THE REAL TRUTH ABOUT PLANTAR FASCIITIS
Summer is finally here! Out come the summer athletes, weekend warriors and even the average folk that spend time cutting the grass or gardening. One of the more common injuries we see during the summer months is plantar fasciitis. We will see posts on social media asking for treatment advice. All the advice comes with good intent. The intent is to help someone hurting. Some advice is better than others. Some advice is just flat out wrong. Some advice is just humorous. Below we will post 5 myths about plantar fasciitis.
1. The Real Name Isn’t Plantar Fasciitis: Doctors used to think that plantar fasciitis was an inflammatory condition. The “itis” in the word fasciitis literally means inflammation. The old theory is that inflammation would occur at or near the attachment of the plantar fascia due to excessive strain/force imparted through the soft tissues of the area. Over the past decade, research has confirmed that this theory is WRONG! Repeated studies have found NO INFLAMMATION in the plantar fascia. Research confirms that degenerative changes to the tissue have occurred (1, 2). Biopsies performed at the time of surgery combined with diagnostic ultrasound studies show long standing degenerative changes to the tissues of the plantar fascia WITHOUT INFLAMMATION. This new information has largely been ignored by medical professionals (medical doctors, osteopaths, chiropractors, physical therapists, athletic trainers, podiatrists, etc.) and by the sports/recreation community. The recommendation for anti inflammatory medication (Motrin, Advil, Aleve, Aspirin, Celebrex, Viox, Indomethacin, Toradol, oral steroids, etc.), steroid injections, and even ice may not be the best treatments for degenerative conditions. These treatments attempt to limit inflammation; however, inflammation is not the real culprit. Actually, we may want to induce inflammation and induce more blood flow to the area to jump start the healing process. Treatments that induce inflammation and blood flow to the area include deep tissue massage, Graston, Active Release Techniques, shock wave therapy, dry needling, acupuncture, heat, laser therapy, and PRP injections). So, the real name isn’t plantar fasciiits. The real name should actually be plantar fasciosis or plantar fasciopathy.
2. The Pain Location Can Vary: Heel pain is classic to plantar fasciosis (notice that we did not use “itis” here). The “typical presentation” is pain in the heel that is worse first thing in the morning or worse with rest and/or long periods of sitting. The pain gets worse with a transition from sitting to standing and during the first several steps that a patient walks.
Heel pain is just one area where a patient can have pain. A 2013 study in the medical journal, Skeletal Radiology, found degenerative changes via diagnostic ultrasound in the plantar fascia at various areas of the foot including the insertion (heel) and non insertional sites (other attachment points on the foot). (3) The implications of this study is that pain location along with degenerative changes can vary.
3. Plantar Fasciosis Isn’t Contageous Nor Inherited: Don’t laugh, but we’ve heard people in the community say things like, “I got this from my father/mother” or “My brother had it, so now I’ve got it too.” The “best” explanation for plantar fasciosis is faulty mechanics (2, 4). Dynamic control over the foot/ankle, arch and toes during gait (walking) can cause abnormal stress to tissues not suited to take the forces applied. Patients typically don’t inherit mechanics from their parents nor do they get their faulty mechanics from their brother. Patients develop their mechanics during the development process (sitting up-turning over-crawling-standing-walking), with lifestyle based factors (our American sedentary based lifestyle) or from repetitive postures and positions assumed. Bad mechanics can be local (foot/ankle/toes) or be distal (knee/hip/pelvis/core/low back/etc.). The key is finding a practitioner who understands how to assess and correct bad mechanics.
