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Insider Arthritis Tips April 2009 Newsletter
April 15, 2009

Table of Contents

How to treat plantar fasciitis

Wei's World

"A pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty." -- Winston Churchill, British prime minister

How to treat plantar fasciitis

This month's topic came about because I recently (within the last two weeks) saw three people with this problem who had failed conservative measures and were supposedly heading to surgery... Fortunately, they all responded to the treatment mentioned at the end of the article and avoided the knife. The rule(s) of thumb are two-fold. Number one: no more than one cortisone injection. Number two: avoid surgery whenever possible.

Plantar fasciitis is one of the most common causes of heel pain. It is due to inflammation of the plantar fascia, a thick piece of connective tissue that runs from the bottom of the heel to the base of the toes.

This is how the condition develops…

Repetitive trauma leads to micro tears in the fascia. Common causes include a sudden increase in physical activity, wearing shoes without arch support, an acute injury, and prolonged standing. Excessive weight can be a contributing factor.

The classic symptom is pain in the heel with the first steps in the morning and after a period of rest. The pain improves with activity but comes back after prolonged weight-bearing, particularly at the end of the day. The pain is usually located in the bottom of the heel but sometimes radiates to the arch.

Four conditions that mimic plantar fasciitis are tarsal tunnel syndrome (entrapment of the tibial nerve), entrapment of the first branch of the lateral plantar nerve, stress fracture of the calcaneus (heel bone), and referred pain from a pinched nerve in the low back. Electrical studies such as electromyograms and nerve conduction testing can assist in diagnosis.

The diagnosis is suspected on history and physical exam and can be confirmed by magnetic resonance imaging (MRI) or diagnostic ultrasound.

Treatment for plantar fasciitis is conservative at the beginning, consisting of non-steroidal-anti-inflammatory drugs (NSAIDS), plantar fascia night splints, well-cushioned shoes, heel pads or heel cups, orthotics, and physical therapy. Stretching of the plantar fascia and heel cord is often beneficial.

Other treatments that have had some success include heel lifts and short leg casts.

While cortisone injections are often given for plantar fasciitis, they should be avoided if possible. Relief is temporary and the plantar fat pad will atrophy. In addition, rupture of the plantar fascia can also occur.

Extracorporeal shock wave therapy generates high pressure sound that appears to relieve soft tissue pain. How this device works is still not completely understood. Theories include the formation of new blood vessels or perhaps damage to sensory pain fibers. It takes about six months before maximum improvement is noted.

While surgery is an option, it’s not a good one. The types of surgery performed include endoscopic fasciotomy, heel spur removal, and plantar fascia release. Debates among surgeons regarding the benefit of endoscopic approaches versus open approaches are common. Both groups claim a better than 90 per cent success rate. Time to recovery varies from three to 10 months in most series.

A much more effective therapy appears to be the use of percutaneous needle tenotomy. This is a procedure where a needle is inserted using ultrasound guidance and the fascia is irritated in order to stimulate inflammation. Platelet-rich plasma (PRP), which is a concentrate of the patient’s blood that contains a large number of platelets, is then injected into the site. Platelets contain multiple healing and growth factors. When they are introduced into an area of injury a cascade of events occurs including healing as well as tissue regeneration.

Physical therapy can be started gently about a week to ten days following the procedure.

In our hands, the success rate, including patients who have failed all other forms of treatment, has been excellent.

A Frustrating Learning Experience...

Wei's World April 2009

My dad taught me how to drive when I was 15. I learned on an old 1963 Chevy Bel-Air station wagon with an automatic transmission.

My parents were not wealthy. We weren’t poor but I didn’t grow up with a silver spoon in my mouth. I was expected to work in the summers during high school and college to help pay for school. So at various times I got jobs like painting numbers on curbs for donations, washing dishes in a restaurant, cleaning toilets, and many other jobs.

My most memorable experience was a miserable failure. I applied to be a Yellow Cab driver in Philadelphia. The classroom learning was pretty easy but then I had to learn how to drive the cab. Cabs at the time all had manual shift on the column. The “training” consisted of going out in the cab with a trainer for two consecutive mornings. I got about 30 minutes (four other people were in the cab and we all got a turn) of “hands on” drive time. It was pretty clear that the other guys knew how to drive manual and I didn’t.

So the day came for me to start my job as a cab driver. They gave me a pair of gray pants, a white shirt, and a hat. I got my cab assignment. I walked over to the car, and got in. It was a hot day and the vinyl got me sweating right away through my shirt and pants. I started the cab up, shifted into first and got rolling. I felt on top of the world.

Unfortunately, the exit out of the parking lot was up a small hill and there was a cab in front of me. I had to brake and then try to get my cab back up the hill to get out of the parking lot. I couldn’t do it. I tried for at least 15 minutes. People in back of me were getting really impatient, yelling at me, honking their horns and such. I was drenched in sweat and in tears from frustration. The manager finally came out to the car and asked me to leave the cab and come to the office.

He sat me down and asked me how I ever got through training. He asked whether I ever learned to drive a standard transmission. I told him I went through the company training. He just shook his head and fired me.

I was pretty miserable when I got home and told my mom what had happened. She consoled me… but I’ve never forgotten that incident. Failure is never pleasant. But now when I tell the story, I usually get a chuckle out of people. And, in time, I have also come to realize that it wasn’t the end of the world.

That's it for this month...

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