12 minute read
The Dreaded Plantar Fasciitis
By Dr. Michael M. Cohen, DPM, FACFAS
The plantar fascia is a tight band of connective tissue which links the ball of the foot to the base of the heel. You can visualize the structure in your arch by holding the foot 90° to the leg and bending the great toe backwards. Imagine this structure as being a cable which maintains the integrity of the arch. Plantar fasciitis is an inflammation of this connective tissue usually located at its weakest link, at the bottom of the heel. Debate continues regarding its exact cause, but some researchers feel that it is a result of some type of overuse mechanism such as a sudden change in shoe gear, ambulating barefoot especially on hard surfaces, females who are postpartum or runners increasing their training intensity too rapidly. Several studies have pointed at a common thread between patients who have this problem, and that is a shortened or tight calf muscle. Plantar Fasciitis may be particularly notable in females who wear or work in high heel shoes. After several hours of standing in high heels, the hamstring and calf muscles become acclimated to a shortened position. Upon returning home the shoes are often traded for a flat heel at which time the person may walk, exercise or run without a good warm-up or stretch. Symptoms will often present as a dull aching pain in the arch and in later stages progress to acute pain in the heel. This is the point at which the plantar fascia attaches to the bone. Pain may become debilitating and not only experienced during walking or running but especially during the first few steps out of bed in the morning or when rising out of a chair. It is often likened to a nail being driven through the center of the heel forcing patients to walk with a limp or even resort to using a cane. Plantar fasciitis is a very common condition seen in both athletes and sedentary people. Studies show that rapid aggressive treatment in the initial stages yields the best outcome. Unfortunately, studies also show that a successful response to conservative treatment diminishes after a period of 6-8 months.
Initial Treatment
Unfortunately, there is no quick solution to this problem, and overcoming plantar fasciitis requires some homework. The initial phase of treatment revolves around eliminating the symptoms. Athletes may apply heat prior to exercising then switching to ice massage after the activity. If pain is particularly acute then impact-related exercises such as running or jumping should be discontinued for a few weeks. At times the foot is immobilized to reduce the inflammation until pain can be controlled. I have found that the stairmaster may aggravate the condition as well. Nonsteroidal anti-inflammatories such Alleve, or Motrin can be used initially but chronic use of these agents is to be avoided as they may actually mask telltale symptoms. Patients with stomach ulcers or blood thinners should avoid nonsteroidal anti-inflammatories. Occasionally in severe cases, a physician may elect to inject a steroid into the heel to reduce inflammation and improve symptoms. This is done with the caveat that chronic use of these agents may predispose the plantar fascia to rupture. Over-the-counter orthotics are usually very beneficial, but more complex foot type may require a molded orthotic.
Yet most agree that the crux of treatment and prevention of plantar fasciitis requires appropriate, focused and consistent static stretching exercises aimed at relaxing the calf muscle. This enhances repair of damaged collagen in the plantar fascia. There are several adjunctive devices on the market which are quite effective at accomplishing this, including the Prostretch wheel, various types of nightsplints or adjustable dorsiflexion stockings such as the Strasburg sock. Vigorous stretching is to be avoided in the acutely painful heel. In these instances, immobilization or at best very light passive stretching and range of motion techniques are employed while sports activity is discontinued temporarily. Beware; a small percentage of heel pain unresponsive to traditional treatment may be a result of misdiagnosed stress fractures, inflammatory arthritis, nerve problems or even partial or complete tears of the plantar fascia. A proper history and MRI study is indicated to fully evaluate these recalcitrant cases. Other treatment adjuncts include wearing supportive shoes with adequate heel cushioning. I prefer the Hoka One/ One, or one of the New Balance Fresh Foam series with a stiffer midsole. One should avoid walking barefoot on hard surfaces such as tile or hardwood floors. The OOFOS, Hoka or Fit Flop sandals work particularly well and should be used at home when not wearing shoes.
ESWT (Extracorporeal Shock Wave Therapy)
Patients who are unresponsive to the initial treatment of plantar fasciitis may be candidates for extracorporeal shock wave therapy (ESWT). ESWT or lithotripsy was initially used to fracture painful kidney stones which allow them to pass through the ureter. Within the past several years ESWT has been implemented in several orthopedic conditions such as chronic plantar fasciitis with very positive results. Literature suggests that it may be an effective nonsurgical modality for the treatment of patients with recalcitrant chronic plantar fasciitis. ESWT focuses controlled shock waves at the area of maximal tenderness. It is speculated that shockwaves may induce an inflammatory mediated healing response. ESWT allows immediate return to activity with the exception of running and jumping sports for a few weeks. Generally, 4-5 weekly sessions are required.
PRP (Platelet Rich Plasma)
PRP or platelet rich plasma has been used to manage dermatologic and oral maxillofacial conditions since 1950. More recently interest has grown exponentially in the use of this technique for orthopedic applications such as plantar fasciitis. Media attention to this treatment modality has been reported due to its popularity with professional athletes. With this technique, a patient’s own blood is separated using a technique referred to as plasmapheresis into white blood cells, red blood cells, plasma and platelets. The technique extracts healing proteins such as platelet derived growth factor, vascular endothelial cell growth factor, and basic fibroblasts which can be detected in high concentrations. Consequently, investigators theorized that PRP may be beneficial in conditions that require tissue healing. PRP is injected into the plantar fascia guided with ultrasound or fluoroscopy. A series of three injections scheduled weekly are usually used.
EPF (Endoscopic Plantar Fascial Release)
Regrettably, a very small percentage of patients with plantar fasciitis will not respond to six to eight months of conservative treatment. For these patients, some may opt for a more definitive form of treatment which uses a procedure referred to as an endoscopic plantar fascial release (EPF). In this procedure approximately 33 to 50% of the plantar fascia is released from its connection to the heel using microincisions. They are allowed to walk in a healing boot for four weeks and transition to a running shoe to allow the plantar fascia to heal properly. The plantar fascia serves an important function during walking and running and its release may result in temporary residual side effects which are eventually overcome. For this reason, surgery is to be considered as a last resort but in most cases, if performed correctly may provide gratifying results with reported satisfaction rates of 80- 90%
▸Michael M Cohen, DPM, is a Board-Certified Foot and Ankle Surgeon and Diplomate of the American Board of Foot and Ankle Surgery. He is a
Fellow of the American Board of Foot and Ankle
Surgeons and Board Certified and Diplomat of the American Board of Podiatric Medicine. He practices with the Foot, Ankle and Leg Specialists of South Florida specializing in lower leg injuries and reconstructive surgery of the foot and ankle. The practice includes Carlo Messina DPM, Al
DeSimone MD, Alexander Bertot MD, David Shenassa MD, Franz Jones DO, John Goodner DPM and Warren Windram DPM. The South Florida
Institute of Sports Medicine in Weston is located at 1600 Town Center Blvd., Suite C, (954) 3895900 and in Pembroke Pines at 17842 NW 2nd
Street, (954) 430-9901. Our practice website is www.southfloridasportsmedicine.org
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