Plantar Fasciitis: A Review

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Review Article

Plantar Fasciitis: A Review Nitin Ajitkumar Menon, Jitendra Jain Department of Pain Medicine, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India

Abstract Plantar fasciitis, though a common condition seen by pain specialists, occasionally presents diagnostic dilemmas and very often the management of this condition suffers from lack of awareness of the varied treatment modalities and progressive escalation of treatment options. For this purpose, we searched through all articles with key words of plantar fasciitis or heel pain in the last ten years for which full text was available and compiled a narrative review to guide clinical decision making. An appreciation of pathomechanics of involved structures, possible differential diagnoses and a review of all treatment modalities presented in this article may perhaps help in simplifying matters. Treatment options consist of non-invasive physical therapy modalities, footwear modification, exercise program and newer modalities like shock-wave therapy, minimally invasive treatments like steroid or platelet-rich plasma injections and surgery in recalcitrant cases. Resorting to combining treatment modalities, step-wise escalation of treatment depending on duration of the condition and using our suggested step-ladder approach maybe an appropriate way of treating this condition. Keywords: Extracorporeal shock wave therapy, heel pain, orthotics, platelet-rich plasma, stepladder treatment

Introduction

when bearing weight, and rigid and tense during push off. These opposite functions are carried out to a large extent by the plantar fascia, which acts as a truss during force absorption and as a taut beam to provide rigidity during propulsion.[4] It does this in two ways—by providing stretch tension to support the medial longitudinal arch during weight bearing to prevent its collapse and by acting as a “windlass” similar to tightening of a rope or a cable during propulsive phase to provide tension and keep the foot rigid.[5] Demands on this structure, which are substantial in normal health, may be greatly enhanced in an anatomically abnormal foot, during the performance of activities such as running, or in overweight individuals.

The origin of the problem is nearly always traced to anatomical abnormalities of the foot leading to biomechanical stress on the joints and supporting soft tissue structures, which fail to adjust due to either long-standing and repetitive nature of such demands or supraphysiological loads on them. The human foot has to subserve two important functions: (a) to provide propulsive force during latter part of the stance phase and (b) to absorb the impact of the body weight during the early part. This requires the foot to be soft and flexible

Clinical Features

Plantar fasciitis is the most common cause of heel pain. Approximately 15% of all foot complaints coming to the attention of health-care professionals can be attributed to this cause.[1] This condition also accounts for 8% of all injuries in athletes in running-related sports.[2] Hence, it can be said that this condition is common in both sedentary and athletic population. It is attributed to chronic weight bearing and repeated overload of the foot in daily activities or sports. As a result, some workers have suggested the term “fasciosis” rather than fasciitis because of the chronicity of the condition and the presence of degeneration rather than inflammation.[3]

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Most patients present with heel pain, which develops insidiously, characteristically affecting the medial part, which may radiate into the medial arch of the foot. Pain tends to be worse in the morning or after a period of rest, with maximal discomfort reported during the initial Address for correspondence: Dr. Nitin Ajitkumar Menon, 3/361A Tambe Building, Dr. Ambedkar Road, Matunga (E), Mumbai, Maharashtra 400019, India. E-mail: [email protected] This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. For reprints contact: [email protected]

DOI: 10.4103/ijpn.ijpn_3_18

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How to cite this article: Menon NA, Jain J. Plantar fasciitis: A review. Indian J Pain 2018;32:24-9.

© 2018 Indian Journal of Pain | Published by Wolters Kluwer - Medknow

[Downloaded free from http://www.indianjpain.org on Friday, May 4, 2018, IP: 5.166.112.32] Menon and Jain: Plantar fasciitis

Table 1: Differential diagnosis Originating structure Plantar fascia Soft tissues

Skeletal (bony tenderness)

Neurological (burning or numbness or tingling, night symptoms)

Condition

Salient features

Plantar fasciitis Plantar fascia rupture Fat pad syndrome Heel bruise Bursitis Tendinitis Calcaneal stress fracture