4. Plantar Fasciosis Could Be Something Else: We find that social media is full of “experts.” The intent to help someone is genuine and welcome; however, we find that anecdotal evidence abounds combined with a shotgun approach from parties wanting to help. For example, a recent post we found had recommendations for ice, Motrin, and stretching for a woman in her mid 30′s with a 4-5 month history of bilateral (both sided) plantar fasciosis that had not seen a medical or allied health provider. The post later recommended a cortisone injection within “a week or two” if the ice, Motrin and stretching did not work. First, a 4-5 month history of anything is a red flag for a comprehensive evaluation. Second, bilateral conditions are correlated to autoimmune disease. Women also have a higher likelihood for certain autoimmune diseases. Wouldn’t you want to know if you had an autoimmune disease? Lab testing would be needed to determine this. Third, the research and efficacy behind cortisone injections is not as good as you think. Read our previous blog entitled, Rethinking The Cortisone Injection – Buyer Beware, for more information (http://thecfim.com/rethinking-the-cortisone-injection-buyer-beware). Fourth, a 1-2 week trial of care of ice, Motrin, and rest is probably not enough to reduce the pain from a mechanical problem as long standing as this one. Rest, ice and Motrin are “band aid” treatments to keep the runner active and never fix the mechanics that could have led to the problem. Fifth, the runner could have had some rare but more serious diagnoses that cause “heel pain.” Some of those diagnoses are listed below (4,5).
Heel Spur: Heel spurs present differently that plantar fasciosis. Heel spurs hurt when the foot strikes the ground (heel strike) compared to plantar fasciosis where the pain is typically during push off (propulsion). Heel spur patients will adapt new mechanics to avoid heel strike (4). Heel spurs tend to hurt at the end of the day as opposed to plantar fasciosis which hurts after periods of rest including first thing in the morning. Obesity is the biggest single predictor of heel spur syndrome whereas the mechanics of the foot/ankle and toes is one of the best predictors of plantar fasciosis (4). The “best” treatments for plantar fasciosis include conservative treatments like manual therapies (joint mobilization, manipulation, soft tissue massage) exercises, stretches , braces/splints and orthotics. The “best” treatments for a painful heel spur are shoe or orthotic accomodations, nutritional recommendations for obesity and weight loss methods (4). Heel spurs despite looking rather sinister on X-rays may not even be a source of pain; so, seeing one on an X-ray is not a definitive reason to surgically remove the spur, inject the area with cortisone, nor recommend other aggressive treatment options. Sometimes the best thing we can do for non painful heel spurs is just leave them alone.
Autoimmune Disease: Heel pain can be a sign of autoimmune disease. The typical pattern is bilateral (both sided), symmetrical pain (pain levels are the same side to side and/or functional losses are the same side to side) combined with swelling and the presence of spurs and/or degenerative changes. Often, the first step in identification is a comprehensive exam followed by X-rays comparing right to left. Second, recommendations call for a comprehensive blood work with the addition of an autoimmune panel. Autoimmune disease CANNOT be treated with manipulation, mobilization, stretches, exercises, splints/braces or orthotics. Autoimmune disease must be treated at the chemical level with treatments focused on controlling/limiting inflammation. Oral medication, supplementation and an anti inflammatory diet are recommended. We can test for the autoimmune disease out of our office. We can also recommend supplementation along with dietary changes to reduce local and systemic inflammation.
Neuropathy: Heel pain can be referred from other areas. Three areas that can refer pain into the heel include the tarsal tunnel (posterior tibial nerve), Baxter’s nerve, and the low back (4, 5). Tarsal tunnel is analogous to carpal tunnel in the hand. The posterior tibial nerve winds it way through a tight area in the foot/ankle called the tarsal tunnel just as the median nerve winds it way through a tight area in the wrist/hand called the carpal tunnel. The posterior tibial nerve can be stretched, compressed or entrapped leading to referred pain in the heel that is not due to plantar fasciosis. The description of tarsal tunnel syndrome/posterior tibial neuritis is different than that of plantar fasciosis. The one thing they do typically have in common is location (heel pain). Posterior tibial neuritis (inflammation of the nerve) or tarsal tunnel syndrome is worse with standing, walking, weight bearing and repetitive use. The more a patient stands, walks, weight bears or uses their foot/ankle the worse the pain gets. Plantar fasciosis is typically worse after sitting/resting for long periods of time including when patient gets up. Plantar fasciosis typically gets better the longer someone is on their feet whereas posterior tibial neuritis/tarsal tunnel syndrome gets worse. The pain is described as burning, tingling or numbness. Plantar fasciosis is described as dull, aching pain at rest that turns to sharp and stabbing pain when transitioning up and walking the first couple steps.
