Pharmacological and Non-Pharmacological Treatment of Plantar Fasciitis

Overweight persons, those who spend most of the day on their feet and those who do a lot of running, walking and jumping are at-risk individuals for plantar fasciitis (Edwards 2003). The vast majority, non-atheltic individuals are the second population at risk. Many of these at-risk populations rely on word-of-mouth, publications and newspaper stories for needed information. And the general public has no access to this information other than the feedback they obtain from the media and other people. There is unqualified need for patients and their doctors to provide the information to these at-risk groups and to address the potential problem in their clinics, workplace, the community, offices and homes. Podiatric pathology laboratories screen 30,000-foot specimens a year and, in a single year, thousands upon thousands of specimens are received and investigated with heel spurs or heel spur syndrome, involving inferior heel pain. Despite the extent of the affected or at-risk groups, the syndrome is too well understood and there is as yet no clear and effective management of the condition.

Plantar Fasciitis

Plantar fasciitis is a chronic inflammation of the plantar fascia, a ligament-like structure that runs from the bottom of the heel to the underside of the toes of the foot (Miller 2004). This structure helps support the foot against downward forces that usual during running and jumping sports activities. Plantar fasciitis is the most common cause of inferior heel pain (Singh et al. 1997, Barret and O’Malley 1999) often incorrectly referred to as “heel spur syndrome,” which suggests that osseous spurs or inferior calcaneal exostoses cause the pain. The presence or absence of exostoses has no connection with the pain and the excision of a spur is not part of the usual surgery for plantar fasciitis. Although pain may be felt along the entire course of the plantar fascia, it is usually limited to the inferior medial part of the calcaneus at the medial process of the calcaneal tubercle. It occurs in both men and women between ages 8 and 80, but more common in middle-aged women, as well as younger male, runners (Singh et al. 1997). Its incidence and severity strongly correlate with obesity.

Plantar fasciitis is one of the most common overuse injuries that affect approximately 10% of runners and athletes in basketball, tennis, soccer, gymnasts and other sports (Shea and Fields 2002). More than 2 million Americans seek and receive treatment every year for the condition. Despite this number, there has been no clear treatment plan to help physicians in managing patients.

Etiology – the plantar fascia is a strong band of white glistening fibres that has an important function in maintaining the medial longitudinal arch (Singh et al. 1997). Its spontaneous rupture or surgical division will lead to a flat foot. It rises from the medial calcaneal tuberosity on the undersurface of the calcaneus. In most cases, plantar fasciitis results from a biochemical imbalance that causes abnormal pronation (Barrett and O’Malley 1999). A person or patient with, for example, a flexible rearfoot varus may at first seem to have a normal foot structure but may later show significant pronation when bearing weight. The talus will flex and adduct as he or she stands, as the calcaneus everts. The pronation significantly increases tension on the plantar fascia. Other conditions like tibia vara, ankle equines, rearfoot varus, forefoot varus, compensated forefoot valgus and limb length inequality can exert an abnormal pronatory force. Increased pronation with a collapse can add stress to the anatomic central band and ultimately lead to plantar fasciitis. This is because the weakest point of the plantar fascia is the origin and not the substance. Plantar fasciitis accounts for about 10% of all running injuries (Miller 2004). There is chronic tugging of the plantar fascia at the point were the tissue attaches to the heel bone. It is an overuse injury that results from the effects of repetitive abnormal forces that lead to the destruction of the cell tissue and trigger the inflammatory process. Prolonged pronation of the foot, with the sole of the foot turning outward and wearing worn-out shoes are major contributing factors to the condition. Foot slap when doing downhill running may make the condition worse (Miller). Other risk factors are sudden gain in body weight or obesity, unaccustomed running or walking, wearing shoes with poor cushioning, increase in running distance or intensity, change in the walking or running surface, tightness of the Achilles tendon, and occupation that involves prolonged weight bearing (Singh et al. 1997).

