therapy, stretching of the calf and plantar fascia, night splints, and prefabricated or custom foot orthoses. Plantar fasciosis can be quite painful and causes a significant gait cycle change (antalgic and sidedness shift) that stresses and causes additional debilitating pain in the ankles, knees and hips. With evidence-based guidelines in short supply, the decision often comes down to clinical experience. Many practitioners depend on their own experiences, because what also continues to exist is a shortage of evidence-based guidance on use of the injections. I usually will start with shoe therapy, a heel lift and taping for people who have mild fasciitis.

Farber, MD, assistant professor of clinical orthopaedic surgery at the University of Pennsylvania Health System in Philadelphia.
Effects of two different doses of epidural steroid on blood glucose levels and pain control in patients with diabetes mellitus. It includes evidence-based clinical practice guidelines, strength training, manual therapy, plantar taping techniques, trigger point dry needling, and specific therapeutic exercise for treatment of plantar heel pain.
The telltale sign is how the patient feels when they wake up in the morning, often feeling pain or stiffness with the first ten to twenty steps out of bed. Orthotics are often beneficial for patients with plantar fasciitis to control the motion of the foot and reduce pronation and stress on the foot, which can lead to small tears and inflammation of the plantar fascia.
Some clinicians dismiss the relevance of orthoses, while others consider them the most crucial aspect of treatment. The American Physical Therapy Association (APTA) published its own set of heel pain guidelines in 2008 and provided significant evidence for its recommendations.3 And although the APTA recommendations agree in many respects with the ACFAS guidelines, the two documents also diverge in important ways. Grades of recommendation range from grade A (strong evidence, based on Level I or II studies) to grade F (in the case of the APTA guidelines) or grade I (in the ACFAS guidelines, “I” signifies “insufficient evidence to make a recommendation”). Manual physical therapy and exercise versus electrophysical agents and exercise in the management of plantar heel pain: a multicenter randomized clinical trial.
Plantar fasciotomy for intractable plantar fasciitis: clinical results and biomechanical evaluation.
Not only is an cortisone injection appropriate, patients many times come in begging for relief of the pain. If people have recalcitrant or long-term pain or it’s very acute, that’s when I involve the corticosteroid injection [for moderate to severe patients],” Campbell said.
This course discusses the current clinical practice guidelines in examining and evaluating the foot and ankle, surface EMG activity for strengthening of the foot intrinsic muscles, trigger point dry needling, plantar taping techniques, and pressure relieving inserts.  This course also discusses various evaluation techniques including differentially diagnosing plantar fasciitis vs.
Treatment concepts will include surface EMG activity for strengthening, plantar taping techniques, appropriate flexibility exercises, and the use of pressure relieving inserts.  Attendees with also have a complete understanding of plantar fasciitis and learn to perform evaluation through special tests, specific manual muscle tests, range of motion, and joint testing. Certain practitioners feel that surgery is inappropriate for fasciitis, while others rely on it to an extent that their colleagues sometimes consider troubling.
Further, as podiatrists, we are able to make a full and definitive diagnosis of the root cause of planter heel pain, applying the appropriate treatments, and speeding recovery. Attendees will be able to implement injury and diagnosis specific rehabilitation programs for individuals with plantar heel pain.
We can and do provide the necessary physical therapy necessary to speed healing, and above all else, understand the biomechanical causes of heel pain enabling us to create podiatric, biomechanically corrective, foot orthoses.

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