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 Tendonosis is a degenerative process that likely results from a decreased blood flow to the pathologic area.13 Inflammation may actually be a positive sign in the treatment of plantar fasciosis. Almekinders notes “it could be argued that an inflammatory response within a tendinopathic area is actually needed since an inflammatory response appears to be predictable followed by a proliferative healing response in healing of collagenous tissues.”3,14
What The Research Reveals About NSAIDs And Corticosteroid Injections
If plantar fasciosis is not an inflammatory condition, as basic objective medical science has conclusively demonstrated, why are we still basing so much of our conservative care on the use of modalities and protocols centered around corticosteroid injections and NSAIDs? I am willing to venture that nearly every podiatrist in the United States uses NSAIDs to treat plantar fasciosis. Surprisingly, researchers have found that NSAIDs are not beneficial in comparison to simple analgesics. They have also found that corticosteroid injections do not improve the natural history of tendonopathy.2,15 Altay, et. al., demonstrated no clinical improvement in efficacy for a corticosteroid injection versus simple lidocaine injection in the treatment of lateral epicondylitis (tennis elbow).16 They administered both agents with a “peppering” technique of 40 to 50 passes through the single injection site without removing the needle from the skin. In the lidocaine group, 56 out of 60 patients demonstrated a good/excellent outcome at one year. In the steroid group, 57 out of 60 patients demonstrated a good/excellent outcome. These authors theorized that the actual patient benefit resulted not from the injected agents but rather from making multiple passes through the tendonosis tissue with the needle.16 This mechanical disruption of tendonosis tissue is theorized to act as a debridement. This in turn promotes an inflammatory response, which is a necessary phase in the wound healing cascade.
Should You Exhaust Conservative Care Before Considering Surgical Options?
In regard to patients diagnosed with plantar fasciosis, there is still pervasive dogma within the podiatric and orthopedic professions that you have to treat these patients with a failed, exhaustive course of conservative care for a period of three months to one year. The assumption or requirement that a long course of failed conservative care is necessary prior to any surgical intervention is erroneous on two fronts. First, unlike many other medical conditions that have different levels of severity and pathological stages (for example, malignant melanoma), plantar fasciosis does not have an accurate staging or grading system.17 One also cannot expect all presentations of plantar fasciosis to respond equally to ill-defined and often nebulous forms of conservative care regardless of the degree of pathology. Indeed, this premise of a long period of conservative care is largely based on the false assumption that plantar fasciosis is an inflammatory condition when it is not. Basic medical science findings in many instances have eclipsed our current clinical paradigms for the treatment of plantar fasciosis. In contradistinction to the overwhelming basic medical science research, there are virtually no scientific robust studies documenting the efficacy of conservative care treatment modalities for heel pain.18 Atkins, et. al., performed a systematic review of different modalities of treatment for the painful heel, and found only 11 randomized controlled studies, which were comprised of small sample sizes and poor methodological construction. The review authors concluded “it was not possible to produce robust evidence of effectiveness for any of the treatments evaluated in the included randomized controlled trials.”18 One can see a basic listing of these 11 randomized controlled studies in “Is There Enough Evidence Of Effectiveness For Conservative Modalities?”. Clearly, after one considers the extremely minimal scientific research and the relatively few numbers of patients in these studies, it is difficult to accept any promulgation of efficacy for any conservative therapy modality on scientific merit. In fact, this contentious point often is the focus of medicolegal discussions and is frequently an allegation by a plaintiff. Some expert witnesses proffer a “standard of medical care.” Then there are the subsequent legal arguments of what constituted an adequate course of conservative care. Did the plaintiff deserve three pairs of orthotic devices and just one more night splint before the defendant performed surgery? Where did this dogmatic approach emanate from and what has propagated it over the last 60 years? Clearly, something that previously made clinical sense with the backdrop of 1940s and ‘50s surgical techniques (and lengthy recovery from open heel surgery) should not hold true today, especially within the current context of better medical understanding and the emergence of improved diagnostic and therapeutic modalities. Peruse any of the many biographies of Joe DiMaggio, an icon of the 1940s and ‘50s, and you will read accounts of his long and difficult postoperative recovery from plantar fasciosis. While stories such as these are certainly lamentable, the decades-old failings of the past still set the tone for entrenched dogma about long exhaustive periods of failed conservative care prior to any surgical intervention for heel pain syndrome.
Musculoskeletal Ultrasound: Is It An Expensive Gimmick?
