Treatment of the condition known as plantar fasciitis is taking a revolutionary turn. Authors of recent publications have advocated replacing the term "plantar fasciitis" with "plantar fasciosis," and increasing scrutiny is being given to inflammation and the use of nonsteroidal anti-inflammatory drugs and corticosteroid injections as long-term treatment options. The effect of these changes in treatment philosophy remains to be seen, but it does appear that practitioners are increasingly willing to use available diagnostic tools and data to reexamine long-held treatment practices and suggest alternatives.

BioMechanics: Dr. Lemont, your article suggests that treatment regimens such as serial corticosteroid injections should be reevaluated in the absence of inflammation. What led you to this conclusion?

Lemont: The reason steroids are used is to control inflammation. And if there is no inflammation, I have to ask, what's the rationale? On reviewing the literature, I have not been able to see clinical evidence of inflammation associated with heel pain. What I do see is physicians using the term inflammation as a synonym for pain. In other words, the patient had inflammation of the heel, what they really meant was, the patient had heel pain. Heel pain is not the same as inflammation.

Bio: What clinical evidence points to inflammation?

Lemont: To confirm that inflammation is present, you need to see both clinical and histologic evidence. Clinical evidence includes redness, heat, swelling, and lack of function. Most of the heel spur patients-unless there is a bursitis, which there could be, and which would be an indication for a steroid-do not present with heat, redness, or swelling. So why call it inflammation?

On a histologic basis, if you look at the literature, there is no supporting documentation showing that what is causing the heel pain in these patients is inflammation.

Bio: How did this get labeled as a fasciitis then?

Lemont: Perhaps the same thing happened as with tibialis posterior tendinitis. For years that was thought to be an inflammation of the tibialis posterior tendon sheath. Podiatrists and orthopedic surgeons and other practitioners were injecting cortisone into the sheath.

Finally, as a result of MRI studies, we started to see tethering and actual tears in the tendon, which prompted pathologists to evaluate it histologically. And guess what? They found degeneration. So they changed the name to tendinosis and no one is injecting steroids anymore.

Bio: So have better diagnostic tools contributed to this change in thought?

Lemont: Yes. I routinely get MRIs on my heel spur patients. It's important because in certain patients you may have just a strain of the fascia and in others you will have a tear, and the only way you will know which is which is to get an MRI.

Bio: Dr. Riddle, in your article, you wrote that little is known about the etiology of plantar fasciitis. Why is that?

Riddle: Identifying why problems occur is a lot more expensive and difficult to measure than determining a valid diagnosis. So given the cost associated with developing valid measures of etiology and risk for a disorder that is common yet not extremely costly in terms of medical care and lost function has not been a big priority. Although plantar fasciitis certainly does have lost function associated with it, it's not like arthritis, degenerative joint disease, or women and ACL tears. Those disorders are more common and more costly. So that's probably why we don't know more about the etiology.

Bio: Your study looks at many risk factors, including ankle dorsiflexion. What is the connection between ankle dorsiflexion and plantar fasciitis?

Riddle: To determine whether it's a true risk factor, a large number of subjects would need to be identified, measured, and studied over time. You'd have to look at which patients developed plantar fasciitis and which did not. Then you would have to compare their dorsiflexion measures.

Bio: That doesn't sound like a cost-effective study.

Riddle: Certainly not at this time. So the next best thing is to identify, after the fact, patients with unilateral plantar fasciitis and compare them to age- and gender-matched individuals who do not have plantar fasciitis, which is what we did. This allowed us to make some comparisons not only about the amount of dorsiflexion but also about other variables that have been hypothesized to contribute to the etiology of plantar fasciitis. And, indeed, we found that ankle dorsiflexion appears to play a role in the etiology.

Bio: Dr. May, can you say a little about the type of patients you see in your practice with the Navy on Parris Island? How do you differentiate between short-term and chronic pain?

May: To answer your second question first, I would use three months as my dividing line. Actually, the majority of patients we see are the more acute patients, since my colleagues and I take care of the Marine Corps training recruits.