Signs and Symptoms – Pain in the heel when taking the first steps in the morning or when suffering a minor foot injury is the first symptom (Barrett and O’Malley 1999, Miller 2004). The symptoms decrease as walking continues. The pain gets localized in the medial calcaneal turbercle, is usually insidious but with no history of acute trauma. Many patients point to the condition as the result of a stone bruise or a recent rise in daily activity. The injury is usually caused by a sudden twist of the foot or when making a misstep (Miller). When the painful heel develops, the condition quickly gets worse until the patient experiences much discomfort in the entire bottom of the affected foot. Many patients tolerate the symptoms and try to relieve these with home remedies before obtaining medical treatment (Barrett and O’Malley).

Diagnosis – This is typically based on the history and a finding or clinical presentation of localized tenderness (Barrett and O’Malley 1999). This is the practice even in this age of modern technology. The tenderness or pain is generally localized at the origin of the anatomic central band of the plantar fascia while no significant pain results from the compression of the calcaneus from a medial to a lateral direction. Standard weight-bearing radiographs in the lateral and anteroposterior projection show the biomechanical nature of the hindfoot and forefoot and may likewise reveal osseous abnormalities like fractures, tumors or rheumatoid arthritis in the calcaneus. Such radiographs, however, only serve as confirming tool in the diagnosis.

Oftentimes, a diagnosis of plantar fasciitis is made on the history and physical examination of a patient with inferior heel pain and investigations are conducted to rule out other disorders causing inferior heel pain (Singh et al. 1997). A patient often reports that the pain can become so incapacitating that he has to limp to the bathroom or hobble around with the heel off the ground. He also reports that the heel pain decreases during the day but gets worse with increased activity, such as jogging or after some time sitting down. Aggravating pain in the morning is typically indicative of plantar fasciitis and usually not of calcaneal stress fractures or nerve entrapment. Pain in the evening should point to other causes of heel pain, such as tumors, infections and neuropathic pain, such as tarsal tunnel syndrome (Singh et al.).

The patient often describes a gradually increasing discomfort over the succeeding weeks (Singh et al. 1997). He often wears shoes with poor cushioning or inadequate arch support or he walks barefoot on hard floors. Plantar fasciitis is usually unilateral, but some patients sometimes report contralateral pain when they shift weight to the other leg. Bilateral disease in young patients should invite suspicion of Reiter’s syndrome. Obesity occurs in 90% of female patients with plantar fasciitis and 40% of male (Singh et al.).

Examination – Physical examination on a patient with plantar fasciitis often yields localized tenderness on the anteromedial part of the heel through the use of firm finger pressure (Singh et al. 1997). Swelling in the area and tightness of the Achilles tendon are also common in 78% of patients with this condition. No other clinical findings in the foot and ankle are usually made. Tenderness should be specific or localized in the calcaneal tuberosity, otherwise, the diagnosis of plantar fasciitis should be doubted. Tenderness at the center of the posterior of the heel should invite suspicion of bruising or atrophy of the heel pad; Tinel’s sign on the medial part of the heel may indicate nerve entrapment to abductor digiti quinti or a tarsal tunnel syndrome; and tenderness on mediolateral compression of the heel through squeeze test should rouse a suspicion of a stress fracture of the calcaneus (Singh et al.).

Investigation – a plain lateral radiograph of the heel can rule out a stress fracture, erosions due to bursitis, or rare bony causes of inferior heel pain (Singh et al. 1997). Isotope scanning should be used when stress fractures are suspected and plain radiographs have normal findings. Magnetic resonance imaging or MRI) may show thickening and inflammation of the fascia, while ultrasonography may show increased thickness and inflammation of the plantar fascia. Complete blood tests are recommended for patients with bilateral disease or an atypical clinical condition. Electrophysiological tests may confirm a tarsal tunnel syndrome or compression of the nerve to abductor digiti quinti, but these tests or studies are difficult to perform and interpret and are not clinically useful in most cases (Singh et al.).

