AND PLANTAR FASCIITIS
A couple sentences after telling us that, "A variety of existing conservative therapeutic options are generally reported as being successful in the treatment of plantar fasciitis," Dr. Allen Jacobs, the author of An Evidence-Based Medicine Approach To Plantar Fasciitis in the October, 2013 issue of Podiatry Today, reveals that, "it is difficult to draw definitive conclusions as to the best non-surgical or surgical options." There is good reason for his statement. According to a position paper from the Department of Rehabilitation Services and Physical Therapy at Bringham and Women's Hospital in Boston, nothing really seems to work very well when it comes to effectively solving Plantar Fasciitis.
"Conservative treatments include non-steroidal anti-inflammatories (NSAIDs), orthotics, heel cups/cushions, night splints, Achilles tendon stretching and physical therapy treatment (including exercise and modalities such as ultrasound, phonophoresis, iontophoresis and friction massage). All of these interventions have demonstrated some positive effect in the outcome of plantar fasciitis, however there is no consensus as to which modality or combination of modalities is the most effective. In their systematic review of literature for the Cochrane Collaborative, Crawford et al, concluded there was limited evidence that any of the conservative treatments were any more effective than no treatment at all."
Plantar Fasciitis (an INFLAMMATION of the FASCIA on the bottom of the foot) is not only miserable (it affects approximately 1 in 10 Americans), but in some cases can be debilitating. Whenever I see people who have struggled with PLANTAR FASCIITIS, I can assume, before even talking with them, that among other things such as NSAIDS, they have had CORTICOSTEROID INJECTIONS. In light of how ineffective "conservative" treatment of PF is, how well do injections work?
Just before telling us that, "a retrospective review of 765 patients diagnosed with plantar fasciitis reported that of the 122 patients who had received a steroid injection, 44 patients (36%) had a fascial rupture as a result of the injection," a 2008 issue of the Journal of Orthopedic and Sports Physical Therapy (Heel Pain—Plantar Fasciitis:Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health) said that, "there is limited evidence to support the use of steroid injection to provide short-term pain relief." Did you catch that? They are not talking long term solutions here; only short term pain relief --- and injections don't even work for that. But as to long term solutions; The Mayo Clinic's website tells us why these injections aren't recommended as a long-term solution either. "A major concern with steroid injection has been the risk of subsequent plantar fascia rupture and plantar fat pad degeneration. Injecting a type of steroid medication into the tender area can provide temporary pain relief, but multiple injections aren't recommended because they can weaken your plantar fascia and possibly cause it to rupture, as well as shrink the fat pad covering your heel bone."
A brand new study from last month's issue of Experimental and Therapeutic Medicine (Corticosteroid Versus Placebo Injection for Plantar Fasciitis: A Meta-Analysis of Randomized Controlled Trials) concurred. In this meta-analysis that included crunching data from a number of studies comparing Corticosteroid Injections to sugar pills (Placebo), it was determined that after two months, "no difference was detected with respect to the VAS. Corticosteroid injection may provide pain relief for a short period of time, but the efficacy may disappear with the progression of time." The VAS (Visual Analog Scale) is the little chart where you list your pain on a scale of one to ten every time you go to the doctor. Not exactly a ringing endorsement for using Corticosteroids for PF.
And if they don't find relief with injections, people will eventually turn to other forms of treatment like ESWT (Extracorpreal Shock-Wave Therapy), which is a heavy duty dose of ultrasound --- similar to the sort they use to break up kidney stones. Although it's been around for decades, I have seen a great deal of conflicted information about this technique being used for those with Plantar Fasciitis. Aetna Insurance says right on their site that they don't cover this procedure because they consider it to be, "experimental and investigational for plantar fasciitis because its effectiveness has not been established." Which leads me to something you've undoubtedly already tried if you've read this far --- orthotics.
In his paper, Dr. Jacobs throws cold water on orthotics when he reveals that, "Studies supporting the utilization of orthotics for the treatment of plantar fasciitis are not overly convincing. Pfeffer and colleagues demonstrated the superiority of stretching exercises only, rubber inserts, felt inserts and silicone inserts in comparison to custom orthotics for the treatment of plantar fasciitis. Landorf and coworkers demonstrated that a prefabricated orthotic was superior to customized orthotics for the reduction of plantar fascia pain". I have been seeing similar studies for years --- a reason that like ESWT, many insurance plans will not cover them.
So; nothing is working and you feel you are out of options. It's now time to get serious. Here is my three-pronged approach to dealing with even the most stubborn and debilitating cases of PF --- probably in this order. For minor cases, you may be able to skip the second bullet point.
- CONTROLLING INFLAMMATION: As you might imagine, one of the factors associated with most orthopedic conditions of the lower extremities (PF included) includes being overweight. Not only is the Plantar Fasciitis itself considered to be an inflammatory condition (the word "itis" indicates Inflammation), but so is OBESITY. Read my last 4 or 5 posts on Inflammation (HERE) to see why it is so heavily associated with SCAR TISSUE / FIBROSIS. A failure to deal with Chronic Systemic Inflammation will be the deal breaker as far as you getting better, if you have stubborn PF. For those hoping to deal with Inflammation via drugs, re-read the first part of this post.
- ORTHOTICS: Wait a minute. I just told you that the peer-reviewed literature frowns on using orthotics to correct Plantar Fasciitis. Because I had PF for at least a decade to the point I was at times ready to have my foot amputated, I have some "earned" credibility in this department. Sure; try some cheap orthotics first, but before you end up with dozens of pairs that don't work, call Shawn Eno of Xtreme Footwerks in Idaho Springs, CO. This is doubly true if you have a high arch. All I can say is that Shawn is the man. Unlike the average practitioner, Shawn understands lower extremity biomechanics as well as anyone on the planet --- and knows how to correct biomechanical deficiencies using orthotics. Not to mention the fact that he solved my problem, despite the fact I had a trash bag full of B.S. orthotics hanging on the wall in my basement. Trust me when I tell you that 99% of the supposed "custom" orthotics on the market are prefabs, even though you will go through any number of casting procedures to get them. You end up with something off-the-shelf that most closely matches (or not) the cast or imprint of your foot.
- THE COMBINATION OF TISSUE WORK / COLD LASER / FOOT ADJUSTMENTS: Intense tissue work will help stimulate Fibroblasts. If you don't understand why this is of critical importance to those of you dealing with any sort of CHRONIC MUSCULOSKELETAL PAIN, you need to READ THIS. COLD LASER is beneficial for just about everything because of the nature of how it works (follow the link to learn more). And if you are one of those people with a cavus (high arch) foot, you are likely in need of having the foot freed up via drop table adjustments.