Bio: How many recruits a year?

May: We are responsible for 22,000 to 23,000 recruits a year. Some of the recruits are out of shape, and because they haven't done a lot of walking, for instance, they present with various problems, one of which is that acute sort of plantar fascial pain.

Bio: What do you mean by a lot of walking?

May: The trainers have these young folks walking, I believe, three hikes-a three-mile, a five-mile, and a 10-mile-soon after they arrive on the island. Then toward the end of basic training comes what they call The Crucible, which totals 48 to 50 miles.

So we will see some acute plantar fasciitis in the new recruits. The more chronic problems we see in those Marines who are here to direct the training and in the support staff.

Bio: What is your regimen for these new recruits who come to see you and need to get back, literally, on their feet?

May: Typically we'll start with the usual protocols, such as an ice massage for their feet and stretching exercises. We often see a tight heel cord on these patients because many of them don't stretch sufficiently, so we have to examine that. Flexibility is also a big issue.

Another issue is foot structure. We check for pes planus, which is the most common cause of plantar fasciitis that we see. We really look at the foot, and once we find out what kind of foot structure the patient has, we prescribe inserts, such as over-the-counter orthoses for boots, and then we make sure he or she wears an appropriate shoe.

Bio: You mention boots. Do you have any latitude to change a recruit's boot?

May: The boots are all the same issue. The Marine Corps did change recently to an overall better boot, but it doesn't come with any arch support, which is fine for the majority of the population. But those patients with pes planus need better motion control. So we make sure they get inserts for motion control.

Bio: Do they ever have to sit out of training for any time?

May: Yes, we will have them rest out of training for about a week and concentrate on icing and stretching. For the young patients, that resolves the majority of their problems.

Bio: And once these patients are past the acute phase, do they often return?

May: We don't see that many repeat patients, as it were, once we get them past that acute phase and get them back in shape, biomechanically. Usually at that point, they can continue. Now some of them may suffer through the pain a little, but most can get on through training.

Bio: Which leads to your chronic patients, of which I assume you have a smaller number. What treatment do you consider with these patients?

May: We take a fairly standard approach. We start out with what I call "relative rest." I am not a big fan of taking someone who is active, especially a runner, and saying, "You can't run for three months." It's difficult for them to hear that and follow through with it.

Bio: Hence, "relative rest."

May: Yes, I want them to rest the affected area, but I want them to be active. I want them to swim, or run in the pool, or ride a bike, or even try the elliptical trainer. They should engage in some relatively low-impact activity so they can stay in shape. They should do it long enough to get the blood pumping, then use the ice and roll it across their feet.

Bio: What else do you offer?

May: Medications are sometimes helpful, but there is a lot of controversy over the use of nonsteroidal anti-inflammatories right now, because there is no real inflammation. When practitioners examine the tendons, what they are finding is that instead of inflammation, there is a sort of collagen degeneration. So the thinking now is that it could be termed a plantar fasciosis or a tendinosis-a degenerative process.

An NSAID is not going to help unless you are trying to achieve pain control, and I would probably limit that to three to five days, maybe use acetaminophen to control the pain. If you get the patient to cut back on the running and start with the ice treatments, that tends to help him or her feel better.

The other thing we like to emphasize is that the patient should never walk around barefoot, in the house or anywhere. That really strains the plantar fascia, so we stress the need to wear some sort of supportive slipper, even around the house.

Bio: Do you ever recommend surgery?

May: Surgery is down the road. It's hard for me to comment on surgery, since I'm not a surgeon. But I would probably wait at least six to nine months and would offer a steroid injection first. The thinking is that if you inject, in a way you may be achieving the same results as doing the surgery without having to open someone up. The steroids cause a bit of atrophy, then maybe just the stress of walking will release the fascia and the pain goes away. We think the patients give themselves the fasciotomy, as it were.

Bio: What is the success rate for this injection?

