Treatments « Plantar Fasciitis and Plantar Fasicopathy (Heel Pain)

Plantar Fasciitis and Plantar Fasicopathy (Heel Pain)

Treatments

Available Treatments for Plantar Fasciitis and Plantar Fasciopathy (listed in alphabetical order):

Astym treatment:

Qualified, specially trained physical and occupational therapists provide Astym treatment. Astym treatment is highly effective and was scientifically developed to stimulate regeneration of the plantar fascia, tendons and other soft tissues. Astym has its foundation in basic science research and is supported by clinical trials, case studies and extensive outcomes collected from a large number of multiple treatment sites4-19. It is a non-invasive treatment (there are no needles involved, no surgery). Instruments are applied topically (on top of the skin) to put light to moderate pressure on the underlying soft tissue and stimulate a healing/regenerative response. On average, 88.7% of plantar fasciopathy patients resolve within 4-5 weeks, and Astym usually is covered by insurance. A directory of therapists who are qualified to provide Astym treatment can be found at www.astym.com. Make sure to check that directory to confirm your therapist is certified in the Astym rehabilitation process. Certification is extremely important, otherwise you will not receive proper treatment.

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Autologous Blood Injections:

Podiatrists (DPMs) and Medical doctors (MDs) perform these injections. There is no certification or special training required, however, there is some training available to doctors. Be sure to ask about your doctor’s training and experience. For these injections, a doctor draws out some of your own blood and then injects it back into you at the site of pain, in an attempt to cause a physiological response that will ease pain and increase function. No controlled studies have been published on these injections, and further study is needed to determine whether this approach will be useful in the treatment of plantar fasciitis and plantar fasciopathy. Health insurance companies generally consider this investigational and do not pay for these injections.

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Botulinum Toxin Injection:

These injections are performed by podiatrists (DPMs) and medical doctors (MDs). Botulinum toxin is injected into the medial (inside) aspect of the heel close to the calcaneal tuberosity (origin of the plantar fascia) or into the arch of the foot near the origin of the plantar fascia. The purpose of the injection is to lessen the pain of plantar fasciitis. Botulinum toxin has been regularly used to paralyze muscles with great success, so it would follow that botulinum toxin could also paralyze or deaden sensory nerves and thereby relieve pain. However, there has been no suggestion that botulinum toxin promotes actual healing of the plantar fascia. There has been very little research conducted on this approach for plantar fasciitis. One well-designed pilot (very small number of patients) study revealed that botulinum toxin resulted in short term improvement in pain and overall foot function20. Since patients were not followed long term, we do not know if they had lasting improvement. Further investigation with larger numbers is needed before the role of this approach in the treatment of plantar fasciitis can be determined.

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Corticosteroid Injections:

Podiatrists (DPMs) and Medical doctors (MDs) may perform these injections. Corticosteroid medication (an anti-inflammatory agent) is usually mixed with a local anesthetic agent and then injected to reduce inflammation and ease pain. The use of corticosteroid injections ("CSI") for the treatment of plantar fasciitis is controversial. There can be side effects. Corticosteroid injection into the superficial fat pad on the heel may cause fat pad necrosis (tissue death, loss of tissue), which can lead to a painful, chronic (long-term) condition where you have little to no padding on the bottom of your heel. To reduce this risk, injections should not be made directly through the heel pad. Even if necrosis does not occur, an injection through the heel pad can be quite painful. Usually the method of injection is on the inside (medial aspect) of your foot (not the bottom) with the needle directed toward the area of maximal tenderness on the medial aspect of the heel bone (calcaneus). After the proper approach is made, the injection should then avoid the superficial layers of the subcutaneous tissue, because a corticosteroid injection into the superficial fat pad can cause the fat necrosis that was mentioned previously.

