Plantar fasciitis can be uncomfortable and outright debilitating if not taken care of appropriately. The options for treatment may seem numerous and in this blog I want to outline why it is my opinion that a well-built physical therapy program in conjunction with PRP and prolotherapy is the best bet for long-term results.
Firstly, it is important to note that there are different causes of plantar fasciitis. You may develop plantar fasciitis as a result of weakness, decreased muscle lengths, poor structural integrity, or trauma induced by one sudden dramatic event or a prolonged event that your feet were simply unprepared for. For the case we are discussing here the initial injury was traumatic and the patient (let’s call her Rocky) initially had significant tears in their plantar fascia. She was seen by a podiatrist who put her in a boot for an eight month period, during which she was unable to perform her job because it required a lot of standing. Near the end of this booted period her pain had not resolved, but she had begun PRP and prolotherapy to regenerate some of the torn tissue. She was referred to PT to try to avoid surgery. Her PT goals were to resume work, and to be able to return to hiking with her sights fixated on doing a rim-to-rim hike at the Grand Canyon.
When Rocky arrived in PT her ankle and foot were very weak. The immobilization while in the boot had caused significant atrophy and loss of control. She still had a significant amount of pain in the heel, but other than that, she had maintained a good arch when she was not in standing. This is the first significant finding. When a patient has maintained a good arch height in non-weight bearing, however loses the arch when weight bearing (standing) I believe this indicates that the passive structures meaning the ligaments and bones are still ready and capable to accept load, but that the muscular strength simply is not sufficient to support load. There are after all 3 structures that support your weight: the bones (passive), the ligaments (passive), and the muscles (active). When you lose one of these structures it places excessive load on the others resulting in injury.
A primary concern was Rocky’s continued heel pain. A thorough physical therapy evaluation revealed the pain to be due to medial calcaneal nerve entrapment in the plantar fascia. To describe this condition specifically is outside the scope of this blog. What is important is that the nerve was able to be released within 1-2 visits resulting in a 80-90% improvement in her primary pain. After this it was simply a process to re-establish strength.
Let’s sum up what’s happened so far. The eight month immobilization resulted in severe weakness and worsening of the initial condition. The PRP and prolotherapy have begun to heal the plantar fascia which is an essential passive structure to maintain the arch. She has begun PT to address the muscular component of arch support.
In PT it’s important that the program be very stepwise and logical. For Rocky, she was unable to maintain an arch when in weight bearing. Through a guided series of progressions that progresses from non-weight bearing to fully weight bearing plyometric (jumping) activity, Rocky was progressed back to her goals over a period of 3 months. Her appointment frequency was 1x/week. She is back to work, hiking, and working towards the Grand Canyon.
It is important to note that both the passive and active structures were restored successfully in this case without surgical intervention. With careful guidance through a strengthening program, we avoid over-stressing the plantar fascia while it is healing. To aid in this, we used temporary orthotics as a progression. She will progress from firm orthotics, to lesser firm orthotics, and then no support whatsoever. For a more in-depth understanding of why temporary orthotics were selected over permanent ones please refer to our “Orthotics: To Support or Not to Support” blog. In some cases, where the passive structures have lost all integrity, permanent orthotics may be necessary.
To best determine appropriate direction of treatment visit a Doctor of Physical Therapy. If you’re seeking physical therapy in Scottsdale, AZ be sure to look us up and we will be happy to get you working towards your goals.
If you are wanting to know more about PRP and are in the Scottsdale area, look up our Sports Doctor Dr. Matthew Hernandez at Ethos Integrative Medicine.