Growth Factors For Chronic Plantar Fasciitis?
Plantar fasciitis/heel pain syndrome is the most common condition treated by podiatric foot and ankle specialists in the United States.1 However, the true etiology of plantar fasciitis is still unknown and has been attributed to many different etiological factors. Even the term “plantar fasciitis” is a misnomer as the plantar fascia is really a tendonous aponeurosis and not a fascial layer.2
It is entirely possible that our whole paradigm for treating plantar fasciitis is based on a false foundation, especially in light of the histological findings of Lemont, et. al., regarding specimens of resected plantar fascia.3 Clearly, these authors’ objective histological evidence must make all those who treat plantar fasciitis rethink their concept of the true etiology of plantar fasciitis. Their proposal that the condition we so commonly refer to as plantar fasciitis be called “plantar fasciosis” is valid and more accurately describes the condition.
These findings are further supported by histological analysis of surgical biopsies of tendons which were affected by “tendonitis,” but had no markers of inflammation.4,5 An adoption of this correct nomenclature throughout the profession is likely far into the future, but would perhaps orient our understanding of the condition better, which could possibly lead to better treatment modalities and regimens.
It is widely believed that mechanical plantar fasciitis results from repeated microtrauma due to overuse, which results in microtears of the tissue substance until a macro injury occurs. The physiological process is then initiated via an inflammatory process — an integral part of the wound healing cascade. This injury of the plantar fascia is not dissimilar to any other musculoskeletal pathological process, such as a tendonopathy.6
Almekinders and Temple have indicated this may be a too simplistic view that is not accurate in chronic tendon pathology.6 However, there has been suspicion that mechanical repetitive trauma may not be the true cause of the degenerative process in tendonopathy as previously believed. Some studies have shown the area of tendon most often affected by tendonopathy is not the area of the tendon that is subjected to the highest mechanical force.7
Should We Rethink The Treatment Paradigm For Chronic Plantar Fasciitis?
Does this overwhelming data that recalcitrant plantar fasciitis (fasciosis) is not an inflammatory disorder change our paradigm for treating this condition? These findings cast doubt on two of the mainstays of conservative treatment: non-steroidal antiinflammatory agents and the corticosteroid injections. A controlled study has demonstrated that an NSAID was no better than a simple analgesic or placebo in the treatment of Achilles tendonopathy.8 Researchers have also demonstrated that corticosteroid injections do not change the pathological process.9