Gustavo,

A disclaimer: I have perhaps treated a dozen or so cases, and my comments would have less weight than those from a podiatrist or specialist such as yourself.

In my experience, cultural factors, such as fashion, or habitual use of shoes that distort the structural alignment of the back, hips, calves, ankle and foot, or unhealed ligament injuries may contribute to chronic pain or tissue damage in the foot that is diagnosed as plantar fasciitis.

As for risk factors:

1. The Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline–Revision 2010 (http://dx.doi.org/10.1053/j.jfas.2010.01.001) “The most common cause cited for plantar heel pain is biomechanical stress of the plantar fascia and its enthesis of the calcaneal tuberosity. Mechanical overload, whether the result of biomechanical faults, obesity, or work habits, may contribute to the symptoms …” They suggest conservative treatments depending on clinical presentation. The article you cited about nerve entrapment would lead to their Tier 3 interventions, after more conservative approaches failed.

2. The Merck Manual combines plantar fasciosis and fasciitis in risk factors (http://www.merckmanuals.com/professional/musculoskeletal_and_connective_tissue_disorders/foot_and_ankle_disorders/plantar_fasciosis.html) “…a sedentary lifestyle, occupations requiring sitting, very high or low arches in the feet, and chronic wearing of high-heel shoes. The disorder is also common among runners and dancers and may occur in people whose occupations involve standing or walking on hard surfaces for prolonged periods.”

I see these risk factors a lot in my practice. Extensive history-taking does direct me to causes in my assessment. However I primarily design interventions to address their functional symptoms. Do you have a more systematic approach linking causes and risk factors with interventions?

Dear Gustavo

This artice may be useful for you:

Cent Afr J Med. 1997 Jan;43(1):23-5.

A prospective study of Plantar fasciitis in Harare.

Chigwanda PC.

OBJECTIVES:

1. To determine the sex distribution of Plantar fasciitis in Harare. 2. To determine the presence or absence of a calcaneal spur and its role in causation and hence treatment. 3. To determine unilateral or bilateral involvement. 4. To determine the response to steroidal injection. 5. To determine the role of occupation and/or activities if any.

DESIGN:

Patients presenting with heel pad pain were carefully examined, the age, sex and occupation recorded. They were followed up at two weekly intervals following treatment.

SETTING:

This prospective study was carried out at a private surgery in a low density suburb. Most patients were referred by their general practitioners and some by patients who had been treated successfully. A few were referred from towns in and around Mashonaland Central Province.

SUBJECTS:

All patients had to satisfy the diagnosis of Plantar fasciitis. Those presenting with well known causes of pain in and around the heel were excluded.

INTERVENTIONS:

All patients had radiographs of both heels requested. The painful heels were injected in the office with 80 mg of depo-medrol plus three to four mls of plain lignocaine using the lateral approach.

RESULTS:

The majority of patients (90%) were female, the mean age 48.5 years. Most patients (60%) had no calcaneal spur, 64% had unilateral disease and this was predominantly left-sided. 94% had relief of their symptoms following a single injection.

CONCLUSIONS:

In this study there were more females treated for Plantar fasciitis, the majority responded to a single injection. The role of occupation and/or activities require further study

HI,

PF, like other enthesopathies, develop from repetitive stress, repetitive inflammation, scarring, and scar constriction that contributes to poor vascularity.

Conservative management are custom orthotics if needed for hyperpronation, PT, massage, exercise, and often decreased jumping, running, and other like activities.

For recalcitrant cases, ESWT is highly effective. This therapy is available in low energy office units that require 5-7 weekly visits, and high energy units, used under anesthesia, that required 1-2 sessions. The patient should continue with custom orthotics if needed for hyperpronation,

We just finished data collection on a study with seemingly good results with 300+ data points. See attached for a literature review (a bit dated, sorry) and contact me if you wish full articles or additional information such as slide presentations, etc.  

Ed

Hi all. A re.emerging problem with an old-established (yet negelcted) solution. I think that there is no more doubt. Plantar fasciitis is mostly one of the potential symptoms of foot overporation and/or (this is often avicous circle) of a shortenin gof the triceps surae. Stretching is often the fast solution (and/or: using higher heels in the acute phase, to slack the triceps). Thisis hyper-evidence based:see all the recent literature (eg Garrett T et al. J Sport Rehabil 2013(, and refer to the seminal paper by the founder of modern podiatry, Merton Root (apart from his classic textbooks, see the old article in J Am Podiatr Med Assoc 1964, still in Medline). Treating pain and/or inflammation is palliative: the cure is restoring a proper biomecahnics of the foot. 

Regards

Gustavo,

Other than the conservative therapies and theories behind chronic heel pain, I would also look at the lateral plantar nerve as a possible source of symptoms.

http://europepmc.org/abstract/MED/7204858

http://europepmc.org/abstract/med/3425404

Best wishes.

Gustavo

Please look for the following contribution to the literature in the coming months/very near future.  I have had the opportunity to review it.  The article is very well written, evidence based and will be an excellent contribution to the literature. 

Heel Pain ―Plantar Fasciitis: Revision 2014

Clinical Practice Guidelines

Linked to the International Classification

of Functioning, Disability, and Health

from the Orthopaedic Section of the

American Physical Therapy Association

J Orthop Sports Phys Ther. 2014:44(_).A1-A_. doi:##.####/jospt.####.####

Hello Gustavo,

Plantar fasciitis is a fascinating and confusing syndrome. I would like to reccommend you to have a look at a research that I participated in - 

Deep massage to posterior calf muscles in combination with neural mobilization exercises as a treatment for heel pain: a pilot randomized clinical trial. Saban B, Deutscher D, Ziv T. Man Ther. 2014 Apr;19(2):102-8. doi: 10.1016/j.math.2013.08.001.

This article presents a new approach to the treatment of plantar heel pain, and also raises some interesting questions as to the origin of the pain. I hope that you enjoy reading it.

Regards

The clinical practice guidelines for this are now published in JOSPT.  Link as follows:

http://www.jospt.org/doi/abs/10.2519/jospt.2014.0303

Worth the review. 

I think that all comments are very interesting and I attach a paper published in JOSPT for us.

Hugs 

Plantar Fasciitis is one of the foot symptoms most frequently observed in chronic musculoskeletal pain patients.  In almost all of these patients ( in my chronic pain practice ) have gravity driven pronation gait patterns:

Isolate the cause of the gravity driven pronation, you will be able to trace back to the cause of Plantar Fasciitis.

Just some food for thought.

PF as Brian notes above is usually more about entire body mechanics rather than the local pathology.  Using the Advanced BioStructural Correction™ protocol people worldwide report clearing of long standing PF within a two week period.

Pertinent site  MeningealRelease.com