Non-Pharmacological Management of Plantar Fasciitis

The ideal management of plantar fasciitis is prevention, which is through appropriate warm-up exercises, quality shoes and exercises at an appropriate training level on a safe surface (Miller 2004).

Barrett and O’Malley (1999) recommend a conservative treatment that addresses the inflammatory element causing the discomfort and the biomechanical factors producing the disorder. To complement the treatment, the patient should be adequately educated on the etiology of their pain, the biochemical factors that produce the symptoms, home therapy that can relieve some of the discomforts and changes that must be introduced to their daily activities, such as wearing suitable athletic shoes with enough medial arch while walking. If the patient has had an increase in exercise or activity associated with the symptoms, he or she should adopt a less straining regimen until the plantar fasciitis condition resolves (Barrett and O’Malley).

1. A removable longitudinal metatarsal pad fitted from the distal part of the medial calcaneal tubercle to the five metatarsal heads. It should serve as a temporary arch support to decrease pronation during midstance of the gait cycle (Barrett and O’Malley 1999). It may also be placed directly against the patient’s skin and taped from a plantar medial to a plantar lateral direction. These can provide greater biochemical support than over-the-counter heel cups or pads.

2. stretching the Achilles tendon as adjunctive therapy for 2 minutes 3 to 5 times a day for 6 to 8 weeks, followed by a re-evaluation (Barrett and O’Malley 1999, Thomas et al. 2001). The patient should face a wall with one foot 6 inches from the wall and the other 2 feet from the wall and then lean towards the wall while keeping both heels on the floor. Other doctors (Singh et al. 1997) recommend doing the stretches at least 10 times five or six times daily. Stretching will not only help in the recovery but also in preventing recurrence (Olson 2003). It should be done gently and not strenuously and on a consistent basis.

3. orthotic devices to counteract pronation and disperse heel strike forces (Barrett and O’Malley 1999, Thomas et al. 2001). These can be heel pads and arch supports (Singh et al1997) made up of softer materials that can cushion and reduce the shock on walking up to 42%. Two randomized trials of orthosis showed that patients had the highest level of improvement in using silicone heel inserts and rubber heel cups after 8 weeks, with prefabricated inserts outperforming stretching alone and customized orthoses (Shea and Fields 2002). Patients should replace worn or worn-out running shoes with new ones with firm arch support and firm heel cup to buffer forces at impact (Miller 2004).

4. ice pack on the plantar part 15 to 20 minutes before going to bed at night for 10 to 14 days or massaging the plantar fascia with an ice block 15 minutes daily for 2 weeks.

5. night splints to keep the foot an angle of 90 degrees or more to the ankle as an adjunctive therapy to prevent contraction while the patient sleeps. A study showed that 83% of patients treated with these splints showed relief from stubborn plantar fasciitis (Barrett and O’Malley 1999). Wapner and Sharkey reported a 79% cure after patients used the splint for an average of four months (Singh et al. 1997). Another study found improvement in all patients using night splints at an average treatment time of 12.5 weeks (Batt et al. As qtd in Shea and Fields 2002). Still another study found that 88% of the involved feet improved at the end of 6 months after using night splints (Powell et al. As qtd in Shea and Fields).

6. short-leg walking cast for several weeks as a final conservative measure. It was found effective for chronic plantar heel pain when worn for a minimum of three weeks (Barrett and O’Malley 1999). Below knee casts for three to four weeks provides relative rest, reduces pressure on the heel, provides arch support and prevents the tightening of the Achilles tendon (Singh et al. 1997).

7. ice massage, stretching, inserts like orthoses for boots (Edwards 2003) and “relative rest” of the affected area (Singh et al. 1997). Icing is the best management for inflammation by using an ice pack of bags of frozen vegetables ideally several times a day (Olson 2003).