In tendons, steroid injections may weaken a tendon, increasing the chance of a rupture or tear. There have been a number of case reports of tendon rupture after corticosteroid injections21,22. This may also be the case with the plantar fascia. Corticosteroid injections are associated with a high rate of rupture of the plantar fascia23. If this happens, you could have great difficulty walking for 6-8 weeks. The arch of your foot may collapse, leading to a flattening of your foot, and how you walk (your gait) may be changed. This can lead to many other problems with muscles and joints in that leg, and chronic disability in some people. On the other hand, some people seem to have little to no ill effect from a rupture of the plantar fascia. Ultrasound guidance may be used with corticosteroid injections to improve targeting and monitor soft tissue changes, which may help minimize complications.24

Corticosteroid injections can reduce pain in the short term, but the benefits of this approach are transient (short lived). Studies have consistently shown no long term benefits to this approach25,26,27. Long term effectiveness for corticosteroid injections in the treatment of plantar fasciitis has not been demonstrated, and in fact, poor long term results have been reported28. Since the goal of these injections is to reduce inflammation, it is understandable why there may be no long-term healing benefit to a degenerated plantar fascia. The true cause underlying most chronic plantar fasciitis is degeneration, so addressing this problem with a treatment aimed at stimulating regeneration would be more productive than trying to reduce inflammation that is probably not present.

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Electrical Stimulation and Iontophoresis:

Usually, physical and occupational therapists provide these treatments. Equipment is utilized to deliver electrical current into the plantar fascia. More than one session is usually done. Sometimes a corticosteroid cream or patch, or other medication is added and that medication is then pushed through the tissue with the electricity (this combination is known as iontophoresis). There is little medical evidence that this approach works for chronic plantar fasciitis. In a well designed study, investigators found that iontophoresis had some benefit in pain relief for plantar fasciitis at two weeks, but at one month there was no statistically significant benefit29. Further investigation and study is needed. Health insurance carriers are becoming hesitant to pay for this treatment.

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Extracorporeal Shockwave Therapy (ESWT):

Podiatrists (DPMs) and medical doctors (MDs) may provide this treatment. Proponents of this treatment also call it orthotripsy. ESWT is either classified high-energy or low-energy, based upon the magnitude of the shock wave generated by the equipment. A doctor (for high-energy application) or a doctor’s office assistant (for low-energy application) uses equipment to deliver a series of acoustic shock waves directly over the plantar fascia. The high energy shockwaves must be done under anesthesia or sedation, and therefore they are done in operating room settings. They are also done with the assistance of imaging to make sure that the shock waves are being delivered to the right area. The machines to perform high energy shockwaves are very expensive, so the high energy shockwave therapy may not be available in all areas.

Even though this has been studied for over ten years, how ESWT may work is not clear. More importantly, whether it works is not clear. The studies have conflicting results as to whether ESWT is effective in treating plantar fasciitis. A recent review found that lower quality studies seemed to favor ESWT in plantar fasciitis, but the high-quality, more reliable studies indicated that ESWT may not be effective in the treatment of plantar fasciitis30. More study of this approach is needed.

The application of ESWT can vary widely in the duration of the treatment, the intensity and frequency of the shock waves, and the timing and number of treatments. These factors make it hard to measure its overall effectiveness. ESWT can be very painful. The high energy waves are usually more painful than the low energy waves, and that is why patients are required to be under anesthesia or sedation in an operating room. The low energy waves can be delivered in an office, but be aware that even low energy ESWT is usually quite uncomfortable and each session will last approximately 15 minutes (multiple sessions are usually required). ESWT remains a controversial treatment for plantar fasciitis and is rarely covered by health insurance.

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Ice:

Ice is often a front-line treatment right after intense activity to help reduce inflammation and relieve pain that may occur in the plantar fascia from the activity. Ice is well accepted and traditionally used for its analgesic, pain relieving effect and inflammation reduction. However, in chronic, longer term cases of plantar fasciitis where inflammation is not likely to be present, its effectiveness is questionable. Chronic cases of plantar fasciitis are degenerative in nature and a treatment designed to stimulate healing and regeneration would be more appropriate.

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Laser/Light Therapy:

This treatment is often delivered by chiropractors, physical therapists, and occupational therapists. Laser or light energy is aimed over the plantar fascia, either through "cold" low level laser therapy (LLLT) or through light emitting diodes (LED) or super luminous diodes (SLD). The effectiveness of this approach for plantar fasciitis is not supported by the medical literature, however, there is some evidence that it may have a positive effect on the healing of skin ulcers/wounds. A randomized, controlled clinical trial studied low intensity laser treatment (30 mW continuous wave diode laser) in plantar fasciitis, and found that it was no more effective than placebo30. This treatment is generally not covered by health insurance for the treatment of plantar fasciitis.

