Term Paper on "Pharmacological and Non-Pharmacological Treatment of Plantar Fasciitis"

Term Paper 14 pages (4160 words) Sources: 1+

[EXCERPT] . . . .

Pharmacological and Non-Pharmacological Treatment of Plantar Fasciitis

Overweight persons, those who spend most of the day on their feet and those who do a lot of running, walking and jumping are at-risk individuals for plantar fasciitis (Edwards 2003). The vast majority, non-atheltic individuals are the second population at risk. Many of these at-risk populations rely on word-of-mouth, publications and newspaper stories for needed information. And the general public has no access to this information other than the feedback they obtain from the media and other people. There is unqualified need for patients and their doctors to provide the information to these at-risk groups and to address the potential problem in their clinics, workplace, the community, offices and homes. Podiatric pathology laboratories screen 30,000-foot specimens a year and, in a single year, thousands upon thousands of specimens are received and investigated with heel spurs or heel spur syndrome, involving inferior heel pain. Despite the extent of the affected or at-risk groups, the syndrome is too well understood and there is as yet no clear and effective management of the condition.

Plantar Fasciitis

Plantar fasciitis is a chronic inflammation of the plantar fascia, a ligament-like structure that runs from the bottom of the heel to the underside of the toes of the foot (Miller 2004). This structure helps support the foot against downward forces that usual during running and jumping sports activities. Plantar fasciitis is the most common cause of inferior heel pain (Singh et al. 1997, Barret and O'Malley 1999) often incorrectly referred to as "heel spur syndrome," which suggests that osseous spurs or inferior calcaneal exostoses cause the pain. The presence or absence of exostoses has no connection with the pain and the excision of a spur is not part of the usual surgery for plantar fasciitis. Although pain may be felt along the entire course of the plantar fascia, it is usually limited to the inferior medial part of the calcaneus at the medial process of the calcaneal tubercle. It occurs in both men and women between ages 8 and 80, but more common in middle-aged women, as well as younger male, runners (Singh et al. 1997). Its incidence and severity strongly correlate with obesity.

Plantar fasciitis is one of the most common overuse injuries that affect approximately 10% of runners and athletes in basketball, tennis, soccer, gymnasts and other sports (Shea and Fields 2002). More than 2 million Americans seek and receive treatment every year for the condition. Despite this number, there has been no clear treatment plan to help physicians in managing patients.

Etiology - the plantar fascia is a strong band of white glistening fibres that has an important function in maintaining the medial longitudinal arch (Singh et al. 1997). Its spontaneous rupture or surgical division will lead to a flat foot. It rises from the medial calcaneal tuberosity on the undersurface of the calcaneus. In most cases, plantar fasciitis results from a biochemical imbalance that causes abnormal pronation (Barrett and O'Malley 1999). A person or patient with, for example, a flexible rearfoot varus may at first seem to have a normal foot structure but may later show significant pronation when bearing weight. The talus will flex and adduct as he or she stands, as the calcaneus everts. The pronation significantly increases tension on the plantar fascia. Other conditions like tibia vara, ankle equines, rearfoot varus, forefoot varus, compensated forefoot valgus and limb length inequality can exert an abnormal pronatory force. Increased pronation with a collapse can add stress to the anatomic central band and ultimately lead to plantar fasciitis. This is because the weakest point of the plantar fascia is the origin and not the substance. Plantar fasciitis accounts for about 10% of all running injuries (Miller 2004). There is chronic tugging of the plantar fascia at the point were the tissue attaches to the heel bone. It is an overuse injury that results from the effects of repetitive abnormal forces that lead to the destruction of the cell tissue and trigger the inflammatory process. Prolonged pronation of the foot, with the sole of the foot turning outward and wearing worn-out shoes are major contributing factors to the condition. Foot slap when doing downhill running may make the condition worse (Miller). Other risk factors are sudden gain in body weight or obesity, unaccustomed running or walking, wearing shoes with poor cushioning, increase in running distance or intensity, change in the walking or running surface, tightness of the Achilles tendon, and occupation that involves prolonged weight bearing (Singh et al. 1997).