It is sad and has been personally frustrating to have patients show up for a second or third opinion because they have not gotten better with months and, many times, years, of failed conservative care because of their misdiagnosed plantar fasciosis. The use of high-resolution diagnostic ultrasound has shown that many of these patients did not to have any demonstrable pathology within their plantar fascia but actually had a different etiology (usually a nerve entrapment) for their heel pain. Now there are some who say that utilizing diagnostic ultrasound to diagnose and evaluate plantar fasciosis is a gimmick and a money making gimmick at that, and that one can make the clinical diagnosis with simple palpation of the medial calcaneal tubercle. While any technology has the potential to be used injudiciously, there is no technology, including MRI, which provides for a clearer evaluation of human plantar fascia than diagnostic ultrasound (see “How To Detect Chronic Heel Pain With Musculoskeletal Ultrasound” on page 66). In regard to skeptics of diagnostic ultrasound, who purport that it is an overutilized gimmick, I would counter that treating a patient for months and months with failed orthotic devices, repeated steroid injections and other costly modalities — only to find that the patient does not have plantar fasciosis via objective testing — is an even bigger gimmick and greater disservice to the patient. Given the objective nature of this technology in combination with what we know from basic medical science research, there should be a paradigm that stages plantar fasciosis similar to the pathology staging of different cancers. This staging of plantar fasciosis would allow the clinician to make a better and more informed assessment of the patient’s condition, and subsequently select a more efficacious and faster treatment regimen.
Are There Shortcomings To The ACFAS Guidelines For Treating Heel Pain?
The American College of Foot and Ankle Surgeons (ACFAS) has developed preferred practice guidelines for the treatment of heel pain with different pathways and recommendations.19 Their complex and lengthy algorithms of treatment are based on appropriate lower extremity physical examination, which they describe as: “… (including) range of motion of the ankle with special attention to decreased range of motion of dorsiflexion of the ankle, palpation of the inferior medial aspect of the heel, palpation of the medial aspect of the heel, the occurrence of bilateral symptoms, and angle and base of gait evaluation.” In the mechanical heel pain pathway, the authors of the guidelines make no mention of using diagnostic ultrasound, especially in the initial part of the evaluation, to objectively evaluate and grade the level of plantar fasciosis. However, they do recommend NSAIDs, corticosteroid injections and home cryotherapy (meaning ice or cold, not freezing with liquid nitrogen), all of which are treatments oriented toward an inflammatory condition, which we now know does not exist in this condition we are treating. At two to three months, if there has been no improvement in the patient’s clinical response, the ACFAS suggests that clinicians consider other diagnoses. This is a long period of time (not to mention the expense) to put the patient through before considering other diagnoses or true objective evaluation of the extent of the plantar fasciosis.
Emphasizing The Need For A Validated Scoring System
I propose that the scoring system I developed be scientifically validated and refined (see “What The Heel Pain Scoring System Entails”).20 After determining the patient’s heel pain score, one could subsequently implement a suggested treatment algorithm based upon this scoring system (see “A New Treatment Algorithm For Plantar Fasciosis”). Given the advent of diagnostic technology, such as musculoskeletal ultrasound and neurosensory testing with the Pressure Specified Sensory Device (PSSD, Sensory Management Services), and the increased awareness of multiple etiology heel pain syndrome (MEHPS), we must develop a new heel pain protocol or paradigm. There are numerous cases of documented peripheral nerve entrapments that can closely mimic plantar fasciosis. This is in addition to those cases in which both etiologies are present.21 By initially scoring the patient and implementing the indicated diagnostic testing from the heel pain score, one can correctly diagnose the etiology of the heel pain, and proceed with more focused and appropriate treatment initially. It makes absolutely no sense to subject the patient to a long period of expensive conservative care based on the dogma that all plantar fasciosis is of the same degree.
Emerging Treatments: From The Intriguing To The ‘Incredibly Ridiculous’
There currently are some interesting and medically sound interventional treatments for plantar fasciosis. These interventions include extracorporeal shockwave therapy, the injection of autologous platelet concentrate to deliver growth factors, and coblative techniques. Endoscopic plantar fasciotomy (EPF) has stood the test of time with nearly 1 million procedures performed worldwide. With what we have learned about postoperative management, the success rate for EPF is high and the complication rate is low. However, there are also incredibly ridiculous, medically unsound and simply dangerous treatments now being presented to the podiatric profession. One of these treatments is cryotherapy (liquid nitrogen). Proponents of cryotherapy advocate freezing of the peripheral nerves of the heel so the patient will not “feel” his or her plantar fascial pain. This type of intervention will cause a peripheral nerve injury and can result in disastrous consequences. It is well documented that freezing peripheral nerves can result in “neuromas in continuity,” a serious nerve injury, instead of the desired conduction block.22 Certainly for a condition such as plantar fasciosis, which clinicians can treat successfully with existing modalities, there is no reason to inflict potentially serious peripheral nerve injury and potentially subject practitioners to medicolegal risk.
