- The key to relieving plantar fasciitis in the long term is to stop the repeated over-stretching of the fascia in gait. We employ a state-of-the-art computerized gait analysis which analyzes the feet in both a static and dynamic position and based on the data collected, one can determine the mechanical imbalances and abnormal stresses that are being placed on the feet. This data is then utilized to manufacture a customized prescription foot orthotic which will stabilize the foot in a position that relieves the stress on the plantar fascia and remaining parts of the foot. Many patients have the impression that they will receive the prescription orthotic and that is it. That is actually the start of treatment as the patient becomes accustomed to the beneficial changes in gait and the plantar fasciitis gradually fades into oblivion.
- There are a number of other treatments for plantar fasciitis, like cortisone shots, but they are for temporary relief only and can have side effects if used incorrectly. A prescription for physical therapy or massage therapy can also provide temporary relief in a safer fashion. Other forms of treatment include, but are not limited to, stretching of the calf muscles, night splints, ice massage. A patient’s lifestyle is a big factor on the success or failure of any specific treatment. This needs to be taken into account when treating this condition and temporary changes in a patient’s activity can be instrumental in the success or failure of their treatment.
- How long have symptoms been present? The longer one has been suffering with these symptoms the more likely the fascia will degenerate due to chronic inflammation of the fascia. Our bodies handle chronic inflammation very poorly, so if the fascia has been inflamed for a very long time, it may not heal no matter what we try on a conservative nature. Usually, when we treat the inflammation and correct the biomechanics of the feet the condition usually takes care of itself in most instances. If that doesn’t happen, the common treatment used to be surgery whereby the fascia is cut off the heel bone.
Now with modern up-to-date technologies, such surgery has been replaced with Extracorporeal Shockwave Therapy (ESWT) in which repeated shockwaves are applied to the fascia(It is also effective for achilles tendon problems), or via Coblation Therapy via the TOPAZ procedure. This procedure is a minimally invasive procedure for plantar fasciitis that involves use of a small wand made by Arthrocare. It employs radiofrequency utilized by the surgeon to debride or thin the fascia at the heel, that is, remove the diseased tissue causing the heel pain. The procedure is performed via tiny “puncture” holes made in the skin at the bottom of the heel that require no sutures and leave no scarring. Patients can walk on the area the next day.Learn More at www.TopazProcedure.com.
Both treatments convert the chronic inflammation to acute inflammation which the body handles very well in repairing the fascia by bringing new blood vessels (neovascularization) to the region. ESWT can be accomplished via one or two high energy session involving anesthesia or by low energy ESWT in which 3 low energy sessions are used in place of one high energy session and no anesthesia is usually needed. ESWT is successful 70 to 80 percent of the time when the plantar fascia does not respond to conventional treatments. One financial issue to consider is that ESWT has very limited coverage by health insurance companies, so it is generally an out-of-pocket expense. Coblation therapy is generally a covered service.
- Other more advanced treatments of plantar fasciitis include:
- MLS Laser Therapy: MLS laser is a modality supplied by Cutting Edge Lasers (www.med.celasers.com). The laser works by employing two synchronized wavelengths of light which treat damaged tissue at the cellular level to stimulate healing, reduce inflammation and pain. CE Lasers were initially sold to the veterinary market in the US despite fairly widespread use of the products in Europe. There is no placebo effect with animals.
- Platelet Rich Plasma (PRP): Platelet rich plasma has become a popular and somewhat glamorous new treatment modality used by professional athletes for injuries. PRP is a concentrate of whole blood of the patient in which the platelets are concentrated in a small portion. The platelet concentrate is then re-injected into the injured area. Platelets are involved in the clotting mechanism so bruising and swelling can be decreased. Platelets contain growth factors so, in concentrated form, the amount of growth factors can be increased in an injured area. Results in the press and literature have been mixed, but there is a reason for this in my opinion. PRP is often used as a primary treatment or sole treatment. There may be a benefit to do so but the underlying cause of tendon and ligament pathologies must first be addressed otherwise lasting relief may not occur.
- Topaz Coblation and Extracorporeal Shockwave Therapy(ESWT): Previously described above.
Dr. Steven Snider DPM, is a San Antonio foot care specialist that has helped many find the foot pain relief they sought. Bunions, heel pain, plantar fasciitis, "flat feet" and any foot issues are handled here at our San Antonio office. For more information about specific conditions, please feel free to read our blog.
Wednesday, January 4, 2012
Treatment For Plantar Fasciitis
In today’s information age, one can Google treatment of plantar fasciitis and see a myriad of different types of treatment, all of which work but not necessarily work for everyone. Treatment sometimes needs to be tailored to that specific individual’s condition taking into account: 1) length of time of symptoms, 2) previous treatments rendered for condition 3) patient’s lifestyle, among other considerations.
Oh! My Aching Feet...
