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11 Articles in Volume 18, Issue #8
Challenges & Opportunities for Pain Management In Veterans
Chronic Pain and Psychopathology in the Veteran and Disadvantaged Populations
ESIs: Worth the Benefits?
Letters to the Editor: Recovery Centers Reject MAT, Cannabis for Chronic Headaches, Central Pain
Medication Management in the Aging
Pain Management in the Elderly
Pharmacists as Essential Team Members in Pain Management
Photobiomodulation for the Treatment of Fibromyalgia
Plantar Fasciitis: Diagnosis and Management
Slipping Rib Syndrome: A Case Report
What types of risk screening tests are available to clinicians prescribing opioid therapy?

Plantar Fasciitis: Diagnosis and Management

Applying an osteopathic approach.

Plantar fasciitis is one of the most common causes of foot and heel pain in adults. Consisting of pain and tenderness at the sole of the foot, this condition affects approximately 1 in 10 persons at some point in their life. Peak incidence occurs between age 40 to 60 in the general population with an additional younger peak in runners and athletes.1,2 The plantar fascia, or plantar aponeurosis, lies superficially to the muscles of the plantar surface of the foot, attaching to the anterior medial calcaneal tuberosity; it divides distally into five slips attaching at the proximal phalanges, acting as a truss to maintain the longitudinal arch of the foot and to facilitate shock absorption during ambulation and other weight bearing.2-5

Physiological and Biomechanical Foot Changes Leading to Plantar Fasciitis

The prevailing hypotheses regarding the pathophysiology of plantar fasciitis involves biomechanical stress leading to inflammation of the plantar fascia, resulting in tightening of the fascia during non-weight bearing periods.6-8 Biomechanical stressors are common in specific populations, such as:

  • obese individuals
  • individuals who engage in prolonged standing or jumping
  • people with flat feet or high arches
  • anyone with reduced ankle dorsiflexion8,2
  • Consistent joggers/runners, suggesting that repetitive microtrauma may contribute to underlying etiology.2

Dancers, especially those performing aerobic-type movement, also suffer from plantar fasciitis due to stress on the Achilles tendon, which translates through the calcaneus to increase tension (and hamstring tightness may produce decreased knee extension and increased load to the forefoot, resulting in increased plantar fascia stress).2

Physical activities and dysfunction may introduce repetitive microtrauma with high calcaneal pressure; opposing traction of the forefoot and Achilles tendon may lead to microtears in the central bundle of the plantar fascia.9,10 When cumulative cellular damage is exacerbated by a failed healing pattern that leads to zones of both hyper- and hypoplasia,11 normal collagen repair cycles may be disrupted, leading to a continuum of cellular damage similar to that in Achilles tendinosis and lateral epicondylitis.12,13 Microtrauma and disruptions in healing and collagen repair can lead to the development of hyperirritable, tender points in taut fascia that refer pain when palpated or compressed by weight-bearing activities, known as myofascial trigger points.14

Evidence also points to a central nervous system role in chronic tendinopathies with programmed cell death (apoptosis), tissue breakdown, and collagen degeneration at the origin of the plantar fascia at the medial tubercle of the calcaneus, accompanied by a distinct lack of chronic inflammatory cells, suggesting that in the chronic stages, plantar fasciitis is not mediated by inflammatory processes.9,10,15,16 Thus, repetitive microtears overwhelm inherent repair mechanisms, rather than perpetuate chronic inflammation.16 Acute inflammation, as well as chronic stress to the plantar fascia may result in a greater morbidity and presents a difficult choice for individuals who maintain regular exercise or whose employment requires extended standing or reliance on active use of their feet. Successful treatments account for the development of acute inflammatory etiology of plantar fasciitis and anticipate its progression into a chronic, degenerative problem.

Other common causes of plantar fasciitis and plantar foot pain should be considered in the differential diagnosis such as inflammatory disorders (especially, spondyloarthropathies), neurologic conditions (ie, neuropathies, nerve entrapment), skeletal causes (ie, stress fractures, trauma, calcaneal fractures, osteomyelitis and malignancy), and soft tissue causes (eg, heel fat pad inflammation).

