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Case Report

2018; 11(4): 162-164

Published online August 1, 2018 https://doi.org/10.1016/j.jams.2018.04.002

Copyright © Medical Association of Pharmacopuncture Institute.

Noninvasive, Multimodality Approach to Treating Plantar Fasciitis: A Case Study

Tamsin L. Lee, Benjamin L. Marx*

Oregon College of Oriental Medicine (OCOM), Research Department, 75 NW Couch Street, Portland, OR 97209, USA

Correspondence to:Benjamin L. Marx

Received: November 12, 2017; Revised: March 30, 2018; Accepted: April 4, 2018

http://creativecommons.org/licenses/by-nc-nd/4.0/

Abstract

Plantar fasciitis, also referred to as plantar heel pain, is a common foot pathology among runners and other athletes. The clinical guidelines of the 2014 Orthopedic Section of the American Physical Therapy Association states, noninvasive therapies including manual therapy, stretching, taping, foot orthoses, and night splints are recommended as primary interventions. Recent studies suggest acupuncture may be an effective treatment compared to standard treatment for long-term relief. This case study reports the effects of a multimodality approach including massage, gua sha, bleeding, acupuncture, and moxibustion to treat acute plantar heel pain.

Keywords: acupuncture, foot pain, massage, plantar fasciitis, plantar fasciosis

1. Introduction

1.1. Biomedical perspective

The aponeurosis of the foot, or plantar fascia, is comprised of three distinct bands of dense connective tissue which support the arch of the foot [1]. The plantar fascia originates at the medial tubercle of the calcaneus, extends distally into the five metatarsophalangeal joints and ends at the proximal phalanges of each digit [1].

Plantar fasciitis has commonly been defined as an inflammatory process resulting from repetitive microtrauma leading to micro-tears of the plantar fascia [2]. However, current literature suggests plantar fasciitis is better referred to as “plantar fasciosis” (PF) due to the chronic and degenerative processes evident in the tissues, rather than inflammation [3]. The repetitive micro-tears lead to a repair response of thickening plantar fascia, collagen necrosis, chondroid metaplasia, and calcification [4].

Common risk factors include obesity, decreased ankle flexion, running, shortened or tight achilles tendon, and high arches or flat feet [5]. Women aged 40–60 years are more frequently diagnosed than other demographics [6].

PF is typically diagnosed clinically [6]. The primary symptom complaint is pain in the arch of the foot when bearing weight, which is worse during the first few steps in the morning and improves with rest [5]. Conservative treatment includes local application of ice, limited activity, supportive footwear, nonsteroidal antiinflammatory medication, and stretching [7]. Moderate treatment may consist of orthoses [8] and injection therapy [9]. Surgery may be recommended if the pain continues to persist over a year [10]. Recent studies suggest that noninvasive therapies, including acupuncture, may be more effective for long-term relief [11-13].

1.2. Traditional Chinese Medicine perspective

The kidney meridian is often affected as it is the only meridian located on the sole of the foot. Local trauma may lead to qi and blood stasis [14] in the kidney meridian that manifests as stabbing, sharp or dull pain, and/or pain on pressure [14]. Qi and blood deficiency is another common underlying pattern due to a weak constitution, chronic strain, and/or poor eating habits. Over time, the liver is unable to nourish the muscles and tendons with qi and blood leading to further stasis and pain [15]. The final pattern, Wind–Cold–Damp, is associated with acute pain aggravated by wind, cold, and/or damp weather conditions [14].

Acupuncture points for the treatment of PF vary greatly; however, common points include GB 34, GB 39, KI 3, BL 60, LI 4, SP 5, and LR 3 [12, 15-17] based on pattern differentiation and point indication. BL 57 and Ashi points along the gastrocnemius and soleus muscles are also frequently used [15] to release muscular tension. Furthermore, PC 7 has been shown to alleviate heel pain [13].

2. Case presentation

A 5ʹ7ʺ, 137 lbs, 43-year-old woman presents with localized pain on the right medial plantar calcaneus that began over a week ago. The pain is described as “stabbing” and is most severe in the morning. Although it subsides throughout the day, she continues to experience pain when walking and with weight-bearing activities. Patient reports no radiation or numbness associated with the pain and denies any recent history of falls or injuries. Owing to the pain, the patient recently switched to wearing flip-flops, which relieves some pain, but otherwise has not received any treatment or medication. At the time of initial intake, pain is rated on a verbal pain scale as a 9/10 in the morning and a 7/10 in general.

She is an active runner who runs 3–5 miles, 3–4 times a week, usually on concrete and in all weather conditions, including rain. She has a history of uterine fibroids and experiences abdominal bloating and dysmenorrhea. Her menstrual cycle is regular, 28 days. She experiences heavy flows, large dark red clots, and low back pain with her menses. The menses last for 5 days with 1–2 days of spotting afterward. She is currently on Ortho Tri-Cyclen. She has no history of pregnancy.