Baxter’s neuropathy is entrapment of a local nerve under the heel by the plantar fascia. The nerve supplies the muscles of the little toe; therefore, entrapment affects little toe motion (4). The location of the pain is what Baxter’s neuropathy and plantar fasciosis have in common; however, characteristics of pain (Plantar Fasciosis: sharp, stabbing, dull, achy VS. Baxter’s: burning, numbness, tingling and weakness) are different.
The last area that can refer pain into the heel is the low back. The low back must be ruled out first otherwise a patient could go weeks to months of care and never get at the true culprit for why they have heel pain. A simple 5 minute screen will rule out the low back as a culprit for heel pain.
Stress Fracture: Although uncommon, stress fractures of the heel are a possibility (4,5). We see stress fractures of the heel typically with runners, triathletes, and in impact sports (basketball, volleyball, dance, cheerleading, poms, etc.). Stress fracture is linked to osteoporosis/osteopenia (4). Stress fractures present with progressively worsening pain with increased activity and with activity on harder surfaces. Plantar fasciosis and stress fractures have the location of pain as similar, but stress fractures differ in the the intensity of pain combined with the reports of worse with increased activity and hard surfaces. A simple test to screen for stress fractures is to squeeze the heel between the thumb and index finger comparing side to side for increased pain. A bone scan for a stress fracture should be considered if the history matches up plus there is a difference side to side with the heel squeeze test.
5. Treatment Depends On The Cause: The last major myth is that one size fits all. This is a common one we see on social media. We see blanket recommendations for ice, stretching, rest, anti inflammatory drugs, etc. Typically, conservative treatments (no drugs – no surgery options) are the best and first line treatments (5, 6, 7, 8, 9).
Have you ever wondered why there are so any recommendations and treatments for plantar fasciosis? Let me list a couple treatments here: ice, heat, ultrasound, phonophoresis, iontophoresis, electric stim, joint manipulation, soft tissue & joint mobilization, laser therapy, dry needling, acupuncture, medication, steroid injections, platelet rich plasma injections, prolotherapy, orthotics, new shoes, therapeutic exercise, gait (walking) retraining, shock wave therapy, taping, braces, splints and surgery. In our opinion, the answer is two fold: 1). there is probably multiple different pathways that lead to plantar fasciosis 2). no one treatment works 100% of the time.
The saying goes all roads lead to Rome. The application here is that multiple different paths all lead to the same end result of plantar fasciosis. Pronated feet can get plantar fasciosis. Supinated feet can get plantar fasciosis. Neutral feet can get plantar fasciosis. Soft, supple feet can get plantar fasciosis. Rigid feet can get plantar fasciosis. Patients with mechanical problems of the hip, knee, pelvis, core, low back, etc. can end up with plantar fasciosis. Plantar fasciosis may even be referred pain from another source. Heel pain may not even be plantar fasciosis at all. Maybe, the treatment should focus on the pathway to get to plantar fasciosis rather than treating the plantar fasciosis itself. This may be true for particularly stubborn cases. The key is finding someone who understands that a one size fits all approach doesn’t help the patient. The key is to match the treatment and the area that needs treatment to the cause.
You’ve probably come to the realization that a lot more goes into the diagnosis and treatment of plantar fasciosis than you once thought. Blanket, one size fits all recommendations usually don’t work well for this condition. Please find a medical or allied health provider (medical doctor, osteopath, chiropractor, podiatrist, physical therapist, athletic trainer, body worker, etc.) that understands these concepts. Time spent in evaluation saves time in treatment. If you don’t have a medical or allied health provider, we’d be happy to help. We treat difficult cases of plantar fasciosis with our comprehensive, conservative care methods. Please call 708-532-CFIM (2346) and ask for either Dr. Dino or Dr. Marie at The Center for Integrated Medicine for more information.
4. Michaud, T.C. (2011) Human Locomotion: The conservative management of gait-related disorders. Newton, Mass: Newton Biomechanics