Pain with first steps Sudden, knifelike pain, ecchymosis Atrophy of heel pad Acute impact injury history Swelling and erythema of heel Pain with resisted motion of tendon Pain worsens with prolonged weight bearing Whole skeletal abnormalities Systemic manifestations Adolescent patients Neuropathic pain, nerve conduction abnormalities As above As above Pain in back, radiation to legs, abnormal reflexes History of alcohol abuse or diabetes

Paget’s disease Tumor Calcaneal apophysitis (Sever’s disease) Tarsal tunnel syndrome Posterior tibial nerve entrapment Abductor digiti quinti nerve entrapment Lumbar spine disorders Neuropathies

Source: Modified from Roxas[7] and Cole et al.[8]

few steps, and progressive improvement as the person continues to walk.[6] Pain may also be experienced during chronic overuse conditions such as running. Clinical examination reveals tender areas along the medial part of heel or medial arch in most patients. However, foot should be examined for the presence of anatomical abnormalities such as cavus or planus deformities, restriction of motion of the ankle–foot complex, scar tissue, and loss of heel pad thickness, as well as document any neurological abnormality—particularly, sensory or motor deficits and the presence of Tinel’s sign. A schema for differential diagnosis of heel pain can be found in Table 1.[7,8]

Diagnostic Considerations The diagnosis is generally made on clinical grounds. Characteristic history and pain pattern is sufficient in most cases. Imaging is useful if another diagnosis is being seriously considered. Radiography may reveal the presence of bony spur on the calcaneum. In Indian population, the incidence of such a finding in patients with heel pain is reported to be 59%.[9] Histological analysis of the spur has revealed degeneration and proliferation of fibrocartilaginous tissue along with areas of ossification, further strengthening the argument that this may be a degenerative rather than an inflammatory condition.[10] It is hypothesized that these generate as a result of body’s adaptive response to redistribute impact forces away from calcaneal insertion site to surrounding tissues. Use of diagnostic ultrasound is gaining more favor among practitioners because of its simplicity to use and ability to guide interventions, if required. Common findings seen in ultrasound are increased signal intensity of the plantar fascia, hypoechogenic plantar fascia, and thickness of plantar fascia more than 4 mm.[11] [Figure 1] Alteration of heel pad fat signals may also be picked up Indian Journal of Pain ¦ Volume 32 ¦ Issue 1 ¦ January‑April 2018

on ultrasound, particularly in elderly individuals.[12] Realtime sonoelastography is an upcoming technique that helps in evaluating whether tissues are less or more elastic, and it is shown to be useful in the diagnosis and planning interventions in plantar fasciitis.[13] The superior ability of magnetic resonance imaging (MRI) to provide soft tissue contrast resolution may be used in doubtful cases, but at an added expense and image acquisition time.[14] The most common findings in MRI are calcaneal edema with increased T2 signals in plantar fascia and thickening of plantar fascia on T1 images.[15]

Management The goal of treatment is to decrease pain, promote healing, restore normal range of motion and flexibility of foot, support tissues, correct any biomechanical abnormalities, and institute correct training methods.[16] Stepladder approach is a useful tool to guide clinical decision-making in managing these patients.[17] [Figure 2] Accordingly, step 1 consists of physical therapy, orthoses, and medications to manage pain for 6 weeks. If relief is inadequate, therapy may be stepped up to level 2 comprising local injections, advanced manipulation, and custom orthoses. Patients who have received adequate conservative trial for 6 months may be referred to a foot surgeon. Referral to a nutritional counsellor should be considered in obese individuals.

Step 1 Initial physical therapy options include manual therapy, which promotes normal joint and soft tissue motion; stretching exercises to prevent and treat contracted muscles and soft tissues; various heating and cooling modalities; and taping techniques. There is good evidence for the use of manual therapy, stretching, taping, and foot orthosis for the management of such patients in the 25


Figure 1: Normal plantar fascia on the right and affected plantar fascia on the left with increased thickness and areas of hypodensity

Table 2: Summary of management strategies Treatment Stage Step 1 (0 to 4–6 weeks)

Step 2 (1–6 months)

Noninvasive

Invasive/systemic

Stretching Footwear modification Heat or cold modalities Off-the-shelf orthotics Osteopathic manipulation Strain–counterstrain release Custom orthotics

Acetaminophen Nonsteroidal antiinflammatory drugs

Step 3 (more ESWT than 6 months)

