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Should You Change Your Approach To Plantar Fasciosis?

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Hi Everyone

The terms plantar fasciosis, plantar fasciitis or plantar heel pain are interchangeable. Is it purely semantics or is it degenerative or inflammatory in nature?

What would be of interest to me is how we diagnose heel pain? Clinicians and academics may differ. For example, should it be based purely on clinical features and symptoms? Should we include extensive diagnostic and biomechanical tests as criteria? Do we just ask the patients based on pain experience?

Also, what do people think the difference is between acute and chronic – how do we differentiate between the two phases?

A consensus opinion may help us in developing a non-surgical intervention package based upon set criteria.

Don't know if I like what is said in the article, but I admire the attempt to try and make the catergory more specific.


Like "low back pain". Typical advice for LBP is "walking is good for it", "swimming is good for it", and "do not rest...remain active".
Rubbish. It depends on what type of LBP it is.


When we understand the condition more specifically, treatments and research can be better targeted, and hence the former can have more clinical relevance...in the main.

I kind of liked what was said, particularly with reference to the quantities of anti-inflammatories prescribed for this and like conditions.

In the UK I believe that NICE (National Inst for Clinical Excellence) have advised GPs that cortisone injections are no longer recommended as a first-line treatment, so I'm not too sure that the article throws up anything new, but I do like the idea of categorising and tabulating both the condition and the severity of that condition.

I see a lot of PF in my Practice, and the way it is treated (by GPs) runs from oral anti-inflams to cheap OTC orthoses, and thence to cortisone injections.
Feedback is that few if any are offered even basic footwear advice regarding height of heel.
Of course, I only see the pts who still have symptoms, so I don't really know how many respond to these interventions, but I have yet to see a robust case (EBM) for the way most PF pts are treated within the NHS system.

Regards,
david

I read the article myself and it was food for thought and counter to what we were taught in school.Dr.Barrett says that plantar fasciosis is not inflammatory,but then I read an article stating that scintigraphy is a good tool to predict the success of injection therapr because one can see where the areas of increased uptake are.....sounds to me like we are discussing inflammation here.
I do agree with one premise:There,of course,is a degenerative element to PF,but I just am not 100% convinced that there is no inflammatory element.Anecdotally,I do see patients feel better after an injection or 2 into the plantar fascia.I do also like what he says regarding the "peppering" technique.

re plantar fasciosis. I think we are seeing the beginning of an understanding that there are multiple entities which reside in the one plantar heel pain syndrome we are familiar with. Some will be inflammatory, some not. However, it is not diagnostic of inflammation that an NSAID has been efficacious. Nerve irritation or compression, not true inflammation, will be mitigated by an NSAID as well. I have been appreciative of Harvery Lemont's article in JAPMA some years back on this subject.

Plantar heel pain was clinically diagnosed as Inferior Calcaneal Bursitis if a lateral X-ray was negative for plantar spur. If a spur was present our diagnosis was plantar heel spur. This was circa 1975 in New York. Plantar fasciitis was diagnosed when there was a palpable tenderness within the central band of th fascia under the Medial Arch, This of course is much less common and is more consistent with fibroma.
Graham an orthopedic surgeon from Texas in the early 80's thought that heel pain and inferior spur were due to stress fractures of the plantar medial tubercle. Baxter, also an orthopedic surgeon from Texas assumed that all heel pain was neurogenic via compression or traction to the first branch of the lateral plantar nerve.
Harvey Lemont whom micro pathologically examined resected plantar heel spurs with fascia and muscle insertions to the plantar heel for 40 years stated that there were no observed evidence of acute inflammation but only chronic myxoid/chondriod degenerative tissue changes consistent with degenerative enthesopathy.
My clinical opinion is that I would agree with Harvey Lemont/ The pain is neurogenic because the pain sensors within the insertion of the central band of the fascia and the periosteum of the plantar medial tubercle are via the first branch of the lateral plantar nerve and that when the fibers of the central band of the fascia eventually heal then the symtoms will resolve. MY OPINION is that Plantar Heel pain will resolve with time. Assuming no radiculapathy of spondyloarthropathy the only other eitiology for plantar heel pain is in elderly patients with loss of elasticity of their plantar heel fat pad with a rigid foot usually planus and the plantar medial tubercle is palpable plantarly.
Steven Levitz DPM NEW YORK

Post static dyskinesia and heel pain is a common clinical presentation Inflammation is well suited as a mechanism to explain this pain pattern.