Given the existing diagnostic technology and what we know about heel pain, specifically plantar fasciosis, there is an impetus to change the way we diagnose and subsequently treat heel pain. I look forward to the day when the average heel pain patient receives a universal score which everyone understands, and clinicians can subsequently institute the most efficacious treatment immediately. Hopefully, we will reach a point where we no longer have the onus of having to treat a patient with six months or more of expensive and failed conservative care when, in fact, he or she may have a different etiology or multiple etiologies for heel pain. This is not an appeal to abandon well-proven conservative, non-interventional modalities for plantar fasciosis. It is a call for the development of a greater awareness of how basic medical science research and improved diagnostic techniques may enhance our ability to treat this endemic condition through the development of better protocols, and the recognition that plantar fasciosis has different levels of severity from case to case. Dr. Barrett is a Fellow of the American College of Foot and Ankle Surgeons, and is an Associate Professor within the Arizona Podiatric Medicine Program at Midwestern University College of Health Sciences in Glendale, Ariz.
1. Aldridge T. Diagnosing heel pain in adults. Am Fam Physician, 2004. 70(2):332-8.
2. Almekinders LC and Temple JD. Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature. Med Sci Sports Exerc, 1998. 30(8):1183-90.
3. Almekinders LC. Breaking with tradition. Rehab Manag, 2002. 15(6):40-2, 45.
4. Ashe MC, McCauley T and Khan KM. Tendinopathies in the upper extremity: a paradigm shift. J Hand Ther, 2004. 17(3):329-34.
5. Khan KM and Maffulli N. Tendinopathy: an Achilles' heel for athletes and clinicians. Clin J Sport Med, 1998. 8(3):151-4.
6. Khan KM, et. al. Time to abandon the “tendinitis” myth. BMJ, 2002. 324(7338):626-7.
7. Maffulli N, Khan KM, and Puddu G. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy, 1998. 14(8):840-3.
8. Lemont H, Ammirati KM, and Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc, 2003. 93(3):234-7.
9. Larson EE, et al. Accurate nomenclature for forefoot nerve entrapment: a historical perspective. J Am Podiatr Med Assoc, 2005. 95(3):298-306.
10. Astrom M. Partial rupture in chronic Achilles tendinopathy. A retrospective analysis of 342 cases. Acta Orthop Scand, 1998. 69(4):404-7.
11. Jozsa L, et. al. [Pathological changes in human tendons (experience in 1791 tendon studies)]. Morphol Igazsagugyi Orv Sz, 1987. 27(2):106-10.
12. Jarvinen M, et. al, Histopathological findings in chronic tendon disorders. Scand J Med Sci Sports, 1997. 7(2):86-95.
13. Taylor MA, et. al. The response of rabbit patellar tendons after autologous blood injection. Med Sci Sports Exerc, 2002. 34(1):70-3.
14. Almekinders LC, Vellema JH, Weinhold PS. Strain patterns in the patellar tendon and the implications for patellar tendinopathy. Knee Surg Sports Traumatol Arthrosc, 2002. 10(1):2-5.
15. Petri M, et al. Randomized, double-blind, placebo-controlled study of the treatment of the painful shoulder. Arthritis Rheum, 1987. 30(9):1040-5.
16. Altay T, Gunal I and Ozturk H. Local injection treatment for lateral epicondylitis. Clin Orthop Relat Res, 2002(398):127-30.
17. Vollmer RT and Seigler HF. Using a continuous transformation of the Breslow thickness for prognosis in cutaneous melanoma. Am J Clin Pathol, 2001. 115(2):205-12.
18. Atkins D, et. al. A systematic review of treatments for the painful heel. Rheumatology (Oxford), 1999. 38(10):968-73.
19. Thomas JL, et. al. The diagnosis and treatment of heel pain. J Foot Ankle Surg, 2001. 40(5):329-40.
20. Barrett SL. A guide to neurogenic etiologies of heel pain. Podiatry Today, 2005 18(11):36-44.
21. Rose JD, Malay SD, Sorrento DL. Neurosensory testing of the medial calcaneal and medial plantar nerves in patients with plantar heel pain. J Foot Ankle Surg, 2003. 42(4):173-7.
22. Schneider RK, Mayhew IG and Clarke GL. Effects of cryotherapy on the palmar and plantar digital nerves in the horse. Am J Vet Res, 1985. 46(1): p. 7-12.