Upon physical examination, the right arch appears normal, and there are no apparent abnormalities in either foot. Her feet felt cold to the touch, and the patient confirmed she typically has cold feet and hands. On palpation, there is a +3/4 severe tenderness along the midline of the right heel; however, she reports improved pain relief with palpation. There is a +2/4 tightness of the right calf muscles compared to the left. She has normal range of motion in both feet and ankles. Her gait appears to have a slight pronation of the right foot with difficulty walking and bearing weight.

The tongue is slightly red and dusky, swollen with a thin white coat. The pulse is weak in both chi position, soft in both the right guan and left cun position, and wiry in the left guan position.

2.1. Diagnosis

The pattern differentiation was Wind–Cold–Damp Bi pain in the kidney meridian with underlying liver qi and blood stasis and liver blood deficiency (Table 1).

Acute pain.

History of running in damp/cold weather condition.

Location of pain.

Liver qi and blood stasis

Fixed, local, stabbing pain.

Pain better with pressure.

History of dysmenorrheal and fibroids.

Wiry left guan pulse.

Dusky tongue coat.

Liver qi and blood deficiency

Tight calf muscles.

Soft right guan pulse.

Cold feet.

&md=tbl&idx=1' data-target="#file-modal"">Table 1

Disease diagnosis and differentiation..

PatternSigns and symptoms
Wind–Cold–Damp Bi pain along kidney meridian

Acute pain.

History of running in damp/cold weather condition.

Location of pain.

Liver qi and blood stasis

Fixed, local, stabbing pain.

Pain better with pressure.

History of dysmenorrheal and fibroids.

Wiry left guan pulse.

Dusky tongue coat.

Liver qi and blood deficiency

Tight calf muscles.

Soft right guan pulse.

Cold feet.



2.2. Treatment

Treatment consisted of a multimodality approach including massage, gua sha, bleeding, acupuncture, and moxibustion.

The patient received a 5-minute Tuina massage focused on bilateral calf muscles and feet to warm the muscles and move qi and blood. She then received a 5-minute gua sha treatment on the right heel to again move qi and blood. Using a sterilized lancet, SP-1 (Yinbai) [18] on the right foot was bled to address blood stasis. The “pinching method”, a bleeding technique in which the bled area is pinched with the thumb and index finger, was utilized until there was minimal bleeding.

The following acupuncture points were chosen based on pattern differentiation: Yin Tang, SP-6 (Sanyinjiao), GB-34 (Yanglinquan), LR-3 (Taichong), BL-56 (Chengjin), and BL-57 (Chengshan) [15, 18]. Sterile disposable, stainless steel DBC .25 × 30 mm acupuncture needles were used and needled to de qi sensation reported by the patient. Indirect smokeless moxibustion around the right heel was used while the acupuncture needles were in place for 10 minutes. Needles were retained for a total of 30 minutes.

Gentle self-massage and stretching along the plantar fascia, gastrocnemius muscles, and the Achilles tendon were recommended. To massage the plantar fascia, it was suggested the patient use a tennis ball and gently roll the bottom of her foot for 1–3 minutes before bed and prior to weight-bearing in the morning. The patient was shown to stretch the calf muscles by placing her hands on a wall, with one leg straight, the other leg in front with the knee bent, pushing the hip toward the wall. Each calf was to be stretched to the point of a light pull without any discomfort or pain, for three intervals of 10 seconds, twice a day. Additionally, a daily 20–30 minute foot soak with ½ cup of Epsom salt in a basin of warm water, proper footwear with support, and avoidance of walking barefoot were suggested. Lastly, it was recommended the patient discontinue running while in treatment, then slowly reintroduce the activity, and continue self-care practices.

As an acute condition, the patient was asked to return 2 days later for a follow-up treatment.

2.3. Outcome

At the follow-up, the patient reported a decrease in pain from 7/10 to 4/10, and morning pain decreased from 9/10 to 6/10. She was also compliant with the self-care recommendations.

The follow-up treatment consisted of an identical multimodality approach and acupuncture point protocol. She was instructed to continue the self-care recommendations and return a week later.

On her 1-week follow-up, the patient reported a decrease of pain from 4/10 to 1/10. Her gait improved significantly and she was able to bear weight without pain. There appeared to be no tenderness upon palpation. She received a final multimodality treatment similar to visits 1 and 2.

3. Discussion

PF is a degenerative condition resulting from chronic repetitive micro-tears that lead to pain, thickening, necrosis, metaplasia, and calcification of the muscles and ligaments. The complexity of the condition requires a multifaceted approach that addresses the acute and chronic symptoms. Although the acute pain symptoms in this single case study were resolved with a multimodality approach of bleeding, acupuncture, gua sha, massage, and moxibustion, the deficiency of qi and blood were not addressed. To prevent future PF, it is important to build qi and blood with proper diet and adequate rest. Chinese herbal therapy may also be useful to treat the long-term chronicity of qi and blood deficiency.