May: It helps the majority of patients who advance to needing an injection, but I would have to check my sources for exact figures. The success rate with traditional therapy is probably 80%, then the injections help probably another 10% of the overall number of patients with plantar fasciitis, then surgery would be recommended for the rest.

Generally, we have them stretch, use cross friction massage, etc. The biggest thing, for us, is that as patients recover, we want to be sure they don't increase the time or distance they spend running by, say, more than 10% at a time. We want them to build gradually.

Bio: Dr. Lemont, do you differentiate between serial injections and a one-time injection?

Lemont: There has to be a rationale for corticosteroid injection. So even if it's just one injection, what is the rationale for giving even that? I was trying to say in the article that if you are going to give injections, for whatever reason, don't give multiple ones. If you like it and want to use it, OK, but why give multiple injections? Because there are downsides to this.

Prevention strategies

Bio: Dr. Riddle, your study is mostly about prevention. What can someone do to help prevent plantar fasciitis?

Riddle: We were mostly concerned with prevention and identifying risk factors. This study provides the strongest data yet arguing for preventive stretching exercises to preclude the possibility of developing plantar fasciitis in at-risk individuals.

Bio: How did you define an at-risk individual in this study?

Riddle: At-risk individuals are those who are obese and those who are spending the majority of the workday standing on their feet. So when you have obese individuals with standing jobs, those are the people who might benefit from exercises designed to increase dorsiflexion.

Bio: It seems like getting runners to stretch wouldn't be as much of an issue as getting, say, factory workers to do it?

Riddle: The point you are making is a good one. There are two different types of people who develop this disorder. One is the individual who does a lot of repetitive running-related activities; the classic person you typically think of developing plantar fasciitis is the long distance runner. That group of patients is fundamentally different from the group of patients we looked at in our study.

In this group of 150 there were only a small number, four or five in each group (see study synopsis) who reported being recreational joggers. So the vast majority were what I consider sedentary, nonathletic individuals, which is the second population at risk for this.

Bio: What can you do in terms of prevention? Does it involve making primary-care physicians and nurse practitioners, as the first line of defense, more aware of the problem? Do you recommend lifestyle changes and more exercise?

Riddle: For the people we focused on in our study, at this time we rely on word of mouth, lay publications, and newspaper stories to get information out. The public has no access to this kind of information other than to hear or read about it in the media and hopefully apply it to their own lifestyles. The other option is for patients and physical therapists to discuss the kinds of exercises people might do to address some potential problems at their health club or fitness center.

Bio: Dr. Lemont, your paper lists 500 or so cases. Was it difficult to find that many?

Lemont: It wasn't. I run a podiatric pathology laboratory, where we see 30,000 foot specimens a year. I've been doing this since 1978, and we have literally thousands and thousands of specimens from patients with heel spurs. This study was something we could do at a moment's notice.

Bio: Where do you see the treatment going in the future?

Lemont: Most patients who have heel pain diagnoses of general plantar fasciitis-and there are subsets-have sedentary lifestyles and do a lot of sitting. As a result, the calf muscle and plantar soft tissue attachments are in a contracted position. When they start to stand, they have an excessive pull at its origin, which is the heel. So that causes pain at rest, post-static dyskinesia. Eventually the fascia can be elongated somewhat and the patient feels good. In those cases, night splints are important to stretch the fascia and calf, stretching exercises are important. I am a firm believer that these patients need to have active stretching exercises for both the posterior calf muscles and soft tissue attachments. I say soft tissue attachments because the problem may be more than the fascia; it may be that some of the muscular attachments are contracted as well. That hasn't been looked at a lot in the literature.

Final thoughts

Bio: Any final thoughts?

Lemont: MRIs are important, especially in those cases where the patient's heel pain started abruptly, because that might mean a tear. And if there is a tear, you want to immobilize.

Riddle: There are other people in healthcare who have a role, when you talk about patients seeing physicians. My suspicion is that physicians have much higher priority issues to deal with in terms of their patient's function than prevention of plantar fasciitis. So the first line of defense would be rehabilitation practitioners, athletic trainers, physical therapists, and nurses, who could give out this information more readily than a physician might.