8. extra-corporeal shock wave treatment is a non-invasive and safe alternative to surgery in treating chronic plantar fasciitis when conservative modes do not work (Langerman 2004). The technology was approved by the Food and Drug Administration or FDA for the condition. Besides its efficacy, it enables the patient to return to normal activities the following day and the capacity of wearing comfortable shoes instead of a walker boot or cast shoes (Langerman).

A study conducted and published by the American Orthopaedic Foot and Ankle Society revealed that 82% of the 100 patients involved recovered completely from their symptoms 4 to 6 weeks after the start of the pedorthic treatment plan (Lukowsky 2005). The plan consisted of Achielles stretching, rest, wearing custom-cushioned orthoses, shoe change, taking of non-steroidal inflammatory drugs, hard orthoses, some injections, plantar strapping, ice or heat and night splinting and educating the patient about the etiology of his or her condition.

CASE STUDY female emergency physician at a level II trauma center, 32 years old, 5″2′ and 125 pounds, presented a 10-year history of chronic plantar fasciitis (Langerman 2004). Her work requires standing or walking for most of her shift. She reported progressing pain since college when she worked as a medical assistant. The pain was consistent throughout medical school and her residency. She tried treating the condition with oral anti-inflammatory medicines, orthotics, stretching and massage. She bought multiple brands and different types of shoe gear, but without improvement. She then had to restrict activities, such as horseback riding, jogging and running. Her everyday pain level ranged from 7 to 10 in a scale of 1 to 10 with 10 as the most severe. Without relief from these conservative modalities, she opted for high energy ESW treatment for bilateral heels. She was given plain bupivacaine anesthesia before the administering of the ESW for each heel. Throughout the operative time, the patient’s heel was maintained on the OssaTron head with good gel interface. After the procedure and on discharge, she was instructed to stretch, wear shoe gear and discontinue using anti-inflammatory and ice. During her postoperative visits every 10 days, the pain progressively decreased, so that at the sixth month, she did not experience pain in either heel. She continued to be pain-free more than a year following the procedure. She went back to full activity level of horseback riding, jogging, kickboxing and work, does not take pain medication or anti-inflammatory medicines and does not wear orthotics. This case study provides excellent example of the benefits of the ESW procedure in restoring activity and the quality of life (Langerman).

Pharmacological Management of Plantar Fasciitis

An adequate conservative therapy must be pursued for several months before considering medications or surgery (Barret and O’Malley 1999, Edwards 2003). The use of anti-inflammatory medications has been under a lot of controversy lately because there is no real inflammation in plantar fasciitis, but a kind of collagen degeneration. Non-steroidal anti-inflammatory drugs can only control pain and should be limited to 3 to 5 days.

A steroid injection as the option after at least 6-9 months, as the steroids cause atrophy (Edwards 2003). Steroid injections account for 10% of successful management of plantar fasciitis, with 80% from traditional therapy and surgery for the rest. Corticosteroid injections are reserved for those who want faster pain relief or faster return to training. Ionophoresis is costly and offers only brief pain relief. Local steroid injection can relieve pain in an extremely tender area and best given from the medial rather than the inferior aspect of the heel (Singh et al. 1997). It involves a series of minor withdrawals and reinsertions to infiltrate the entire reach of the inflamed fascia and avoiding the inferior surface so as not to cause fat pad atrophy. Steroidal injections may lead to osteomyelitis of the calcaneous or iatrogenic rupture of the plantar fascia. The use of steroidal injections are now advocated only occasionally for patients with refractory symptoms (Singh et al.)

Non-steroidal anti-inflammatory drugs to play a limited role and offered primarily for short-term pain relief (Shea and Fields 2002). They should be withdrawn as soon as the pain subsides.

Lithotripsy as a possible alternative to surgery for patients with chronic plantar fasciitis. Trials conducted produced good to excellent results in reducing pain in 70-75% of the enrolled patients. More than 70% of the patients who opted this mode were pain-free after 6 weeks but the pain resolution decreased significantly at 36.9 months (Shea and Fields2002).

