Evolution in the Treatment and Management of Plantar Fasciitis

Dr. J. Adrian Wright Sports Medicine,

We receive many people in our office with the presenting concern that they have heel pain. As with all medical problems, it is important to determine the key details of the issues. If you have been experiencing heel pain, pay close attention to what the pain feels like, when does it start, how long does it last, and what makes it better or worse. These key details will help your doctor determine an accurate diagnosis and proper treatment plan. Let's review some of the basics.

Does your heel pain start in the morning with the first few steps out of bed or after long periods of driving or sitting? This may sound strange to you as resting is supposed to make the problem better, but one of the most common causes of heel pain after rest is plantar fasciitis. At night, the foot rests in a plantarflexed position (toes pointing downward) with the calf muscle in a shortened position as well as the plantar fascia in a contracted position. The first steps out of bed can cause tension on the plantar fascia resulting in microtears that can be quite painful. More recently we also understand that a key component in the development of this pain is the immune system (the system in the body that fights infection, as well as works to repair daily stress and damage to the body). In the evening, the body's cortisol levels tend to taper resulting in an increased activity level of the immune system. Ever wonder why when you have a cold the symptoms are worse at night? This is also the culprit for why your hands and feet will feel more stiff in the morning if you have a seropositive condition like rheumatoid arthritis. Historically, we used to treat plantar fasciitis with steroid injections to attenuate this immune response but recent studies suggest that the employment of steroids is only effective if done within a certain window of symptom onset. If this condition has been present for months, the likelihood of success for steroid use is minimal.

Understanding what causes a condition, and how the body responds to it, is one of the most challenging aspects in medicine. Sadly, many times a scientific breakthrough leads to more questions than answers, leaving us humbled by how little we really know. Fortunately, we always gain insight from each discovery that allows us to at least improve somewhat our treatment modalities. With that in mind, what are some of the advancements in medicine for the treatment of plantar fasciitis?

Extracorporeal Shockwave Therapy (ECSWT): for the past couple of decades ECSWT has gained traction as an excellent tool for the management of chronic inflammatory conditions not limited to plantar fasciosis but also tendonosis, and bursitis. ESWT delivers focused sound waves that create controlled microtrauma in the targeted tissue. These acoustic pulses penetrate deep into the plantar fascia and surrounding areas, triggering the body's natural healing response without requiring surgery. The key components of this are:

Neovascularization: Stimulates the formation of new blood vessels, improving blood flow to the chronically injured area

Cellular regeneration: Activates stem cells and promotes the production of growth factors that help repair damaged tissue

Pain reduction: Disrupts pain signals by affecting nerve endings and can desensitize pain receptors

Tissue remodeling: Breaks down scar tissue and calcifications while promoting the formation of healthy collagen

Treatment process: Sessions typically last 15-20 minutes, with treatments spaced about a week apart. Most protocols involve 3-5 sessions total. You might experience some discomfort during treatment and temporary soreness afterward.

Effectiveness timeline: Results aren't immediate - healing typically occurs over 8-12 weeks after treatment as new tissue forms and blood supply improves. Success rates for plantar fasciosis range from 60-90% in various studies.

ESWT is particularly effective for chronic cases (fasciosis) that haven't responded to conservative treatments, since it addresses the underlying tissue degeneration rather than just inflammation.

Regenerative Medicine / Regenerative Matrix Injections: are another rapidly evolving area in the management and treatment of plantar fasciitis. Injectable human umbilical cord and amniotic membrane matrix serums are a flowable amniotic membrane injection derived from human amniotic tissues that contains naturally occurring growth factors, cytokines, and anti-inflammatory agents. It is important to understand that although stem cells are responsible for producing many of these protein cascades, the actual stem cells are not present in the injections.

How it works: The treatment harnesses the unique regenerative properties of placental tissue. The growth factors present in these injections help modulate inflammation and promote cellular proliferation, leading to accelerated healing processes. Specifically, it works through several mechanisms:

• Growth factors: Promote cellular growth and repair of damaged tissues by carefully modulating cellular behavior.

