Reexamining The Fundamentals In Treating Plantar Fasciitis (Or Plantar Fasciosis)

     When we put our editorial calendar together each year, one of the struggles is putting together an entire theme issue of fresh perspectives on heel pain. It is one of the most common conditions that DPMs see in practice and plantar fasciitis reportedly accounts for over 1 million patient visits a year in the United States. Given the prevalence of the condition, we continue to address this topic in depth every November. Hopefully, the collection of feature articles in our 7th Annual Heel Pain Theme issue will stimulate discussion and debate.      In the cover story, “Conquering Posterior Heel Pain In Athletes,” Christopher R. Corwin, DPM, and David C. Erfle, DPM, discuss a number of key considerations in diagnosing and treating various forms of posterior heel pain, and emphasize the importance of proper shoe gear (see page 36). At one point, the authors note that using custom orthoses and posterior heel pillows in sneakers and cleats can be “quite beneficial” in managing heel pain due to conditions such as apophysitis, tenosynovitis and retrocalcaneal bursitis.      While many have cited anecdotal success with the use of orthoses in the treatment regimen for alleviating plantar fasciitis pain, there have been conflicting results reported in the literature. A recent study published in the Archives Of Internal Medicine found short-term benefits with orthoses in terms of function and pain relief but no long-term benefits in treating plantar fasciitis (see “Are Orthoses Effective Against Plantar Fasciitis In The Long Run?” on page 8 in the September issue of Podiatry Today).      However, Stephen Barrett, DPM, and Paul Scherer, DPM, two of the authors in this issue, say there may be a tendency by clinicians and the public to use “plantar fasciitis” as a catch-all term and it may be a completely erroneous term at that.      In separate feature articles, Drs. Barrett and Scherer (see “How To Address Mechanically-Induced Subcalcaneal Pain” on page 77) both cite a 2003 study published in the Journal of the American Podiatric Medical Association by Harvey Lemont, DPM, and colleagues.      As Dr. Barrett points out, Lemont’s study found “no histological mediators of inflammation” within 50 specimens sent for pathological examination from surgical cases for plantar fasciitis. Accordingly, Dr. Barrett notes Dr. Lemont’s use of the term “plantar fasciosis” instead of “plantar fasciitis” due to the degenerative nature of the condition and the lack of inflammation.      Dr. Barrett takes this a step further in his provocative article, “Should You Change Your Approach To Plantar Fasciosis?” (see page 48). He says the common approach to exhausting conservative care options before exploring surgical options is based upon the notion of plantar fasciosis being an inflammatory condition and adds that there is a profound lack of studies that document the efficacy of conservative modalities for heel pain. Accordingly, Dr. Barrett calls for a scientifically validated scoring system for heel pain and posits a working model for this.      While this may be a tad too provocative for some to accept, one of the common themes that runs throughout all the feature articles in this theme issue on heel pain is the emphasis on fundamentals. Namely, all the authors in this issue emphasize the importance of narrowing down and identifying the precise etiology of a patient’s heel pain complaint.      This common sense point seems to ring true amidst all of the conflicting studies, anecdotal results and theories. As all the authors maintain, clearly defining the source of the pain is essential to providing effective treatment.