Endoscopic plantar fasciotomy as a minimally invasive intervention, it is less traumatic than the traditional open heel-spur surgery and allows earlier weight-bearing after surgery (Barrett and O’Malley 1999). It has been considered a controversial technique but a recent study showed that it has a high 97% success

Surgery should be considered only for intractable pain that has not responded to proper conservative treatment after 12 months (Singh et al. 1997). Various surgical procedures include plantar fascia release with or without calcaneal spur excision, Steindler stripping, neurolysis and endoscopic procedures., which all claim success, although others believe surgery achieves satisfactory results only in 50-60% of cases and with substantial complications. The surgical procedure should be individualized. It has been recommended that only 40% of the plantar fascia should be incised to avoid flattening of the arch and the deep fascia of abductor hallucis divided to decompress the enrve to abductor digiti quinti. A management plan (Singh et al.) uses multiple conservative modes with an aim at hastening recovery without harming the patient. The patient is made to understand that the treatment involves several methods and requires a total rather than fragmented effort. The patient is reassured that the condition is generally self-limiting over several months and his fears are allayed that the bone spur is causing the symptoms and should be removed.

Prolotherapy, which involves the injection of a dextrose or sugar water solution into the ligament or tendon attaching to the bone to increase the blood supply and flow of nutrients and stimulate the tissue to repair itself (Wheaton and Hauser 2005). This is useful for many other types of musculoskeletal pain, such as arthritis, back pain, neck pain, fibromyalgia, chronic tendonitis, partly torn tendons, ligaments and degenerated or herniated discs, temporo-mandibular jaw and sciatica. Response to prolotherapy varies from person to person and depends on individual healing ability. The average number of treatments is between 4 and 6 for the area under treatment. Prolotherapy causes the proliferation of new ligament tissue in areas where it has become weak. A version of this technique was first used by Hippocrates for dislocated, torn shoulder joints. The principle has remained the same, which is to stimulate the involved tissue to heal itself.

CASE STUDIES

1. A 40-year-old female had a 1 I year history of left foot pain without apparent injury (Wheaton 2005). She reported sharp and tight pain, which increased when walking.

She said that hot and cold packs with massage were useful in relieving her pain and that her pain was worse in the morning. X-ray findings showed a heel spur. Patient had physical therapy without change of symptoms. She saw a chiropractor and took medications, including cortisone injections, which did not produce relief. She was diagnosed with plantar fasciitis.

Prolotherapy was recommended for her condition to provide increased support and to decrease pain. At the beginning of treatment, her pain level was 5-6 out of 10, with 10 as the most severe. Treatment was done on the ligament and tendon attachments along the bottom of her foot in three sessions from September to December that year. After her third treatment, she reported that nothing offered medically helped, but this one worked. She said that she had recommended the treatment for chronic pain to others. Her pain level reached level 1 out of 10 or a 90% improvement overall. She said that she could move better, that the affected parts were less stiff and less painful, especially in the morning and that she could go back to daily walking schedule (Wheaton).

2. A 37-year-old man came to Caring Medical in June 2000, complaining of pain on his right heel and left ankle (Hauser 2005). He said that he had two surgeries on his right foot to remove a morton’s noroma cyst in November 1999 and a planter faciitis in January 1998. He also said he had been receiving cortisone injections but got no relief from them. He underwent prolotherapy on these parts. On his second treatment in July 2000, he reported that the first treatment on his left foot was 100% better. On his third and fourth treatments, he could stand for two hours with no pain, whereas before he could not stand for even five minutes without severe pain. After his fourth treatment, he said that he had 80% overall improvement (Hauser).

Conclusion

When you get out of bed in the morning and experience severe pain in the heel of your foot, you may have plantar fasciitis (Your Orthopaedic Connection 2001). It is a condition or injury resulting from overuse of the sole or flexor. You are likelier to get it if you are a woman, overweight and with a job that requires a lot of walking and standing on hard surfaces. If you do a lot of walking and running for exercise and have tight calf muscles that limit your flexing your ankles, you may have it. Those with very flat feet and very high arches are also more prone to develop plantar fasciitis.