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Massage and Friction Massage (both tooled and traditional):

Therapists often teach patients how to perform massage on the plantar fascia at home. To perform this type of massage, use your thumbs or fingers lengthwise along the plantar fascia. Friction massage is also something most people can do on themselves. It is a deep massage that moves across muscles, tendons and other soft tissues, and its purpose is to mechanically break down tissue. There is little to no medical evidence showing that friction massage consistently works, however, there have been reports from individuals who have had some positive benefit. The Cochrane Review, an official medical review evaluating medical literature, concluded there was no benefit to friction massage over controls in the treatment of tendinitis31. There are a variety of different tools that are used to do friction massage. Some of the tools are: GSO, Intracell, Fuzion, Acuforce®, Graston®, Jacknobber, Sastm, T-Bars, handles of reflex hammers and various kitchen utensils. Some tools promote a type of friction massage approach called Instrument Assisted Cross-Fiber Massage or Instrument Assisted Soft Tissue Mobilization, such as Graston® and Sastm. The only published article on Instrumented Cross-Friction Mobilization shows that it has minimal to no long-term benefit on healing32.

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Needle/Percutaneous Fasciotomy:

Podiatrists (DPMs) and medical doctors (MDs) perform this procedure; it involves puncturing the plantar fascia with a large bore (18 gauge) needle area multiple times (50-100 punctures usually) per session. There is no standard protocol. Some place the punctures together or near each other to make a larger hole, others make one puncture and move the needle back and forth inside the plantar fascia, and others make a grid or fanning pattern of smaller holes. Local anesthesia helps the patient tolerate the procedure and it is often done under the guidance of ultrasound imaging. Usually, patients receive only one session. If the condition recurs or persists, and good results were seen after the first procedure, then the patient could receive more sessions. The local bleeding and trauma that is produced by the multiple punctures may cause a similar physiological response to actually injecting a patient’s own blood around the affected area (autologous blood injections). This may be how fenestration might help the plantar fascia to heal. In addition to multiple punctures to the plantar fascia, the procedure can include mechanically breaking up calcifications and abrading the adjacent bone. A small study on this treatment for plantar fasciitis was not of high quality, and although it did produce a statistically significant positive result for this approach, the results did not appear to be clinically relevant (have results that would matter to patients in a real world situation)33. Preliminary research on this procedure for chronic tendinopathy (which has similarities to chronic plantar fasciitis) indicates that this procedure improves chronic tendinopathy in a notable number of patients34, 35. It is questionable whether health insurance will pay for this procedure.

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Night Splints:

Night splints are used to keep the ankle in a neutral position during sleep, allowing for the calf and the plantar fascia to be passively stretched during the overnight period. The goal is to allow the plantar fascia to rest and hopefully heal while it is in the elongated position. The medical evidence for this approach is minimal. Very little research has been done. There are some lower quality studies that suggest this approach is helpful36-40, and the theory behind this approach seems reasonable. However, a different study compared a group of patients with night splints, NSAID medication and exercise to another group with no night splints and just NSAID medication and exercise. It was found that the night splints had no beneficial effect41. The study is limited by the fact that it was comparing multiple approaches, did not have a control group and patients were only monitored for a short period. More quality research needs to be done.

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NSAIDs/Anti-inflammatory Drugs:

This medication comes in both prescription strength and over-the-counter versions. There does not seem to be any particular drug of choice for NSAIDs. Oral NSAIDs (non-steroidal anti-inflammatory drugs), have been used to treat chronic plantar fasciitis for decades. Recently, gels or patches with this medication in them have also been used. The medical literature contains frequent references to the use of NSAIDs in the treatment of chronic plantar fasciitis and other degenerative conditions such as common chronic tendinopathies, however, there is "surprisingly little quality evidence supporting this …option"42. The use of these drugs in acute (sudden, short term) plantar fasciitis can be justified by the belief that inflammation is present in short term cases, and a medication to reduce that inflammation is appropriate. However, the use of anti-inflammatory medications in cases where inflammation is not likely to be present (chronic cases – usually having a duration of over 8 to 12 weeks) is more controversial.

