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January 2010

Treatment Triad for Plantar Fasciitis

Treatment Triad

I coined the term "treatment triad" for plantar fasciitis a few years back to better describe the disease process and its treatment. 

Acute plantar fasciitis is basically a sprain of the fascia, it is an inflammatory condition. It thus can be treated successfully with anti-inflammatories -- oral or injections or cortisone plus the use of soft heel pads or OTC inserts (acute PF can sometimes progress to chronic PF but lets leave that out for simplicity's sake for now).

Plantar fasciitis that persists or becomes chronic does so for one of two reasons....
...abnormal or excessive strain persists on the fascia. This may be due to work conditions, poor shoegear, poor body mechanics: subtalar joint overpronation, midtarsal joint oversupination, tight achille-gastrosoleus.

...tissue quality deteriorates. This can occur due to chronic inflammation which leads to tissue damage, genetic factors leading to poor connective tissue quality or a combination of both.

LEG #1 = inflammation, 

LEG #2 = abnormal biomechanics, 

LEG #3 = poor tissue quality(degeneration of the tissue due to long term chronic inflammation)

The 3 "legs" of the triad thus have different "height" at different times.

Initially the first leg, "inflammation" is by far the predominant process. As such expect modalities such as cortisone shots to work reasonably well in the first few weeks or few months, then gradually decrease in effectiveness with time. As time goes on and if plantar fasciitis persists, the second leg must be focused on. The body can and does repair itself and if that is not happening then one must remove impediments, ie. find and remove the biomechanical problems preventing that from occurring. Look carefully at the second leg from 6 weeks to 6 months. Inflammation and tissue damage occurring for extended periods of time (say greater than 6 months) will compromise the body's ability to repair tissue. The tissue becomes badly scarred and devascularized. This is the point where the third leg predominates -- tissue quality.

Problematic biomechanics is best treated by a practitioner trained in that area.  There are many who dabble in the area of biomechanics, from shoe fitters to retail stores, etc.  Expertise in biomechanics is derived from years of study. Biomechanical issues are addressed by changes in shoegear, prescription foot orthotics, manual therapy/physical therapy.  Dr. Ed Davis explains how foot orthotics can be effective:


How is the third leg treated. The term "plantar fasciosis" is a relatively new term that specifically defines this degneration of the fascia. Such degeneration can easily be diagnosed by use of diagnostic ultrasound or sonography. It is important that the presence or absence of fasciosis be established early on so that treatment can be adequately targeted.  Surgical release of the plantar fascia was used at this stage but carries a potentially long recovery period as well as what I would consider an unacceptably high complication rate. It has been supplanted by less invasive, safer and more effective treatments to include ESWT (extracorporeal shockwave therapy) and more recently, the Topaz procedure,, which is also known as a partial fasciectomy via coblation.  Coblation is a term meaning "cold ablation" and is a trademark of the Arthrocare Corp.

Now, one caveat, plantar fasciitis often waxes and wanes in the early stages for a number of patients so the "stages"  or "legs" I am discussing be affixed to firm time periods. For example, a patient can low grade chronic plantar fasciitis for years, change jobs to one that requires more standing and develops a bout of acute plantar fasciitis superimposed on the chronic process.

Heel Pain - Getting The Proper Diagnosis

Heel pain
The first step in treating heel pain is finding out the cause of the problem.

We see many patients with heel pain in our  practice as a San Antonio podiatrist, who have had the problem for months, if not years but have never had a well defined treatment plan.
Such treatment plan starts with an accurate diagnosis.

Plantar fasciitis, inflammation of the ligament which supports that arch and originates on the heel bone is the most common cause of heel pain.   Plantar fasciitis can be caused by overuse and be transient but can often become chronic if the underlying causes are not identified and resolved. The plantar fascia is the large ligament that supports the arch and structures that support the foot.  It is strong but can be damaged over time.  The fascia has terrific tensile strength or pulling strength but is not strong when twisted. Twisting or torsional strain of the fascia occurs when overly soft shoes without support are worn or if the patient has biomechanical problems.  Overpronation, the foot rolling in too much or oversupination, the foot rolling out too much can strain the fascia causing it to become thickened and painful. The plantar fascia is not visible on x-ray so the most important first step is to obtain an ultrasound exam in the office to determine it's condition.

Treatments for chronic plantar fascia that are aimed at the cause may include use of more stable shoes (shoes with a shank), orthotics and physical therapy.  OTC orthotics or store purchase orthotics are primarily arch supports and lack the features of prescription orthotics but can be tried first.  For more information on orthotics please visit:

Occasionally, the fascia can thicken over time to where is is more difficult to treat and has been called "intractable plantar fasciitis."  The actual name for that condition is plantar fasciosis, which is a degenerative condition of the fascia.  That is readily identified by an ultrasound exam.  Plantar fasciosis includes a separate and distinct set of treatments from plantar fasciits.  Treatments for plantar fasciosis may include extracorporeal shockwave therapy (ESWT) and the Topaz Procedure:  and

Other causes may include:..

Stress fractures of the heel bone (calcaneus): 

Baxter's neuritis - a nerve entrapment of a small nerve branch beneath the heel bone:

Rrheumatologic entities such as Reiter's syndrome, rheumatoid arthritis, gout, psoriatic arthritis, irritable bowel syndrome, ankylosing spondylitis; chronic pain syndrome due to overuse of steroids (cortisone shots), plantar fascial tears, plantar fibromatosis, infections, tumors, cysts....Ed Davis, DPM, FACFAS