Signs and Symptoms - Pain in the heel when taking the first steps in the morning or when suffering a minor foot injury is the first symptom (Barrett and O'Malley 1999, Miller 2004). The symptoms decrease as walking continues. The pain gets localized in the medial calcaneal turbercle, is usually insidious but with no history of acute trauma. Many patients point to the condition as the result of a stone bruise or a recent rise in daily activity. The injury is usually caused by a sudden twist of the foot or when making a misstep (Miller). When the painful heel develops, the condition quickly gets worse until the patient experiences much discomfort in the entire bottom of the affected foot. Many patients tolerate the symptoms and try to relieve these with home remedies before obtaining medical treatment (Barrett and O'Malley).

Diagnosis - This is typically based on the history and a finding or clinical presentation of localized tenderness (Barrett and O'Malley 1999). This is the practice even in this age of modern technology. The tenderness or pain is generally localized at the origin of the anatomic central band of the plantar fascia while no significant pain results from the compression of the calcaneus from a medial to a lateral direction. Standard weight-bearing radiographs in the lateral and anteroposterior projection show the biomechanical nature of the hindfoot and forefoot and may likewise reveal osseous abnormalities like fractures, tumors or rheumatoid arthritis in the calcaneus. Such radiographs, however, only serve as confirming tool in the diagnosis.

Oftentimes, a diagnosis of plantar fasciitis is made on the history and physical examination of a patient with inferior heel pain and investigations are conducted to rule out other disorders causing inferior heel pain (Singh et al. 1997). A patient often reports that the pain can become so incapacitating that he has to limp to the bathroom or hobble around with the heel off the ground. He also reports that the heel pain decreases during the day but gets worse with increased activity, such as jogging or after some time sitting down. Aggravating pain in the morning is typically indicative of plantar fasciitis and usually not of calcaneal stress fractures or nerve entrapment. Pain in the evening should point to other causes of heel pain, such as tumors, infections and neuropathic pain, such as tarsal tunnel syndrome (Singh et al.).

The patient often describes a gradually increasing discomfort over the succeeding weeks (Singh et al. 1997). He often wears shoes with poor cushioning or inadequate arch support or he walks barefoot on hard floors. Plantar fasciitis is usually unilateral, but some patients sometimes report contralateral pain when they shift weight to the other leg. Bilateral disease in young patients should invite suspicion of Reiter's syndrome. Obesity occurs in 90% of female patients with plantar fasciitis and 40% of male (Singh et al.).

Examination - Physical examination on a patient with plantar fasciitis often yields localized tenderness on the anteromedial part of the heel through the use of firm finger pressure (Singh et al. 1997). Swelling in the area and tightness of the Achilles tendon are also common in 78% of patients with this condition. No other clinical findings in the foot and ankle are usually made. Tenderness should be specific or localized in the calcaneal tuberosity, otherwise, the diagnosis of plantar fasciitis should be doubted. Tenderness at the center of the posterior of the heel should invite suspicion of bruising or atrophy of the heel pad; Tinel's sign on the medial part of the heel may indicate nerve entrapment to abductor digiti quinti or a tarsal tunnel syndrome; and tenderness on mediolateral compression of the heel through squeeze test should rouse a suspicion of a stress fracture of the calcaneus (Singh et al.).

Investigation - a plain lateral radiograph of the heel can rule out a stress fracture, erosions due to bursitis, or rare bony causes of inferior heel pain (Singh et al. 1997). Isotope scanning should be used when stress fractures are suspected and plain radiographs have normal findings. Magnetic resonance imaging or MRI) may show thickening and inflammation of the fascia, while ultrasonography may show increased thickness and inflammation of the plantar fascia. Complete blood tests are recommended for patients with bilateral disease or an atypical clinical condition. Electrophysiological tests may confirm a tarsal tunnel syndrome or compression of the nerve to abductor digiti quinti, but these tests or studies are difficult to perform and interpret and are not… READ MORE

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