(Source: 123RF)

Making a Differential Diagnosis

Patients typically present with complaints of sharp pain localized to the medial aspect of the heel at the calcaneal insertion of the Plantar Fascia. Pain patterns may also involve the arch of the foot, typically during the first few steps in the morning, or after long periods of non-weight bearing.2,6,7,17,18 Regarding the former, after about 10 to 20 steps, the plantar fascia will begin to stretch, allowing for a gradual decrease in the sharp, burning pain. However, symptoms such as a throbbing, dull ache or fatigue-like sensation in the medial arch of the foot commonly recur after prolonged periods of standing (or weight bearing).17-19

The diagnosis of plantar fasciitis is typically made on the basis of a thorough history and physical exam. In assessing the patient, particularly with runners and athletes, careful attention to the six S’s (shoes, surface, speed, stretching, strength, and structure) may assist the clinician in confirming a diagnosis.20 On physical exam, plantar fasciitis will elicit local point tenderness along the bottom of the foot. This is best achieved by dorsiflexing the patient’s toes, pulling the plantar fascia taut, and then palpating along the plantar fascia from the heel to the forefoot.2 Tender points due to microtrauma and disrupted healing confirm such a diagnosis, but also represent markers for treatment focus, such as with osteopathic manipulation or corticosteroid injections.2,21

Laboratory, radiographic, and ultrasonographic studies are generally not necessary to diagnose plantar fasciitis. While not routinely used, ultrasound imaging may show evidence of a thickening of the plantar fascia and associated edema from inflammation. The diagnostic utility of ultrasound for plantar fasciitis has not yet been shown as beneficial for routine use.2,22,23 However, these diagnostic modalities may be useful in considering the full differential diagnosis of foot and heel pain.

Common Approaches for Short- and Long-Term Relief

Multiple treatment modalities for plantar fasciitis are available. The most commonly utilized options include glucocorticoid injections, dry needling, braces, and orthotics. The majority of patient cases respond to conservative, nonsurgical therapies within 6 to 18 months.24-26 However, approximately 5% to 10% of patients may progress to require surgical intervention to achieve sufficient restoration of function and pain relief.26

Glucocorticoid injections: Injections of glucocorticoid are commonly recommended when conservative options such as braces, orthotics, physiotherapy, and stretching fail after four weeks of therapy.2 Tender points along the plantar fascia are injected with glucocorticoid alone, or mixtures of glucocorticoid and local anesthetic, resulting in short-term pain relief and reduction of inflammation. Findings reported from randomized trials suggest significant pain control at four-week follow up with mixtures of glucocorticoid and local anesthetic injections while long-term benefit was found in a single injection of glucocorticoid at 12 weeks.2

However, these trials did not indicate any difference in relief from palpation – versus ultrasound-guided injection, nor was there a difference in single versus peppered injections of glucocorticoids.2 Judicious use of glucocorticoids is necessary given the risk of heel pad atrophy in rare cases of plantar fascia rupture.2,5 Common adverse effects of injection include pain, minor subcutaneous bleeding, and risk of infection.

Acupuncture: Acupuncture is a commonly employed pain relief method drawn from traditional Chinese medicine. Similarly, dry needling has been used for the treatment of musculoskeletal pain associated with trigger points.8,14 Since patients suffering from plantar fasciitis may develop myofascial trigger points, dry needling has been shown to alter the biochemical and electrical environment within myofascial trigger points of skeletal muscle and ligaments with a reduction in substance P and increase in beta-endorphin levels and blood flow.14

Results of a meta-analysis of 7 trials indicated that dry needling of myofascial trigger points resulted in significant pain reduction as compared to placebo with maintenance of pain relief at 12-month follow up.14 However, data on the effectiveness of dry needling versus injection is lacking. Common adverse side effects of dry needling include pain, minor subcutaneous bleeding, and risk of infection at treatment sites.

