Plantar Fasciitis

Volume: 13
Issue: 4
April 15, 2018
Plantar Fasciitis

Dear Colleagues:

One of my pet peeves in medicine is pseudo-diagnosis – labelling a condition with a name suggesting knowledge that does not exist. “Arthritis of the spine” comes to mind, used for non-specific backache associated with disc degeneration on x-ray. This is a standard “out” for physicians who don’t have a clue as to what is causing the patient’s backache, but feel they have to tell the patient something. 

The suffix -itis is similarly misused. Attaching “itis” to the name of a painful organ or structure implies that inflammation is present even when calor, rubor, or tumor is not. All we have is dolor – but not enough to justify the “itis” suffix. I have already written about pseudo-diagnosis of this kind in the case of trochanteric “bursitis” (Vol. 7, No. 2) now more properly called “greater trochanteric pain syndrome”.

A similar situation occurs with “plantar fasciitis”, that common condition of pain in the posterior sole of the foot – dolor, but no calor, rubor or tumor – at least at a macroscopic level. However I was surprised to find on a PubMed search considerable literature on the subject. And yes, there is objective evidence of something going on in the fascia but it is not inflammation.   Histological studies have shown that the condition is a degenerative process, which means that steroid injections and/or anti-inflammatory medication are not indicated. Ultrasound and MRI demonstrate a thickening of the fascia confirming what is a relatively simple clinical diagnosis: pain on taking the first few steps in the morning, and after prolonged standing; tenderness at the plantar-medial aspect of the heel; and pain on passive dorsiflexion of the ankle and toes.

Plantar fasciitis is most common in middle age, in the obese, in runners and those spending much of their time on their feet. Almost twice as many women are affected as men. In one study, 45% of patients had pain persisting at 15 years from onset. And up to 50% have bilateral symptoms. The pathophysiology is felt to be one of repetitive strain and micro-tears. 

Most treatment has been directed at the plantar fascia itself, with corticosteroid injections, plasma rich platelet injectionsextra-corporeal shock wave therapyprosthetics and orthoticstaping and other conservative measures showing minimal benefits. Osteopathic manipulative treatment of the foot may provide short-term relief, but no evidence exists of a lasting effect. However I could find nothing about the use of more general osteopathic treatment (at least in PubMed and “Foundations for Osteopathic Medicine”). And plantar fasciitis is not mentioned in the Dosch or Barop neural therapy textbooks. 

It is a little known fact that pain can be referred to the underside of the heel from the sacrotuberous ligament. Hackett demonstrated this in his studies of pelvic ring ligament referral patterns*. Because referred pain is often also tender, this scenario can easily be misdiagnosed as “plantar fasciitis”. Correction of pelvic ring imbalance with manipulative treatment, or perhaps prolotherapy, can relieve this type of heel pain. In my practice, heel pain from the sacrotuberous ligament is not rare. 

Recently however, I came across a case of plantar fasciitis that fit none of the above categories.  A relatively healthy 64 year old man presented with a variety of complaints including psoriasis for 15 years, gastrointestinal reflux for 40 years, a myocardial infarction two years previously and left plantar fasciitis of about two years duration. Past trauma included a fractured right forearm requiring orthopaedic surgery in his teens, a right inguinal hernia repair at age 59 and several root-canalled teeth

I obtained a complete history and examined the man thoroughly, but decided to concentrate on a few physical findings that potentially related to the plantar fasciitis. His left hamstrings were tighter than his right, the left pube was a few millimetres inferior to the right (while supine) and the left sacroiliac joint was looser than the right – while prone, gentle cephalad pressure on the left side met less resistance than the same maneuver on the right. (I call this an “innominate upslide” – similar to an “innominate upslip” except that the ischial tuberosities are level and the sacroiliac joints are motion-tested. See “The Innominate Upslide sign…”)

Autonomic response testing indicated an interference field in the medial half of the hernia scar. This was treated using the Tenscam device (an alternative treatment would have been infiltration with dilute procaine) and the pelvic ring assymmetry returned immediately to normal. Four weeks later the man reported that his plantar fasciitis was 60% better; at two months it was almost normal.

I suspect that in this case the heel pain was referred from the sacrotuberous ligament that had been under strain from the pelvic ring imbalance. This mechanical imbalance was in turn a result of an interference field in the inguinal hernia scar. 

The “take-home” lessons here are: beware of the suffix “-itis”. Not all pain and tenderness is due to inflammation. And even if inflammation is present, we should not stop there. Let us find out the cause and treat it. It could be due to an interference field!

*Ligament and tendon relaxation treated by prolotherapy, Hackett GS, Hemwall GA, Montgomery GA. (1991) 5th ed. P.29.

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