• Cytokines: Control inflammation, reducing pain and swelling while facilitating, to a certain degree, phagocytosis (cellular ingestion of diseased tissue).

• Anti-inflammatory agents: Decrease inflammation and expedite recovery

• Tissue regeneration: controls discomfort and inflammation from plantar fasciitis and helps long-term tissue regeneration

Treatment process: The area may require a small amount of anesthesia prior to delivery of the regenerative matrix. Some mild pain / swelling may occur after the first few days, and improvement in function is usually reported gradually over the course of 4-8 weeks. The effects of the regenerative matrix may even last up to 90 days.

Clinical results: A study by Midwest Orthopedic Consultants, revealed that almost 100 percent of the 43 patients in the clinical trial saw some level of improvement with pain dropping on average from 7/10 to 1/10 on a VAS scale. Most cases saw improvement in about three to four weeks.

Key advantages: Unlike corticosteroid injections that can degrade tissue, or PRP therapy that uses your own potentially compromised healing factors, regenerative matrix injections can offer regeneration and healing, helping to modulate inflammation and bring new cells into the area for healing.

So you've been diagnosed with arthritis . . . now what?

You have started to notice pain in your hands and feet. A trip to your doctor leads to the diagnosis of "arthritis". Like many others, you have probably asked your doctor, what you should do about it and get a vague response to the effect of "take ibuprofen" or "you should see a specialist". Many times these referrals lead to a reiteration of the same information, leaving you frustrated and not knowing where to go next. If any part of this scenario resonates with your story, read on.

The most important first step is to get a concrete diagnosis. There are many types of arthritis. Some are the result of daily wear and tear (osteoarthritis) whereas others are the effect of an irregular immune response (such as rheumatoid arthritis, psoriatic arthritis, etc). To determine what type of arthritis is present, your doctor will likely need imaging and / or blood work. An X-ray will give information of the wear pattern, or any key findings to suggest one type of arthritis over the other. Sometimes an ultrasound or MRI can provide more information, however many insurance plans make it extremely difficult to get a MRI relegating you to imaging that is not considered "high tech". Certain forms of arthritis, like rheumatoid arthritis will have key findings such as erosion of the bone around the margin of the joint. This is usually present in 30% of individuals with early stage rheumatoid arthritis, and approximately 60% of individuals with a later stage of the disease. Blood work is very important for determining the type of arthritis. Certain tests such as Anti-CCP can determine the type of arthritis you have as well as the possible severity of the disease long term. This test is important as many pharmaceuticals are available to combat certain types of arthritis to limit and even prevent their progression in certain cases. There are many other types of lab tests that can be performed that we will go into in a later article for those individuals that are newly diagnosed.

If you have already been diagnosed with a form of arthritis, quickly determining the right treatment option is very important as early intervention can delay, and sometimes halt, the progression of disease. The best treatment is not the same for everyone. Large institutions are constantly attempting to "standardize" medicine, but unfortunately there is only so much standardization that can be done. As physicians, we go to school for many years because medicine is anything but simple. Our treatment options must be flexible to address the individual needs of our patients. Some patient's do well with immunomodulating drugs, others have side effects that are more severe than the condition being treated. Some patients do well with non-steroidal anti-inflammatory drugs (NSAIDS) whereas others cannot take them as a consequent of a gastrointestinal bleed (ulcer). We will not belabor the issue, but you get the point. Let's discuss some treatment options and suggestions for each type of arthritis. For sake of brevity, we have limited this review to the most common forms of arthritis. Should you possess a more rare variant, it is crucial you see a rheumatologist for specific management of your condition.