(Source: 123RF)

An Osteopathic Medicine Approach

The Osteopathic philosophy is based in a holistic treatment of any problem and considers addressing pain and dysfunction as well as identifying the cause of pain. Osteopathic physicians (DOs) utilize a broad variety of manual, hands-on techniques collectively described as osteopathic manipulative treatment (OMT). While appropriate osteopathic training is necessary to perform OMT, holistic approaches may be employed by a variety of health professionals in the evaluation and treatment of plantar fasciitis. Multiple OMT techniques have extensive clinical history in treating plantar fasciitis, and will be described briefly but a detailed discussion of OMT techniques are beyond the scope of this paper.

Strain/Counterstrain: This technique involves identifying tender points in the tissue and passively positioning the tissue to approximate the bony attachments of muscle taking advantage of natural neuromuscular reflex arcs to relax tissues.20,21,27-29 When the foot is properly positioned, the tender point may no longer feel as painful. To achieve relief, this position is held for 90 seconds after which the foot is permitted to passively return to normal. Tender points amenable to counterstrain treatment are found at insertion of the plantar fascia—at the calcaneus, as well as in the belly of the quadratus plantae muscle.20,27,28

Muscle Energy: This technique involves active engagement of the muscle by the patient and is especially useful in reducing hypertonicity of muscle groups, particularly in the extremities. The clinician will position specific muscles, then ask the patient to exert a brief, three-second, low intensity flexion of the muscle. The muscle is further stretched between repeated actions of muscle flexion. In general, techniques for plantar fasciitis target muscle groups, including the anterior and posterior tibialis muscles, peroneus muscles, gastrocnemius, quadriceps, iliopsoas, and hamstrings.20 Dysfunctions of these muscles may be prominent in athletes, dancers, and gymnasts, and may perpetuate or mimic plantar fasciitis.2,29

Myofascial Release: In this technique, the practitioner engages and holds tissues in specific positions either generating or releasing tension in the tissues.27 Plantar fasciitis may be approached with a direct application of myofascial release, with the physician applying distal and medio-lateral traction on the plantar fascia and overlying soft tissue and skin.27

Balanced Ligamentous Tension/Articular Strain: This approach aims to treat ligamentous strains in the lower extremity by positioning the bony attachments to reduce and naturally rebalance tension in ligamentous structures employing sclerotomal neurologic reflexes.20,27-29 Useful areas of focus include the metatarsals and interosseous membrane between the tibia and fibula and the calcaneus.

Articulatory and High Velocity, Low Amplitude (HVLA): These methods correct for misalignment and malrotation of bones in the lower extremities especially those of the foot, ankle, and leg, which disrupt normal tensions in tendons and ligaments. These techniques involve the correction of bone and joint position through thrusts to the affected bone or joint and are frequently used in chiropractic and other forms of manual medicine. The bones of the foot represent key areas of focus in foot pain, in particular plantar fasciitis, because of their ligamentous and muscular attachments within the arches.30

Other modes of treatment for foot pain with anecdotal support include: weight loss, stretching regimens such as yoga, anti-inflammatory foods, nutritional supplements, topical capsaicin (ie, for osteoarthritis), conventional physiotherapy, extracorporeal shock wave therapy, immersion contrast baths, autologous whole blood or platelet-rich plasma injections, and Botulinum toxin A injections (to address paralysis of the adjacent flexor digitorum brevis muscle).31

Conclusion

Usually a comprehensive physical exam and history will be sufficient to establish a diagnosis of plantar fasciitis, especially when pain is elicited by pressing on the calcaneal insertion of the plantar fascia. While laboratory or imaging studies are usually not necessary to make a diagnosis, these diagnostic options may be utilized as needed to rule out other conditions. Fortunately, there are a wide variety of treatment modalities, which should focus on addressing the histopathologic changes in both the acute and chronic phases of plantar fasciitis. While glucocorticoid and dry needling are used most often, holistic approaches may be valuable clinical tools. As such, osteopathic manipulation represents an additional time-tested and widely utilized manual management modality that recruits the self-healing ability of the body to address pain in tissues but also to consider other structures that may have caused the plantar fasciitis to develop.

Last updated on: November 7, 2018
Continue Reading:
Effective Protocol for the Management of Plantar Fasciitis
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