The research shows that although NSAIDs may provide short-term pain relief, there is little to no evidence of a positive effect on long-term healing43. In fact, there is conflicting evidence in animal models regarding the effect of NSAIDs, with a suggestion that NSAIDs may actually inhibit healing44,45,46. The medical literature now consistently refers to chronic plantar fasciitis/fasciopathy, plantar fasciosis and chronic tendinopathies as primarily degenerative in nature, with little or no inflammation present, so it is easy to understand why a medication designed to reduce inflammation has little to no effect on the underlying degenerative problem of chronic plantar fasciitis/fasciopathy, and plantar fasciosis. Instead of trying to reduce inflammation, the better goal would be to try and stimulate regeneration (and reverse the degeneration, which is the real cause of the condition).

It is important for patients to know that long-term use of NSAIDs carries the risk of significant side-effects, including increased risk of gastrointestinal bleeding, liver damage, renal failure, and cardiovascular complications associated with this type of medicine43. Common names of some NSAIDs include generic ibuprofen (and brands such as Advil® and Motrin®) and generic naproxen sodium (brand name: Aleve®) and prescription strength celecoxib (brand name: Celebrex®).

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Orthotics:

Arch supports are orthotics that support the arch of the foot and decrease excessive pronation (rolling in of the foot while walking) in order to decrease stress on the plantar fascia and thereby reduce symptoms. They are usually inserted into the shoe(s) of the patient. The arch supports can either be custom made or "casted" to fit the patient’s foot exactly (this is the most costly option), pre-fabricated (some fitting may be necessary, but pre-made to a good extent) or off-the-shelf (available right away, and the least costly of the three). A long-term, well-designed, comprehensive clinical study concluded that both custom and pre-fabricated orthotics had only small short term benefit in function and perhaps pain, however, there was no long term benefit (at 1 year). It also showed that pre-fabricated and custom orthotics were equally effective (one was not better than the other)47.

Another form of orthotics is the simple heel pad or heel cup (a rubber or silicone heel pad that contours to the heel). They are relatively inexpensive, and available at most drug stores or surgical supply stores. Materials for the heel pads vary, but all try to absorb the shock on the heel from activity. Heel pads can be made from silicone, rubber, felt, foam or gel. They are often used as a front line treatment for plantar fasciitis, but there is little medical evidence to support their use30. Studies have reviewed the force of the heel strike on patients who have plantar fasciitis in one heel, but not in the other. The force of the heel strike is similar in both the plantar fasciitis heel and the unaffected heel. So it is concluded that the force of the heel strike should not be causing plantar fasciitis48. In another study, heel pads were not proven useful in the treatment of plantar fasciitis, but heel pads did help patients with localized pain from contusions (injury).49

More quality study of orthotics is needed to determine their role in the treatment of plantar fasciitis and plantar fasciopathy.

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Platelet Rich Plasma (PRP) Injections:

These injections are done by podiatrists (DPMs) and medical doctors (MDs). The doctor draws blood from a patient and then places it into a machine that spins the blood down and produces a layer of platelet rich plasma (PRP). The doctor then injects the patient with this derivative of their own blood, in an attempt to cause a physiological response that will increase function and ease pain.

There are different brands of machines which produce different platelet layer concentrations. This approach is similar to autologous blood injections. The major difference is that the platelet rich portion of the blood is separated and only the platelet rich plasma is injected. Some believe this may cause less local inflammation, however, it does require more blood to initially be drawn out of the patient.

If a good PRP injection is performed under imaging guidance (ultrasound), it may possibly be effective on a small area of degeneration (about ½ inch square) if it is followed by proper rehabilitation. The growth factors in the PRP injection only spread out so far, and after the growth factors are in the tissue, they degrade rapidly – that is why its potential effectiveness, like most injection techniques, is limited to a very small area. If the PRP injection is not guided by imaging (ultrasound) to target the area of degeneration, then the injection can easily miss the optimal injection site and its potential to be effective is lost. This treatment can require multiple injections (if there is not an immediate response) and most of the time the patient must limit activity and training for a period of time (2-4 weeks) after each injection. The course of the treatment may easily take up to 6 months. PRP injections usually require the use of a large bore (thick) needle.