If not treated, plantas fasciitis can become chronic and if you are active, you may not be able to maintain your level of activity and also develop symptoms of foot, knee, hip and back problems because plantar fasciitis changes the way one walks. Knowing what conduces to the development of plantar fasciitis, it can be prevented. But if it has developed, the patient has a variety of conventional and more radical therapies to choose from and which have documented a high percentage of efficacy. Non-pharmacological management includes rest, exercise, the use of appropriate shoes, pads, orthotic devices, ice pack, night splints, casts and ESW. And pharmacological management covers steroids, non-steroidal anti-inflammatory drugs, lithotripsy, endoscopic plantar fasciotomy and surgery. Tests show that these modalities have a high degree of success and guarantee that the patient will be able to go back to his or her previous type and level of activity.

Bibliography

Barrett, S.L. And O’Malley, R. 1999, Plantar Fasciitis and Other Causes of Heel Pain, vol 59 number 8, American Academy of Family Physicians. http://www.aafp.org/afg/990415ap/2200.html

Beck, K 2005, Carrie Tollefson: a Case Study in Talent, Tenacity and Treatment, January-February, Running Times Magazine. http://www.runningtimes.com/issues/05janfeb/tollefson.htm

Edwards, a. 2003, Plantar Fasciitis Treatment Steps into New Territory, CMP Media LLC. http://www.biomech.com/db_area/archives/2003/0309.roundtable.bio

Lukowsky, M 2005, Pedorthic Management of Plantar Fasciitis, Comfort Shoe Specialists. http://www.comfortshoe.com/pedorthic_management_of_plantar_html

Langerman, Jr. R.J. 2004, High-Energy Extra-corporeal Shock Wave Treatment, Orthopedic Technology Review, vol 6 number 4,-page 34. http://www.orthopedictechreview.com/issues/mayju04/pg34.htm

Miller, MD. 2004, Plantar Fasciitis, University of Virginia Health System. http://www.healthsystem.virginia.edu/internet/orthopaedics/fasciit.cfm

Olson, W.R. 2003, Treating Plantar Fasciitis, Coaches and Athletic Trainers’ Corner, American Academy of Podiatric Sports Medicine. http://www.aapsm.org/ct0199.html

Prolotherapy.com, Prolotherapy. http://www.prolotherapy.com/prolodefine.htm

Shea, M and Fields, K.B., 2002, Plantar Fasciitis: Prescribing Effective Treatments, the Physician and Sports Medicine, vol 30 number 7, the McGraw-Hill Companies. http://www.physsportsmed.com/issues/2002/07_02/fields.htm

Singh, D, et al., 1997, Plantar Fasciitis, BMJ Publishing Group Ltd. http://bmj.bmjournals.com/cgi/content/full/315/1101/172#treatment

Thomas J.L. 2001, the Diagnosis and Treatment of Heel Pain, Clinical Practice Guideline, the Journal of Foot and Ankle Surgery, http://www.acfas.org/HeelPainCPG.pdf

Weil L.S., Jr. et al., 2002. Extra-corporeal Shock Wave Therapy for the Treatment of Chronic Plantar Fasciitis. Foot Ankle Surgery, 41 (3) pp 166-72, Weil Foot and Ankle Institute. http://www.ncbi.nlm.hih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubM

Wheaton M. And Hauser R, Prolotherapy Case Histories – Foot Pain. Beulah Land Corporation. http://www.getprolo.com/foot_pain_and_prolotherapy_case_histories.html

Your Orthopaedic Connection, 2001, Plantar Fasciitis, American Academy of Orthopaedic Surgeons. http://orthoinfo.aaos.org/fact/thr_report.cfm?Threat_ID=144&topcategory

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