Steroid injections Botulinum toxin Prolotherapy Platelet-rich plasma injections Surgery

short term (1–6 weeks), but evidence for the effectiveness of electrotherapy modalities, physical agents, laser, phonophoresis, and ultrasound is not as robust.[18] Review of various exercise modalities has shown that supervised exercises are better than home exercises, but nature of documented pain relief is short because of inadequate follow-up of clinical trial designs.[19] Advanced forms of physical therapy such as osteopathic manipulation and strain–counterstrain technique have shown promising results in a few cases and may be attempted if initial measures are unsuccessful.[20,21] Orthotics or foot support devices help in reducing pain and improving comfort by absorbing some of the shock due to heel strike that is normally absorbed by plantar fascia. It may also attempt to correct postural deviations that may predispose one to plantar fasciitis.[22] Medial arch support, cushioned heel pads, or insoles are the most commonly prescribed off-the-shelf devices, and all are equally useful without any one being significantly better.[23] Studies have shown that custom orthoses combined with stretching exercise are more effective than either.[24,25] However, some studies have shown that there is no difference between custom orthoses or prefabricated devices.[26,27] Semirigid or rigid devices such as supramalleolar orthosis or University of California and Biomechanics Laboratory (UCBL) foot insert have been tried with varying degrees of success. The UCBL insert has been reported to have 26

superior characteristics with significant pain relief lasting up to 6 months in comparison with heel pads or cups.[28] Use of night splints made in dorsiflexed position of the ankle to promote stretching of plantar fascia has been reported to be effective.[29] Most orthotic devices whether custom-made or bought off the shelf have short-term effect (up to 3 months), but are not proven to be effective in the long term as a stand-alone treatment option.[30] Judicious use of acetaminophen (paracetamol) or nonsteroidal anti-inflammatory drugs may be useful in the initial few weeks to support recovery and promote exercises and other therapies.

Step 2 If the aforementioned measures do not achieve desired results, more invasive treatments may be attempted. Such interventions include dry needling, prolotherapy, injection of local corticosteroids, or the recent platelet-rich plasma (PRP) preparations. Conventionally, depot steroid injections delivered close to plantar fascia insertion at the calcaneum are considered as an effective early intervention. A recent Cochrane review[31] however concluded that local steroid injections, in comparison to placebo or no treatment, may slightly reduce heel pain but only up to 1 month and not subsequently. Tendon rupture, collagen necrosis, plantar fascia rupture, plantar fat pad atrophy, plantar nerve injury, calcaneal osteomyelitis, and skin necrosis are some of the reported side effects of local steroid injections.[32] Palpation-guided injection and ultrasound-guided technique are not significantly different with regard to pain relief.[33] In recent times, interventions that are considered more physiological have generated interest, especially as studies have proven their effectiveness. A study of 84 patients treated with dry needling over a 6-week period showed significant improvement compared to sham needling with pain relief lasting for up to 12 weeks.[34] Myofascial trigger points are identified over the leg and foot muscles, and standard dry needling techniques are used to release these triggers. Dry needling may not improve the range of motion of foot and ankle joints but is reported to significantly decrease pain and improve foot function.[35] Traditional Indian Journal of Pain ¦ Volume 32 ¦ Issue 1 ¦ January‑April 2018


Table 3: Summary of evidence for treatment of plantar fasciitis (Oxford Centre for Evidence-Based Medicine method) Grade of recommendation A A B D

Level of evidence 1,2 1 2 5

Treatment

Exercises ESWT[46] Orthoses[27,28] Nonsteroidal anti-inflammatory drugs[17] B 2 Dry needling[34,35] C 4 Prolotherapy[43] A 1 Steroid injections[31] B 2 Botulinum toxin[37,38] A 1,2 Platelet-rich plasma[40,41] C 4 Surgery[48] A = level 1 studies, B = level 2 or 3, C = level 4, D = level 5, 1 = RCT, 2 = reviews, 3 = case control, 4 = case reports or series, 5 = expert opinion/insufficient evidence [18,19]

highly variable results for singular therapies, and urged the usage of combined therapies to achieve better results.[44]

