Should You Change Your Approach To Plantar Fasciosis?

By Stephen L. Barrett, DPM, MBA, CWS

    It is universally accepted that the most common cause of heel pain is plantar fasciitis.1 In this same vein, there is a widespread perception that plantar fasciitis is often easily treated with whatever eclectic “recipe” an individual has developed.

    Interestingly, even our present use of the term “fasciitis” is erroneous, not to mention that there is a huge gap between our general understanding and what basic medical science demonstrates in regard to our clinical understanding and treatment of plantar fasciitis. There have been recent and significant advancements in the treatment of recalcitrant plantar fasciitis over the last two decades during our profession’s push for “outcomes-based” or “evidence-based” medicine. However, there is still a large abyss between our comprehensive understanding of heel pain and what is the most ideal, efficacious and cost-effective treatment protocol for heel pain syndrome.

    Accordingly, let us take a closer look at some of the salient current basic medical science of plantar fasciitis and how these scientific facts either support or refute the current therapeutic modalities and paradigms clinicians currently utilize for the treatment of heel pain. Hopefully, the insights offered here will help to further elucidate the diagnosis of this very common pedal malady, and facilitate improved treatment paradigms and patient outcomes.

    Unfortunately, many specialists within the universe of podiatric medicine as well as other practitioners with a primary focus of foot and ankle pathology generally believe that inflammation is the most common cause of plantar fascial heel pain. Accordingly, they also believe the mainstay of clinical treatment for plantar fasciitis should be antiinflammatory in nature. Many clinicians also mistakenly believe that the etiology of pain in most musculoskeletal conditions is due to inflammation, which various researchers have shown is not the case as evidenced by microscopic histological examination.2-7

    Yet corticosteroid injections and nonsteroidal antiinflammatory drugs (NSAIDs) for the treatment of plantar fasciosis are well accepted, widespread, and are considered keystones of an effective conservative care regimen.

Redefining Plantar Fasciitis: How Much Of A Role Does Inflammation Actually Play?

    Perhaps one of the most pivotal points to address is the fact that what we commonly call plantar fasciitis is not inflammatory but is actually a well

    documented degenerative condition. Accordingly, we should refer to this condition as plantar “fasciosis.”8
It is important to understand that tendonitis is a myth as well as a misnomer. If one extrapolates tendon to fascia and to aponeurosis, then plantar fasciitis also has to be a myth. Medical nomenclature can be very important as the erroneous use of terms can mislead clinical understanding and subsequent treatment.9

    From a histological viewpoint, it is imperative to understand that the human plantar fascia is indiscernible from any other human tendonous tissue. With that said, we are able to draw on large amounts of well-accepted, sound, peer-reviewed scientific data.

    Animal studies conclusively demonstrate that within two to three weeks of insult to tendon tissue, inflammatory cells are not present.6 Anecdotally, I cannot recall a single heel pain patient telling me in the history of present illness that the pain was less than several weeks in duration.

    In his landmark 2003 study, Lemont demonstrated the same findings in human plantar fascia. There were no histological mediators of inflammation within 50 specimens sent by surgeons for pathological examination from their surgical cases treating plantar fasciitis.8 He correctly points out that we should really call this condition “plantar fasciosis” because of its degenerative nature without the presence of inflammation. There are numerous references that substantiate Lemont’s findings.10-12

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