Week 2: Plantar Fasciitis
I decided to focus on plantar fascia pain this week because I have a lot of patients that suffer from this condition. However, as I was researching and trying to find resources that I could direct my patients to for information, I came across a lot of misinformation. I found a lot of poor and even incorrect advice on how to diagnose and treat this common problem. Plantar fascia pain affects more than 2 million people in the United States, so there are a lot of people out there every day searching the internet for answers and pain relief. However, they are not always getting the correct information, so I want to make sure there is an accurate resource available to my patients and to those 2 million people seeking answers.
Plantar Fasciitis vs. Plantar Fasciosis?
While browsing the internet, the most common problem that I noticed was in the name itself - Plantar Fasciitis. The suffix -itis infers inflammation, which generally occurs with an acute injury or trauma such as a bruise, sprain, or strain. Inflammation usually follows a very predictable pattern. The acute phase of the healing process normally lasts about 3 weeks, so if you have inflammation or “itis” resulting from an injury, that phase should be complete in about 3 weeks. Once the healing phase has surpassed a timeframe of 3 weeks, up to 6 at the very most, it is no longer considered an inflammatory state and is now considered as “osis,” meaning it has now reached a chronic state. We are no longer working with an acute injury, but we are now dealing with a condition or disease process. This applies to any connective tissue pain lasting more than 3-6 weeks. In this case, if you have plantar fascia pain that has lasted longer than 6 weeks, rather than having plantar fasciitis, you actually have plantar fasciosis.
Why does the differentiation matter? The biggest issue with this misnomer or problem with the diagnosis of fasciitis when it is actually fasciosis is that these two problems are not treated the same.This means the treatments that are normally used during an inflammatory process are no longer going to be effective. In fact, you could actually be slowing the healing process if you continue to try to treat an osis like an itis. When most people are trying to treat an itis, they are trying to bring that inflammation down by using ice and anti-inflammatories. Once your body has reached a state of “osis,” we actually want to trigger an inflammatory response to get your body to recognize the fact that it needs to heal because once it’s achieved an osis, your body is actually no longer aware of the problem and isn’t doing a lot to treat it.
Understanding The Anatomy & Diagnosis
Image taken from https://3d4medical.com/blog/fascia; text and drawing added by In2it Medical
The region that is usually most affected with plantar fasciitis is the proximal end of the plantar fascia. For the most part, plantar fasciitis is diagnosed clinically by palpating this region and if you experience pain at the calcaneus or somewhat to the inside of your heel, this is the most common place for plantar fascial pain. If the pain continues beyond the typical 3-6 healing phase, the pain is now being caused by plantar fasciosis and you most likely have had micro trauma in the fascia which has led to a longitudinal split tear or the possibility of a longitudinal split tear. The best way to describe this would be like a frayed rope. You don’t snap it or break it in half. It gets worn down and frays. That frayed rope or those tears never heal properly because in the case of most athletes, professionals, or workers, you start having pain, but it’s fairly livable pain or pain that you can push through, so you don’t take the proper time or utilize necessary treatments for the injury to properly heal.
Seeking Treatment
Before I discuss treatment options, I want to discuss seeking out the most appropriate or best treatment. As physicians, especially within the diagnostic and interventional community, we often say that the procedure or imaging modality a patient receives is user dependent or operator dependent. This means that most studies and procedures are limited by the knowledge and the capabilities of the person performing it. That being said, I’d like to stress the importance of selecting a practitioner or a physician that you feel comfortable with and that you also feel confident in their skillset specific to the procedure(s) being performed. That user dependence or operator dependence is a real thing unfortunately and every physician varies. With that notion in mind; if you go to a practitioner you don’t like or you don’t seem to click with, go to another one. Don’t give up on your problem. Your pain is probably fixable or resolvable in the right hands, but it does require a little bit of effort to keep searching out that person that you can develop a good association with.
If conservative treatments have not helped, one treatment option to consider would be a steroid injection. The most efficacious or the best place with the longest lasting effect would be if you place the injection deep into the plantar fascia just as it inserts onto the heel. The reason for this is if the plantar fascia is compressing that nerve, you will get a two-for-one effect where you can decrease the swelling in the nerve while at the same time decrease the pain in the plantar fascia. If you decide to go this route, it is imperative that you receive the injection under image guidance to ensure proper placement.
For those who are dealing with plantar fasciosis, another treatment option is to remove the damaged tissue all together - known as a percutaneous fasciotomy. At In2it Medical, we use a specific non-invasive technique to accomplish this utilizing a tool called a TX MicroTip made by TenexHealth. You can learn more about this procedure and process here.
At-home Exercises & Remedies
There are a few exercises that we recommend to our patients who are dealing with plantar fascia pain.
Alfredson Heel Drop Protocol
Knee straight
Standing on the edge of step, raise onto your toes using both legs, with your hands on banister or rail for balance (Image A)
Transfer to standing only the affected leg once raised onto your toes, and SLOWLY and CONTROLLED lower your weight and heel down so the heel is lowered over the edge of the step. (Image B)
Transfer weight back onto both legs to lift back up onto toes (Image A)
Knee bent
Standing on the edge of step, raise onto your toes using both legs, with your hands on banister or rail for balance. (Image A)
Transfer to standing only the affected leg once raised onto your toes, with your knee slightly bent, and SLOWLY and CONTROLLED lower your weight and heel down so the heel is lowered over the edge of the step. (Image C)
Transfer weight back to both legs to lift back up onto toes. (Image A)
Complete 2 sets of 10 of both knee straight and knee bent 2 times daily
Calf Stretch/Towel Stretch
While in a seated position, hook a towel under your foot and pull your foot and ankle back until a stretch is felt in your calf area
Keep your knee straight during this stretch
Hold the stretch for 30 seconds
Repeat on both sides
Perform 3 times a day
Frozen Water Bottle Foot Roll
Slowly roll your foot along a frozen water bottle