Step 3 Extracorporeal shock wave therapy (ESWT) is an option for patients not responding to initial line of treatment and with persistent symptoms beyond 3–6 months. Shock waves, generated by a device and delivered to the patient by means of a probe, are believed to stimulate tissue hyperemia leading to vascularization and healing.[45] ESWT is reported to be effective in reducing intensity of pain and improving function lasting up to 6 months, particularly low-intensity type.[46] Shock waves are of two types: focused (concentrating on one particular area) and radial (dissipating to surrounding tissues). In a study of 68 patients in whom radial ESWT (4–8 sessions) was used for the treatment of plantar fasciitis, there was a mean reduction of 86% in visual analog scale scores at 1 year and only 8% recurrence at the end of that period.[47] Extremely difficult to treat cases may be considered for surgery. Patients who do not obtain relief from multiple previous interventions and conservative trials and who are significantly disabled as a result are suitable candidates. Options include plantar fasciotomy, plantar fascia release, and decompression of nerve bundles. Results are considered “good,” but risks of biomechanical deterioration are present with such surgery [Table 2].[48]

Conclusion Figure 2: Plantar heel pain treatment ladder (modified from Thomas et al.[17])

Chinese acupuncture is also reported to be useful in few cases.[36] Botulinum toxin A injected into the painful areas, quadratus plantae and short toe flexors (total 100 units), is reportedly useful in producing relief from pain.[37] A group of 22 patients with heel pain injected with botulinum toxin showed improvement lasting for up to 8 weeks.[38] Injection of PRP obtained by spinning patient’s own blood is helpful in a number of chronic painful conditions including plantar fasciitis.[39] Platelets contain growth factors in their alpha granules, which stimulate fibroblasts, help with the recruitment of other healing cells, stimulate new blood vessels, and promote growth of extracellular matrix. A meta-analysis showed that in 12 studies consisting of 445 patients injected with various preparations of PRP, all showed superior response compared to steroid injections even in single doses, especially when given with peppering technique (multiple punctures).[40] Other studies have also reported similar outcomes.[41,42] Prolotherapy with injection of hyperosmolar dextrose solution (1 mL of 25% dextrose with 1 mL of 2% lignocaine, 3–4 injections 1 week apart) in a group of 40 patients with chronic plantar fasciitis showed improvement lasting for up to 12 months in a small case series.[43] A review of all conservative therapies showed Indian Journal of Pain ¦ Volume 32 ¦ Issue 1 ¦ January‑April 2018

Plantar fasciitis is a common cause of foot pain with a number of treatment options available to the clinician. However, a lack of good quality, randomized control trials makes writing treatment recommendations a challenge. A few principles though may be kept in mind: a. Initial management should consist of ruling out other causes of foot pain with good history, appropriate examination, and imaging studies. b. Physical therapy measures such as stretching, hot or cold modalities, footwear modification, and off-the-shelf orthosis should be prescribed at the outset as they are cheap, fairly effective, and without side effects (grade A, grade B recommendation). c. Interventions such as steroid injection (grade A), PRP (grade A), dry needling (grade B), botulinum toxin (grade B), and prolotherapy (grade C) may be attempted, if the above measures lead to suboptimal pain relief. d. ESWT (grade A) and surgery (grade C) may be reserved for hard to manage cases persisting beyond 6 months, where all other treatment modalities have been attempted [Table 3].

Future Research We encourage well-designed trials comparing each treatment option against standard treatments or placebo to help more precise decision-making. 27


Financial support and sponsorship

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Indian Journal of Pain ¦ Volume 32 ¦ Issue 1 ¦ January‑April 2018

Nil.

Conflicts of interest There are no conflicts of interest.

References

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47. Malliaropoulos N, Crate G, Meke M, Korakakis V, Nauck T, Lohrer H, et al. Success and recurrence rate after radial extracorporeal shock wave therapy for plantar fasciopathy: a retrospective study. Biomed Res Int 2016;2016:9415827. 48. Wheeler P, Boyd K, Shipton M. Surgery for patients with recalcitrant plantar fasciitis: good results at short-, medium-, and long-term follow-up. Orthop J Sports Med 2014;2: 2325967114527901.

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