Previously, very limited research had been done on this approach for treating chronic plantar fasciitis and other degenerative conditions, such as chronic tendinopathy50. There was hope that this approach would be proved effective through research, however, a well-designed study was recently published in the Journal of the American Medical Association (JAMA) and it clearly shows that PRP is no more effective than placebo (ineffective or sham treatment)51. Some former proponents of this method are now questioning its application in chronic tendinopathies and other degenerative conditions such as chronic plantar fasciitis. It is generally considered experimental or investigational by health insurance carriers and is not covered under health insurance. Most patients have to pay cash for this service.

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Prolotherapy (Sclerotherapy):

Podiatrists (DPMs) and medical doctors (MDs) perform these injections. An injection of an irritating substance is made into the affected area and it is believed that the area then scars down as a result of this injection. The injection may destroy the nerve fibers that are transmitting pain. Originally, prolotherapy was used to scar down an area of instability in a joint. If a joint was loose, the creation of scar tissue could help tighten it up by adding dense scar tissue to the joint capsule. Some more adventurous doctors have now applied this approach to the treatment of chronic plantar fasiitis, plantar fasciopathy and other degenerative conditions such as chronic tendinopathies. How prolotherapy works (the "mechanism of action") in the treatment of chronic plantar fasciitis and other degenerative conditions such as chronic tendinopathies is unclear52. Some initial studies have been done on this approach, but so far the research has mostly been underpowered not well designed/controlled42, so there is no solid support in the medical literature for this procedure in the treatment of chronic plantar fasciitis and other degenerative conditions such as chronic tendinopathies. However, there are some individual stories with perceived positive results that have been published in the popular media. Proper, well-designed research would necessarily have to include injecting patients consistently with the same substance. In current practice, different doctors often inject very different substances for this procedure. Another concern with this procedure is that scarring down in one area of the body may lead to increased stress on structures in other areas of the body, with the potential for injuries or pain in areas other than the original site of pain. Prolotherapy is generally considered investigational or experimental by health insurance carriers, and not covered under their policies. Most patients have to pay cash for this service.

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Relative Rest/Immobilization:

Podiatrists (DPMs), medical doctors (MDs), and physical and occupational therapists often recommend this kind of treatment. This is a common recommendation for patients with plantar fasciitis and other soft tissue dysfunctions, such as tendinopathies. However, once resting is over, and immobilization (not moving) is stopped, plantar fasciitis often returns. Resting the area rarely leads to healing or resolution of the underlying problem of chronic plantar fasciitis (the degeneration of the plantar fascia). However, it may be helpful where plantar fasciitis is acute (sudden, short-term) and the underlying problem is only inflammation.

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Stretching:

Often patients with plantar fasciitis are given exercises to stretch the plantar fascia and Achilles tendon. Stretching is a mainstay treatment for plantar fasciitis, however there is no unanimously accepted standardized stretching protocol. Large, well-controlled studies are needed to determine the best stretching program for plantar fasciitis and plantar fasciopathy. Recent medical evidence does not give much guidance on effective stretching. One well-designed study showed calf stretching to be ineffective for plantar fasciitis at two weeks. There was no data collected after that period, so it is unknown whether stretching would have had some benefit if patients continued to be monitored after two weeks53. Another study compared stretching of the Achilles tendon to a plantar fascia specific stretching technique, and found that in the short term (8 weeks) the patients stretching their plantar fascia specifically fared better, however, over the long term, neither stretching approach was superior54,55. Stretching may help guide the healing of the body, and also may help align tissue properly. However, stretching alone rarely provides enough stimulation to cause significant healing of chronic plantar fasciitis and other degenerative conditions such as chronic tendinopathies. Stretching is one of the most common recommendations in treating plantar fasciitis and also one of the most common recommendations generally as part of rehabilitation and pain management programs, yet relatively little is known about its effectiveness. Much of the research done to date on stretching the plantar fascia has been underpowered or has had flaws in the design or execution. More quality study on stretching is needed.

