Dry needling- whereby anesthesia is first infiltrated into the heel area. Then using ultrasound guidance, an empty hypodermic needle is inserted into the plantar fascial ligament in the area giving the patient the most pain. This is repeated multiple times. The theory here, once again, is to create blood flow into a structure that is generally poorly vascularized. The increased blood flow of course then brings nutrients into the area to heal the plantar fascial ligament, just like blood normally does for other injured parts of the body.
It is also felt that the actual needling of the plantar fascial ligament will also help break up any scar tissue that may have formed. The authors of the original study also recommended directing a cortisone injection into the area once the dry needling was finished to reduce inflammation.
In my opinion I do not think the cortisone injection is very helpful for a couple of reasons. One, more than likely patients who are undergoing this procedure have already had one or more cortisone injections (which did not work) and for anyone who treats plantar fasciitis, it is not very difficult to direct the cortisone into the painful area even without ultrasound guidance.
Two, one of the theories regarding recalcitrant heel pain is that the brain is not recognizing the inflamed plantar fascial ligament and thus is not doing what needs to be done to fight the inflammation. This is part of theory already mentioned above regarding the concept of plantar fasciosis.
So, in my mind I would be more inclined to avoid the cortisone injection and allow the inflammation to happen.
After the office procedure it is recommended that the patient wear a walking boot for one week to protect the plantar fascial ligament because since it has been punctured in multiple areas this may actually weaken the ligament and there is a chance of rupture. After the boot is removed I would recommend wearing a good orthotic for a couple more weeks.
The benefits of this procedure is that the authors of this study suggest a 95% success rate, but please keep in mind this was done on a small population of people with heel pain. They also found that relief lasts upwards of ten months and probably longer is the patient takes the necessary steps to avoid re-injury. Relief may not be immediate, but should occur within two to three weeks. This treatment is a one time treatment, performed in the office and since it is not a surgical procedure there is overall less risk and less expense.
Surgical intervention- lastly, when all else fails, surgical correction should be entertained. Today’s foot specialist is trained in doing both conventional large incision procedures and minimal incision procedures. Keep in mind, that surgery for a heel spur or plantar fasciitis can have a very long recovery period. The simple truth of the matter is that after surgery, every time you step on that heel you are basically aggravating the surgical site and for that reason the healing process can take a long time. Thankfully, most cases of heel pain can be resolved without surgical intervention.
My surgical treatment of choice for heel spurs and plantar fasciitis is a small incision approach performed on the bottom of the heel. This procedure is relatively quick with minimal trauma to the foot, thus allowing the foot to heal quickly.
Basically I palpate where the patient is experiencing the most pain and mark the spot with a surgical marker. Once the patient is sleeping, I am able to insert a needle through the bottom of the foot where I previously marked the foot. Using fluoroscopy I am then able to see how close I am to where the plantar fascial ligament attaches into the heel bone. If I am not close enough I can re-insert the needle until I am satisfied I am right at the attachment point.
I then make a small stab incision where the needle is located. The incision is usually less than a half inch long. Through that incision I take a scalpel and detach the plantar fascial ligament from its attachment to the bone. In these cases we do not want to totally detach the ligament, for this can result in destabilization of the lateral side of the foot and result in lateral column pain (see below).
Once the ligament is severed, I then take a bone rasp and smooth out any bone spur that may be present. Keep in mind, a bone spur may not always be present. After that I place 2-3 sutures to close the incision.
Update, November 2010 Like any surgical procedure there are inherent potential complications. One of the problems with any surgery on the plantar fascial ligament is it that will tend to weaken the function of that ligament. This can lead to a condition known as lateral column pain.
At a medical conference I just attended we were shown a "before" x-ray prior to a partial plantar fascial release and then an x-ray taken ten years later revealing a marked drop in the arch of the foot. Now, even though the patient was not having any problems with his foot, the fact that his arch had collapsed so much would lead one to believe that he will eventually suffer from early arthritic changes within the foot as a result of the change.
WHAT ABOUT STRETCHING FOR PLANTAR FASCIITIS?
I would not say there is a raging debate going on in the medical profession about stretching for plantar fasciitis, but if you do enough research you will find those that recommend stretching the ligament while there are others who feel it is counter productive.
I guess I fall somewhere in between and here is my feeling on the subject.
If your heel pain is from an acute problem (wearing flip flops one day and doing a lot of walking, as an example), and the pain is not outrageously painful, and most of your pain is evident when you first stand up on the foot and then dissipates as you walk, then stretching the arch of the foot is not a bad idea simply because the plantar fascial ligament is tightening up and the "looser" you can keep it, the less pain you will have.
However, if your heel pain is more the result of a biomechanical problem meaning it is a result of the way your foot functions or if you happen to be overweight and have a job where you stand all day on hard floors, or you are an athlete who developed the problem while participating in your sport, then perhaps stretching of the ligament is not your best bet.
In all these examples just cited, the plantar fascial ligament has been over-stretched and has become inflamed. Continuing to stretch in an attempt to make it feel better, may actually make your symptoms worse or at the very least, may delay the healing process.
But, even in these cases there is an indication for stretching but it is not the plantar fascial ligament; it is the achilles tendon.
Many cases of non-traumatic plantar fasciitis occur simply due to a tight heel cord. An equinus (tight heel cord) is when your foot has the limited ability to bend upwards at the level of the ankle. In most cases the foot will not bend beyond 90 degrees to the lower leg. Without the ability of the ankle to adequately bend upwards, the foot is forced to compensate by flattening out. What happens when a foot excessively flattens out or pronates? You over-stretch the plantar fascial ligament.
In this scenario, depending on your age, doing calf stretches to try and increase the range of motion at the ankle joint may be of benefit. In general, the older you are, the less effective stretching exercises will be. As a side note, in many cases where we find a tight heel cord and are going to make an orthotic for plantar fasciitis, we will also add a heel lift to the device. Adding a heel lift reduces the tension on the achilles tendon and thus does not force the foot to pronate as much.
In instances where the tight heel cord is the culprit, an achilles tendon lengthening may be performed to resolve the problem.
continue....home remedies for plantar fasciitis treatment
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Specific Recommendations For This Condition
In my opinion, the best pre-made orthotic available. Offers the best combination of support and cushioning. Will work in the greatest percentage of people who try a pre-made orthotic. (keep in mind, everyone's foot structure is different and so unlike a prescription orthotic, pre-made devices can be hit or miss) Click the link below for a full description.
Many of you are forced to wear dress shoes on a daily basis and it can be difficult to get an orthotic into a dress shoe since there is limited space. Redithotics are a pre-made orthotic designed specifically for this purpose. Click the link below for a full description.
LOW PROFILE NIGHT SPLINT
For those of you who suffer from severe pain from plantar fasciitis or achilles tendonitis when you first get on your feet in the morning, the night splint is an excellent product. Most night splints are very bulky and people complain they cannot sleep with them. This low profile splint is very comfortable and just as effective.
TOPICAL PAIN RELIEVER
unlike other topical medications which give the sensation of heat or cold to mask your pain, Blu-Mjk contains actual pain medication which works directly on your painful area