Bio: What about shoe store employees?

Riddle: Absolutely, shoe store employees are many times pretty well-versed in some of these preventive issues. They could be another good source for the lay public to learn about this risk.

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PANEL

Todd J. May, DO, LCdr USNR, is clinical director of the Sports Medicine and Reconditioning Training Clinic on Parris Island, SC. May's comments should not be taken to represent those of the U.S. Navy, U.S. Marines, or U.S. government.

Daniel L. Riddle, PhD, PT, is a professor of physical therapy and assistant chair of the department at Virginia Commonwealth University in Richmond, VA.

Harvey Lemont, DPM, is a professor of podiatric medicine at the Temple University College of Podiatric Medicine in Philadelphia.

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STUDY SYNOPSIS - Lemont et al, 2003

Lemont and colleagues reviewed histologic results from 50 cases of heel spur surgery and found myxoid degeneration with fragmentation and degeneration of the plantar fascia. These findings support their thesis that "plantar fasciitis is a degenerative fasciosis without inflammation, not a fasciitis."

Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc 2003;93(3):234-237.

STUDY SYNOPSIS - May et al, 2002

May and colleagues at the Branch Medical Clinic on Parris Island note that plantar fasciitis is the most common cause of rearfoot and heel pain, with an estimated two million patient visits a year to primary-care practitioners. According to their review of the literature, 80% of the population will experience some type of foot pain, most of which can be treated conservatively.

Biomechanically, the long and short plantar fascia and plantar aponeurosis provide ligamentous support of the longitudinal and transverse arches. Also, tightening of the plantar fascia assists in initiating swing phase of gait.

In their practice, the authors report that the primary differential diagnosis is calcaneal stress fracture, which can be difficult to diagnose. Tarsal tunnel syndrome should also be considered in a patient with heel pain. They report that plain radiographs are often useful for placement of a steroid injection, but are not helpful in locating a calcaneal osteophyte (see Lemont's comments for more on diagnostic imaging).

The authors go on to detail their treatment regimen, including relative (or active) rest, NSAIDs, ice, and nighttime splinting. They also touch on stretching, footwear, and fitness, before finishing with the pros and cons of steroid injections.

May TJ, Judy TA, Conti M, et al. Current treatment of plantar fasciitis. Curr Sports Med Rep 2002;1(5):278-284.

STUDY SYNOPSIS - Riddle et al, 2003

Riddle and colleagues used an epidemiological design to try to determine risk factors for plantar fasciitis. In 50 consecutive patients, all with unilateral plantar fasciitis, the researchers examined limited ankle dorsiflexion with an extended knee, obesity, and percentage of each workday spent weight-bearing. The authors used a matched-case-control design, two controls for each patient, with age and gender being the matching criteria. Data collected included height, weight, proportion of the workday spent weight-bearing, and whether the subject was a jogger or runner. The researchers used a goniometer to measure passive ankle dorsiflexion bilaterally. The main outcome measure was the adjusted odds ratio of plantar fasciitis associated with varying degrees of limitation of ankle dorsiflexion, different levels of body mass, and the subjects' reported weight-bearing.

Compared with matched controls who had greater than 10 degrees of ankle dorsiflexion, patients with less than 10 degrees of dorsiflexion were 23.3 times more likely to incur plantar fasciitis (with a 95% confidence interval). In comparison, individuals who spent the workday on their feet were 3.6 times more likely than controls to develop plantar fasciitis, and individuals with a body mass index of greater than 30 kg/m2 had a risk 5.6 times higher than the control-matched subjects who had a body mass index of lesser than or equal to 25 kg/m2.

While reduced ankle dorsiflexion appeared to be the most important risk factor, the authors concluded that obesity and work-related weight-bearing also appear to be risk factors that should be monitored by practitioners.

Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for plantar fasciitis: a matched case-control study. J Bone Joint Surg 2003;85-A(5):872-877.