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Surgery:

These procedures are performed by podiatrists (DPMs) and medical doctors (MDs), usually orthopedic surgeons specializing in foot and ankle. Surgery is usually only recommended as a last resort and only to a small number of patients. Surgical procedures should be considered only for patients with persistent, severe symptoms that do not respond to more conservative treatments for at least 6 to 12 months.56 There is no high quality evidence from randomized, controlled clinical trials to show the effectiveness of surgery. Since the outcome can be unpredictable, the vast majority of patients opt for more conservative treatments and decline surgery. It is also important to note that low patient satisfaction after surgery has been reported (less than 50%), and it is possible for patients to have some continued functional limitations after surgery57.

Isolated partial or complete release of the plantar fascia ("fascial release"), which can be combined with the removal of a heel spur, removal of abnormal tissue, and nerve decompression are surgical options. These procedures may be open (large incision) or endoscopic (small instruments used through a tiny incision). Although the surgical procedure involving the complete release (severing) of the plantar fascia (plantar fasciotomy) was done routinely years ago, it has since fallen out of favor somewhat, due primarily to successful management of chronic plantar fasciitis in other ways and the fact that a complete fasciotomy results in a profoundly weakened arch and a certain degree of disability for most patients. Basically, the complication can be that the arch of your foot collapses and for several weeks you could have great difficulty walking. Following the arch collapse, how you walk (your gait) may be changed. Without proper arch support, this can lead to many other problems with muscles and joints in that leg, and chronic disability in some people. If surgery is necessary, it is recommended that a partial release of less than 40% of the plantar fascia be done in order to minimize the effect on arch instability and maintain normal foot biomechanics58. All surgery has risks. Those associated with the surgery for plantar fasciitis/plantar fasciopathy include: infection, rupture of the plantar fascia, transient swelling of the heel pad, calcaneal fracture, nerve injury (of the posterior tibial nerve or its branches), and flattening of the longitudinal arch with resultant midtarsal pain.

A fairly new and uncommon type of surgery for plantar fasciitis/plantar fasciopathy is radiofrequency microtenotomy. It can be minimally invasive. Basically, a hot microwave (which is a high frequency radio wave) tip is inserted into the plantar fascia to burn the tissue and relieve symptoms. How and why this approach would work is unclear. This approach does induce sensory nerve fiber degeneration, and any pain that was being transmitted to the brain by these fibers could be eliminated since those fibers are eliminated59. The concern with this method is that the procedure may result in tissue that is not as strong or elastic as normal tissue, predisposing patients to further injury in the treated area at a future time. Research and study is needed on this method to determine its role in the treatment of plantar fasciitis and plantar fasciopathy.

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Taping:

Applying athletic taping to support the bottom of the foot is frequently used in the treatment of plantar fasciitis. The purpose of the taping is to distribute forces away from the plantar fascia and decrease the stress that activity or weight may put on it. In a recent systematic review of controlled trials on taping, it was found that although there was some limited evidence that taping could reduce pain in the short term, no results could be drawn on whether taping could affect the disability (function) of a patient with plantar fasciitis60. Where low-dye taping (a technique designed to support the foot and limit pronation) was studied, it helped patients with the pain of the "first step" in standing or getting out of bed61, but not much other benefit was noted. A few patients complained of the taping being too tight or having an allergic reaction to the tape, so be aware of these possible temporary drawbacks A small study reviewed calcaneal taping (tape specifically encompassing the heel only) for just a week and found there was some benefit in pain during that short period62. No reliable, long term studies on this method could be found, so additional research is needed to determine whether taping is an effective way to treat plantar fasciitis.

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Ultrasound and Phonophoresis:

These procedures are provided most often by physical and occupational therapists. They use ultrasound equipment to deliver high frequency sound waves into the affected area, which heats the targeted tissue. Multiple sessions are usually done. A corticosteroid cream or other medication can be applied to the skin over the affected area and then ultrasound waves can be used to push the medication through the tissue (this combination is known as phonophoresis). A study comparing therapeutic ultrasound to sham ultrasound was conducted, and it was found that therapeutic ultrasound was no more effective than placebo (the sham ultrasound)63. This study did not have an ideal design, so further research should be done in this area before we can draw a firm conclusion. Sometimes ultrasound is covered by insurance, but now certain health insurance companies are beginning to deny payment for this form of treatment.

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