Summer is almost here and Autumn and Winter are not far behind. Most of us have been active with work and activities that have placed the feet under a lot of stress which can result in soreness or pain to one or both of our feet. One of the most common ailments we encounter in our office is pain to the heel(s). Most Heel Pain is associated with Plantar Fasciitis.
Pain associated with plantar fasciitis is derived from the excess repetitive strain on the plantar fascia. The pain has little to do with the heel striking the ground. In fact, placing something too soft under the heel will often aggravate the condition by letting the arch sink down lower thereby adding strain to the plantar fascia. Each time the foot strikes the ground, the heel hits first, followed by the ball, followed by the arch coming down. The plantar fascia bowstrings across the arch decelerating the speed at which the arch comes down. It is a shock absorbing mechanism for the body. A foot that flattens too rapidly or too much overstretches the plantar fascia and it is the repetitive overstretching that leads to painful heels. Heels that display pain in this area is due to where the fascia attaches to them. That flattening of the arch actually occurs with the foot rolling in too much, often called overpronation.
Overpronation is often associated with heel pain.
There is no “cure all” to plantar fasciitis despite the various “gadgets” being sold on the internet. The key to helping plantar fasciitis often is related to the ability to decrease the tension or strain on the fascia. An arch support which “props up” the arch can help, but an orthotic which works by relieving tension from the heel and ball (the areas where the fascia attaches) can be much more effective. Basically, if one turns the heel inward and the ball of the foot the opposite way, tension is relieved from the plantar fascia. The goal of an orthotic is just to minimize that tension. If one can use the orthotic long enough to allow tension to be taken off the fascia, the fascia is no longer being overstretched and can heal itself.
Plantar fasciitis which has been around for a long time can lead to a deposit of calcium at the heel bone along the area where the fascia attaches. When that deposit of calcium is viewed from the side, considering the fact that x-rays are two dimensional, one sees a pointy area of calcium referred to as a heel spur. The heel spur is really a “shelf” of bone or calcium deposited along the origin of the ligament and points in the direction of the toes. The so-called “heel spur” thus has little or nothing to do with the pain experienced but is a two dimensional manifestation of a three dimensional shelf of calcified fascia. The spur itself is not the cause of the heel pain but rather a manifestation of it. It is just an “island” of calcification or ossification (bone formation) that forms in the area of fascia that is chronically inflamed.
When I examine a patient, I look at the “mechanics” of the foot by watching the patient walk. Individuals with plantar fasciitis often have feet that roll in (pronate) too much. Such feet often flatten too much with weight bearing pressure, placing tension on the plantar fascia. That can happen to an individual with a high arch, low arch or a medium arch. One does not have to be flat footed to have heel pain.
Sonography involves the use of diagnostic ultrasound to look at the fascia itself. Remember that the fascia is a ligament, so it does not show up on x-rays. X-rays can be helpful to rule out things like stress fractures, arthritis, tumors but does not show the fascia. Sometimes calcium will deposit itself along the origin of the fascia, especially when the fascia has been inflamed for a long time. Since x-rays are two dimensional representations of a three dimensional object, one can see, from the side, a shelf of calcified ligament which is termed, somewhat mistakenly as a heel spur. Heel spurs, in actuality, do not exist but are simply a side view of the plantar fascia, showing a shelf of calcified ligament. The so-called spur always points forward in the direction of the ligament and is not the source of the pain.
MRI’s or ultrasound machines (Sonography) actually allows one to look at the plantar fascia itself studying the orientation of the fibers in the fascia and how thick they are. Sonography can be done, usually in the doctors’ office on the initial visit and costs about 1/20 the price of an MRI. The average thickness of the fascia as measured by ultrasound is about 3.5 mm. a thicker fascia can be indicative of a diseased, overstressed fascia. The sonographer also looks at the orientation of the fibers which should be parallel and neat. If the fibers are running in various directions or if one sees swelling (dark areas) in the fascia, that can indicate a bad or diseased plantar fascia.
Role of weight, occupation, time on feet. The more weight one has on their feet, the more tension is placed on the plantar fascia. That is true whether one is overweight or has an occupation which involves standing for long hours on hard surfaces.
People’s occupation often cannot be readily modified but your doctor can order light or modified duty. Additionally, a doctor can do something as simple as writing a note to an employer requesting use of preferred shoe gear. Preferred shoe gear may include shoes with a lot of cushioning and support, running shoes like the New Balance 1123, New Balance 925 (the all black or all white version of the 1123), the Brooks Beast or the Brooks Addiction 6 (the all black or white leather version AKA the Addiction Leather). Use of the right prescription orthotic in the shoe can render a shoe to become therapeutic in the standing process.
Body weight is a tougher subject. Nevertheless, if you have heels that are sore enough to make it tough to get through the day, then it may be hard to do certain exercise as walking. Keep in mind that almost all exercises can be done in an aerobic (fat burning) fashion when using lighter reps but higher frequency.