What alternative explanation can be offered if instead it is assumed that the pain is primarily neurogenic? Is it possible for an irritable nerve to initiate an acute pain response after rest, which settles after a brief period and becomes worse with continued activity? And what then is the underlying causative factor: increased tension in the plantar fascia causes selective disruption to those pain fibres overlying the plantar medical calcaneal tubercle: how? Simple tissue tension / weight bearing compression could do it perhaps.

If the inflammation is not important, how can we explain the often dramatic (but also sometimes totally inert) effect of cortisone infiltration and other anti-inflammatory measures? And on those occasions when heel pain is followed up with radioisotope bone scans demonstrating positive uptake how is this finding related?

When ultrasound studies are used to measure the plantar fascia thickness and there is a demonstrable difference is this a separate phenomenon?

When fascia samples are taken the disease is already well established and can represent the more advanced stages of this syndrome on a line of continuum.

Is it more likely there is no single cause for heel pain and as suggested instead there are sub groups, which require clinical identification so that the best treatment programme can be determined. Predominantly inflammatory / neurogenic / heel pad related with secondary additional findings?

In my clinical experiance non trauma heel pain usually is composed of multi sub groups the most common - medial calcaneal neuritis ,distal tarsal tunnel,calcaneal periostis,bursitis,stress/strain neuritis,plantar fasciitis . Ive found in-office diagnostic ultrasound a very valuable tool in evaluating heel pain allowing real time imaging with direct feed back from patient. Patients with fasciitis show increased hypoechoic thickening at times with intrafascial tears,sub cal bursas,other inflammatory changes. But they may also have a concurrent nerve entrapment secondary to local inflammatory compartment syndrome. This may be due to biomechanical induced mictro trauma, etc,etc. Bottom line- heel pain multifaceted classification system nice for research/data collection/guide to treatment protocol. Key to successful practice- listen to your patient's feedback- adjust your treatment based on clinical response. In my practice plantar fasciitiis by itself response well to basic biomechanical tx less than 30 days.Nerve entrapment/compartment syndrome a different story.

I think the point being aluded to above is that the "classic" plantar fasciitis is probably more than one clinical entity. We already have that evidence from a radiology jnl (sorry do not have ref handy) that a percent of those with classic plantar fasciitis have bone marrow oedema in calc at insertion - to me that makes it being >2 types of plantar fasccitis - we have no idea if the clinical symptoms in those with bone marrow oedema are different or if they respond to different clinical modalities ..... so much to do ...

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

We all treat the same heel PAIN
Subjective Pain First step in Morning
Objective Pain on palpation of the Plantar Medial Tubercle
Assesment Heel Pain/Proximal plantar fasciitis/osis
Treatment Antiinflammatorey meds work at times because they also have analgesic properties
Cortisone injections work at times maybe because of their fibrinolytic properties[Just my theory] I am allowed to have theory's aren't I?. This is probably why partial plantar fasciotomy is so sucessfull. All {Fluid/increased uptake or thickening} either on x-ray/ultrasoud/bone scan or MRI in my opinion makes no difference as to diagnosis and treatment.
Again I would assume that we all agree that in almost all of the cases the symptoms resolve. Just my opinion 30 yrs clinical experience
Steve

Dr.Levitz,you taught me in 1990 in Ortho clinic at NYCPM.
Neurologic pain in the heel is an overlooked diagnosis.I had a patient recently who had heel pain but it did not "behave" like a calcaneal spur.I(and another pod) diagnosed nerve entrapment as she presented with typical sequellae of it(severe pain right where the calcaneal nerve is).
I hope our colleagues are not overlooking this.

Hello John
I remmember you during clinical rotation.
If the patient has [subjective pain first step in the morning] and {MOST IMPORTANTLY PAIN ON PALPATION OF THE PLANTAR MEDIALTUBERCLE} THEN THIS PATIENT SHOULD IMPROVE WITH ALL AND ANY OF THE CONCERVATIVE TREATMENTS FOR PROXIMAL PLANTAR FASCITIS. SOME PATIENTS MAY TAKE 12-16 MONTHS TO BE PAIN FREE. When symptoms last for 2 years or more one should be suspicious of malingering. I have seen cases where chronic heel pain is a true intrinsic Plantar Fascia/neuritc pathology and in these cases the patient is either overweight and or on their feet for 8-10 hrs per day or both with stress related work.
GOOD TO HERE FROM YOU JOHN
STEVE LEVITZ
24/7 TREATING PATIENTS WITH FOOT PATHOLOGY
MANHATTAN/QUEENS/BROOKLYN
26 YEARS

Thank you for the advice and for being a great teacher.I did learn a lot from you.I am in agreement with you here,most if not all cases of plantar fascitis/heel spur do resolve with the standard treatments