Thursday, August 14, 2008

Plantar Fasciitis

Plantar Fasciitis is an injury caused by excessive stretching of a broad band of fibrous tissue which runs along the bottom surface of the foot, attaching at the bottom of the heel bone and extending to the forefoot. The band stores energy from heel contact in a windlass mechanism and returns most of it to push the foot off the ground. The term is often used to include the layer of muscles which adhere to it. A chronic plantar fasciitis eventually becomes a heel spur in most cases. My treatment will typically begin by determining and addressing the cause or causes of the injury. No injury can have a set cookie cutter treatment. Each patient's treatment plan varies according to the contributing causes.

The common causes and aggravating factors are:

  • Over-pronation (flat feet)

  • But also a foot with a high arch

  • A sudden increase in length and intensity of workouts

  • Excessive weight change

  • Pregnancy

  • Improperly fitting footwear

  • Tightness of the foot and calf (gastocnemius and solues are most common culprits)

  • Training errors

  • Old running shoes

  • Improperly fitting running shoes (especially too wide)

  • Improperly designed running shoes

  • Rheumatoid variant types of arthritis (HLAB27 antigen positive) and disorders of connective tissue healing

  • Running on surfaces too soft

  • fixated or subluxation at calcaneal cuboid and talo-crural joints

The use of medical grade silicone gel heel cushions, and compression socks used as first aid is as close as I come to a universal thing to do. This is rarely curative but is meant to reduce symptoms . Some people like to tape the foot. This is okay for short time intervals as a taping lasts 3-5 days. Socks with spandex woven into them when the need is likely to be more long term. Nonsteroidal anti-inflammatory drugs (e.g. aspirin, ibuprofen, etc.) have significant benefits only in arthritis induced cases. Arthitis induced cases are rare. Most cases of plantar fasciitis lack inflammation. Hence, such drugs often misused for this condition. Deep tissue massage is helpful in some cases. Night splints (which immobilize the ankle during sleep) are well hyped. They have been used with mixed results, at best over the last decade. Stretching and strengthening programs are good for those people who have a tightness of a weakness. Orthotic devices are considered only for those people with a biomechanical fault. A Cortisone injection into the scarred attachment has a success rate of about 50%. Healing modulators, such as injectable preparations containing Arnica Montana have been shown to speed the healing course. Manual mobilization of the calcaneal-cuboid and/or talo-crural joint help those people with subluxations or fixations. The final option, surgery to release the tight fascial bands has a 70-90% success rate. Shockwave therapy fits is as an alternative to surgery. Shockwave or more formally known as Extracorporeal Shockwave Treatment is a relatively new delivery of high energy sound waves to affected areas of the body. It is very similar to the units used in certain cases to brake up kidney stones. It works theoretically by creating controlled injury of the plantar fascia insertion. Proponents are claiming to have success similar to percutaneaous (small incision) surgery. It requires anesthesia and has a timetable similar to small incision surgery. Shockwave theapy is contraindicated in people with diabetes, concurrent nerve-related problems, vascular, pregnancy, clotting disorders (or taking any drug which thins the blood) or various types of arthritis.The present studies I have read on the effectiveness of this therapy are mixed and controversial. Because of this, it is not covered by many insurance companies. The positive studies so far have all been funded by companies who make the unit. I would like to see one by a source with no vested interest before I start to forge my own opinion of the therapy. Only time will tell how good this alternative will be. You have heard the phrase "time heals all wounds? Well time also wounds all heels.

There are also other treatments used in plantar fasciitis by me in cases of an atypical cause of the problem. For example, I remember one athlete on a college scholarship who had seen just about every sports medicine doctor in the Boston area. Both the athlete and her coach were very frustrated after over 3 years of inability to run. The only thing I could find was a wart on the ball of her foot. A wart does not hurt with direct pressure but it usually very painful with side to side pressure. To make a long story short, I removed the lesion and all pain went miraculously away. Not all heel pain is plantar fasciitis. Spinal impingement (at the 5th lumbar or 1st sacral vertebra), tarsal tunnel syndrome, nerve entrapment, Sever's Disease (calcaneal apophysitis), bone cysts and benign tumors can all mimic plantar fasciitis symptoms.

Hopefully this information will enlighten readers of this blog about their McFeet. For we all need help from the sign of the golden arches one time or another.

1 comment:

John Dudley said...
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