…Coming Up Next – Treatment of Plantar Fasciitis
Pain associated with plantar fasciitis is derived from the excess repetitive strain on the plantar fascia. The pain has little to do with the heel striking the ground. In fact, placing something too soft under the heel will often aggravate the condition by letting the arch sink down lower thereby adding strain to the plantar fascia. Each time the foot strikes the ground, the heel hits first, followed by the ball, followed by the arch coming down. The plantar fascia bowstrings across the arch decelerating the speed at which the arch comes down. It is a shock absorbing mechanism for the body. A foot that flattens too rapidly or too much overstretches the plantar fascia and it is the repetitive overstretching that leads to painful heels. Heels that display pain in this area is due to where the fascia attaches to them. That flattening of the arch actually occurs with the foot rolling in too much, often called overpronation.
Overpronation is often associated with heel pain.
There is no “cure all” to plantar fasciitis despite the various “gadgets” being sold on the internet. The key to helping plantar fasciitis often is related to the ability to decrease the tension or strain on the fascia. An arch support which “props up” the arch can help, but an orthotic which works by relieving tension from the heel and ball (the areas where the fascia attaches) can be much more effective. Basically, if one turns the heel inward and the ball of the foot the opposite way, tension is relieved from the plantar fascia. The goal of an orthotic is just to minimize that tension. If one can use the orthotic long enough to allow tension to be taken off the fascia, the fascia is no longer being overstretched and can heal itself.
Plantar fasciitis which has been around for a long time can lead to a deposit of calcium at the heel bone along the area where the fascia attaches. When that deposit of calcium is viewed from the side, considering the fact that x-rays are two dimensional, one sees a pointy area of calcium referred to as a heel spur. The heel spur is really a “shelf” of bone or calcium deposited along the origin of the ligament and points in the direction of the toes. The so-called “heel spur” thus has little or nothing to do with the pain experienced but is a two dimensional manifestation of a three dimensional shelf of calcified fascia. The spur itself is not the cause of the heel pain but rather a manifestation of it. It is just an “island” of calcification or ossification (bone formation) that forms in the area of fascia that is chronically inflamed.
Diagnosis of Plantar Fasciitis
Plantar fasciitis is often diagnosed by history of the disease process. Most patients note heel pain or arch pain upon arising in the morning or after rest. Often, the harder they have used their feet the day before, the more tender the heel will be upon arising the next day.When I examine a patient, I look at the “mechanics” of the foot by watching the patient walk. Individuals with plantar fasciitis often have feet that roll in (pronate) too much. Such feet often flatten too much with weight bearing pressure, placing tension on the plantar fascia. That can happen to an individual with a high arch, low arch or a medium arch. One does not have to be flat footed to have heel pain.
Sonography involves the use of diagnostic ultrasound to look at the fascia itself. Remember that the fascia is a ligament, so it does not show up on x-rays. X-rays can be helpful to rule out things like stress fractures, arthritis, tumors but does not show the fascia. Sometimes calcium will deposit itself along the origin of the fascia, especially when the fascia has been inflamed for a long time. Since x-rays are two dimensional representations of a three dimensional object, one can see, from the side, a shelf of calcified ligament which is termed, somewhat mistakenly as a heel spur. Heel spurs, in actuality, do not exist but are simply a side view of the plantar fascia, showing a shelf of calcified ligament. The so-called spur always points forward in the direction of the ligament and is not the source of the pain.
MRI’s or ultrasound machines (Sonography) actually allows one to look at the plantar fascia itself studying the orientation of the fibers in the fascia and how thick they are. Sonography can be done, usually in the doctors’ office on the initial visit and costs about 1/20 the price of an MRI. The average thickness of the fascia as measured by ultrasound is about 3.5 mm. a thicker fascia can be indicative of a diseased, overstressed fascia. The sonographer also looks at the orientation of the fibers which should be parallel and neat. If the fibers are running in various directions or if one sees swelling (dark areas) in the fascia, that can indicate a bad or diseased plantar fascia.
Role of weight, occupation, time on feet. The more weight one has on their feet, the more tension is placed on the plantar fascia. That is true whether one is overweight or has an occupation which involves standing for long hours on hard surfaces.
People’s occupation often cannot be readily modified but your doctor can order light or modified duty. Additionally, a doctor can do something as simple as writing a note to an employer requesting use of preferred shoe gear. Preferred shoe gear may include shoes with a lot of cushioning and support, running shoes like the New Balance 1123, New Balance 925 (the all black or all white version of the 1123), the Brooks Beast or the Brooks Addiction 6 (the all black or white leather version AKA the Addiction Leather). Use of the right prescription orthotic in the shoe can render a shoe to become therapeutic in the standing process.
Body weight is a tougher subject. Nevertheless, if you have heels that are sore enough to make it tough to get through the day, then it may be hard to do certain exercise as walking. Keep in mind that almost all exercises can be done in an aerobic (fat burning) fashion when using lighter reps but higher frequency.
…Coming Up Next – Treatment of Plantar Fasciitis
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