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.