HEEL PAIN AND PROLOTHERAPY

BY FRED G. ARNOLD, NMD

If you have ever had pain in the heel and bottom of your foot you may already be aware of a condition called plantar fasciitis that is one of the most common causes of heel pain. Plantar refers to the bottom of the foot and fasciitis refers to a band of connective tissue on the bottom of the foot called the fascia. The condition is also known as plantar fasciosis or jogger’s heel.

Typically there is a stabbing pain in the bottom of the foot near the heel. There may also be a stiffness in the bottom of the heel and the pain may be dull or sharp. The heel may also ache or burn. The pain is usually worse with the first few steps after awakening, although it can also be triggered by long periods of standing or getting up from a seated position. Climbing stairs and after intense activity can aggravate the condition. The onset of the pain may develop slowly over time or come on suddenly after intense activity.

It is estimated that 4% to 7% of people have heel pain at any given time and about 80% of those cases are due to plantar fasciitis. Approximately 10% of people will have this problem at some time during their life. Although it is more common as we age, it is unclear if one sex is affected more than the other. In a third of people both feet are affected.

THE ACTUAL CAUSE OF THE CONDITION
Under normal circumstances, your plantar fascia acts like a shock-absorbing bowstring, supporting the arch in the foot. If there is tension on that bowstring and it becomes too great, it can create small tears in the fascia with collagen breakdown and scarring. As inflammation plays a minor role in the condition, some feel that the condition should be called plantar fasciosis rather than plantar fasciitis.1 Plantar fasciosis refers to the tears in the connective tissue where as plantar fasciitis refers to inflammation of the connective tissue.

PREDISPOSING FACTORS
There are predisposing factors that may increase your risk of developing tears in the plantar fasciitis:

• Age: it is most common between the ages of 40 – 60.
• Exercise: Activities that place a lot of stress on your heel and connective tissue such as long-distance running, ballet dancing and dance aerobics.
• Overweight: Excess pounds puts more stress on the bottom of your foot and heel.
• Foot Biomechanics: being flat-footed, having a high arch or foot flare, and excessive pronation will affect how your body weight is disturbed to the bottom of your foot. Wearing shoes that don’t fit or are worn out also will affect biomechanics.
• Occupations: People who spend most of the work time walking or standing on hard surfaces can damage their fascia.
• While calcaneal spurs are frequently found with plantar fasciitis, there can be present without there ever being any pain. I consider these spurs to be a result of the foot instability rather than the cause of the pain.

EXAMINATION
To determine if you have plantar fasciitis a physical examination should be performed. You may be asked to stand and walk and the doctor will examine your foot and press where it hurts. It is important to know your past health, including what illnesses or injuries you have had. The nature of your symptoms, such as where the pain is and what makes it better or worse is important to know. An ultrasound evaluation or X-rays of the foot may be ordered to rule out a stress fracture or some other active disease process. It is important that the doctor examine the whole foot for the pain may also be found in other areas of the foot, not just on the bottom of the foot. It is rare I ever find pain localized only to the bottom of the foot. Pain of the plantar fascia is normally a symptom of instability of the foot and multiple areas of the foot need to be treated.

TREATMENT

CONVENTIONAL
The convential or traditional approach to treating this painful condition involves pain medication, such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) to reduce pain and inflammation. Heel and foot stretching exercises and night splints to wear while sleeping to stretch the foot may be recommended. Patients are usually recommended to rest the foot as much as possible for at least a week. Other steps to relieve pain include applying ice to the painful area, wearing a heel cup or shoe inserts. If these treatments do not work, the foot may be put in a boot cast for 3-6 weeks. Steroid shots or injections into the heel are given and foot surgery if the condition persists.

PROLOTHERAPY
Although, patients may experience some degree of pain relief with the above conventional treatments, none these treatments address the cause of the problem: micro tears in the connective tissue with collagen breakdown. Not only do anti-inflammatory drugs like advil and motrin prevent the body from trying to heal injured tissue, steroid injections breaks down the weakened connective tissue and can worsen the condition. Prolotherapy is a proven nonsurgical treatment that stimulates the body’s natural healing response to heal and strengthen the damaged connective tissue. Tissue growth and repair with prolotherapy injections can be documented with ultrasound and confirmed with magnetic resonance imaging (MRI). 2 In a study by the American Journal of Roentgenology, prolotherapy (dextrose) injections “showed a good clinical response in patients with chronic plantar fasciitis…”3 In addition to prolotherapy injections, it is important to address those predisposing factors that contribute to plantar fasciitis to speed up the recovery and prevent a reoccurrence of the condition.

CONCLUSION:
Plantar fasciitis is a very common condition affects many people who spend a lot of time on their feet and are active with work or sports. There are many conventional treatments to address this painful condition; however, none of these address the cause of the actual pain that is being experienced. It is the micro tears that are produced in the connective tissue by a variety of pre-disposing factors that actually cause the pain and inflammation experienced in the foot. Prolotherapy is a proven and extremely effective way to treat and plantar fasciitis and should be considered for this painful condition practically if the doctor wants to inject the foot with steroid that can weaken the fascia and make the foot worse. Because prolotherapy works so well for this condition, surgery should only be considered as a very last resort.

REFERENCES:

1. Beeson P, "Plantar fasciopathy: revisiting the risk factors". Foot and ankle surgery: official journal of the European Society of Foot and Ankle Surgeons, September 2014
2. Arch Phys Med Rehabil. 2008 Feb;89(2):377-85. High-resolution ultrasound and magnetic resonance imaging to document tissue repair after prolotherapy: a report of 3 cases. Fullerton BD. Patient-Physician Partnership, Austin, TX, USA.
3. M B Ryan, A D Wong, J H Gillies, J Wong and J E Taunton Sonographically guided intratendinous injections for the treatment of chronic plantar fasciitis of hyperosmolar dextrose/lidocaine: a pilot study, Br. J. Sports Med. 2009;43;303-306.