OSTEOARTHRITIS (OA)

Osteoarthritis, or OA, is the "wear and tear" arthritis. It is usually the consequent of aberrant anatomic alignment as well as environmental factors such as type of stress and strain that has been placed on the joints over the years. This is typically seen later in life. Like discussed above, if OA is diagnosed early, certain measures can be taken to prevent further progress. Forms of durable medical equipment (DME) such as custom or prefabricated orthotics can be used to limit the strain on certain joints. If you have already developed chronic symptoms of pain in the joint, conservative measures should be attempted prior to any form of surgical intervention such as steroid injections or physical therapy. A more recent, cutting edge technology for the management of arthritis pain, Class IV laser therapy, is available for patients wishing to pursue conservative measures only.

RHEUMATOID ARTHRITIS (RA)

Rheumatoid, or RA is very different from OA in that younger individuals can develop the disease as a consequent of the body's immune system (the system that protects you from bacteria, viruses, parasites and fungus) attacking your cartilage. In this particular condition, as well as other immune based arthritic conditions, the body's immune system gets confused, attacking your own body as though it is a pathogen (bacteria, fungus, virus, etc). Although some of the treatment methods for OA such as cortisone injections and Class IV laser therapy has been shown to improve and sometimes resolve the symptoms of RA, it is recommended that you see a rheumatologist to discuss medications that could control the progression of the disease.

PSORIATIC ARTHRITIS Psoriatic arthritis is a seronegative arthritis that affects approximately 329,000 Americans. It is recommended that individuals with psoriatic arthritis seek the counsel of a rheumatologist in the management of the condition. Numerous medications are available to manage psoriatic arthritis. Your rheumatologist will determine which medication is right for you, but a summary of the different classes of drugs are NSAIDs, corticosteroids, and disease modifying anti-rheumatic drugs (DMARDs). There are two arms of DMARDs, biologic and non-biologic. It is important to monitor how your body tolerates certain drugs. DMARDs are known for their side effects and they do not affect all individuals the same. Pay close attention to changes in your body when starting these drugs. Your rheumatologist will review the warnings as well as precautions prior to taking the medication.

Pain in the Ball of Your Foot

Do you sometimes develop pain in the ball of your foot? What if you have recently developed this pain and it has not improved? There can be many contributing factors to forefoot pain, but the most apparent is ill-fitting shoe gear or no shoe gear at all. It's important to first determine the exact point of pain. In medicine we refer to this as the point of maximum tenderness. Let's review some steps to determining the most likely cause of the pain based on the location.

Pain in the ball of the foot at the base of the second toe

This is one of the most common areas for pain in the ball of the foot. Patient's with this pain will many times describe the recent use of shoe gear with a heel or walking barefoot. The source of pain usually presents from inflammation of the capsule surrounding the 2nd metatarsal phalangeal joint and specifically a thickening of the bottom of the capsule called the plantar plate. Individuals suffering from this type of pain should see a foot and ankle specialist to rule out the presence of a tear in the plantar plate. Delayed treatment of this condition, many times referred to as Predislocation Syndrome, can result in a complete tear of the plantar plate, followed by subluxation of the joint and the second toe overlapping the big toe.

Pain in the ball of the foot and at the base of the big toe

Do you feel pain when pressing the ball of the foot at the base of the big toe? If so, this could be indicative of sesamoiditis, or the two small bones that are present under the end of the first metatarsal. It is important to recall any point of trauma to this area. Although not as common, individuals with pain in this area after landing forcefully on the forefoot can have a sesamoid fracture. It is very important, especially with a history of trauma, to seek medical attention immediately. Fractures of the sesamoids can result in avascular necrosis (the bone dying due to lack of blood supply).

Pain across the entire ball of the foot

As we age, the elasticity of ligaments is compromised along with the integrity of collagen. The ball of the foot requires these structures to secure the fat pad on the plantar forefoot. When there is migration or movement of the fat pad towards the toes, the bones of the forefoot, mostly the metatarsal heads, rest on non-supportive tissue. This will quickly lead to pain in the forefoot when standing on any hard surface. The most simple solution is to wear shoe gear whenever walking or standing. Accommodative orthotics can also be used for the management of this condition.