Disclosure statement


The authors report no conflicts of interest.

There is no Figure.

Table 1 . Disease diagnosis and differentiation..

PatternSigns and symptoms
Wind–Cold–Damp Bi pain along kidney meridian

Acute pain.

History of running in damp/cold weather condition.

Location of pain.

Liver qi and blood stasis

Fixed, local, stabbing pain.

Pain better with pressure.

History of dysmenorrheal and fibroids.

Wiry left guan pulse.

Dusky tongue coat.

Liver qi and blood deficiency

Tight calf muscles.

Soft right guan pulse.

Cold feet.


References

  1. Healey K, Chen K. Plantar fasciitis: current diagnostic modalities and treatments. Clin Podiatr Med Surg. 2010;27:369-80. https://doi.org/10.1016/j.cpm.2010.03.002.
    Pubmed CrossRef
  2. Schwartz EN, Su J. Plantar fasciitis: a concise review. Perm J. 2014;18. https://doi.org/10.7812/TPP/13-113.
    Pubmed KoreaMed CrossRef
  3. Werber B. Amniotic tissues for the treatment of chronic plantar fasciosis and achilles tendinosis. J Sports Med Hindawi Publ Corp. 2015;2015:219896. https://doi.org/10.1155/2015/219896.
    Pubmed KoreaMed CrossRef
  4. Snider MP, Clancy WG, McBeath AA. Plantar fascia release for chronic plantar fasciitis in runners. Am J Sports Med. 1983;11:215-9. https://doi.org/10.1177/036354658301100406.
    Pubmed CrossRef
  5. Gill LH. Plantar fasciitis: diagnosis and conservative management. J Am Acad Orthop Surg. 1997;5:109-17.
    Pubmed CrossRef
  6. Johnson RE, Haas K, Lindow K, Shields R. Plantar fasciitis: what is the diagnosis and treatment? Orthop Nurs. 2014;33:198-204. https://doi.org/10.1097/NOR.0000000000000063.
    Pubmed CrossRef
  7. Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treatment. J Am Acad Orthop Surg. 2008;16:338-46.
    Pubmed CrossRef
  8. Lewis RD, Wright P, McCarthy LH. Orthotics compared to conventional therapy and other non-surgical treatments for plantar fasciitis. J Okla State Med Assoc. 2015;108:596-8.
    Pubmed KoreaMed
  9. David JA, Sankarapandian V, Christopher PR, Chatterjee A, Macaden AS. Injected corticosteroids for treating plantar heel pain in adults. Cochrane Database Syst Rev. 2017;6. CD009348. https://doi.org/10.1002/14651858.CD009348.pub2.
    Pubmed KoreaMed CrossRef
  10. Kirkpatrick J, Yassaie O, Mirjalili SA. The plantar calcaneal spur: a review of anatomy, histology, etiology and key associations. J Anat. 2017;230:743-51. https://doi.org/10.1111/joa.12607.
    Pubmed KoreaMed CrossRef
  11. Digiovanni BF, Nawoczenski DA, Lintal ME, Moore EA, Murray JC, Wilding GE, et al. Tissue-specific plantar fasciastretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am. 2003;85-A:1270-7.
    Pubmed CrossRef
  12. Clark RJ, Tighe M. The effectiveness of acupuncture for plantar heel pain: a systematic review. Acupunct Med J Br Med Acupunct Soc. 2012;30:298-306. https://doi.org/10.1136/acupmed-2012e010183.
    Pubmed CrossRef
  13. Zhang SP, Yip T-P, Li Q-S. Acupuncture treatment for plantar fasciitis: a randomized controlled trial with six months followup. Evid-Based Complement Altern Med. 2011;2011. 154108. https://doi.org/10.1093/ecam/nep186.
    Pubmed CrossRef
  14. Maciocia G. The Practice of Chinese Medicine: The Treatment of Diseases with Acupuncture and Chinese Herbs. 1e First (1st) Edition. 3759th edition. 1st Edition, 1994. Elsevier - Health Sciences Division, 1994.
  15. Reaves W, Bong WC. The Acupuncture Handbook of Sports Injuries & Pain. 1st ed. Boulder, Colorado: Hidden Needle Press, 2009.
  16. Liu M, Nie R, Chi Z, Tang X. [Observation on therapeutic effect of acupuncture at Xuanzhong (GB 39) combined with Chinese herbs pyrogenic dressing therapy for treatment of calcaneus spur]. Zhongguo Zhen Jiu Chin Acupunct Moxibustion. 2010;30:189-91.
    Pubmed
  17. Tillu A, Gupta S. Effect of acupuncture treatment on heel pain due to plantar fasciitis. Acupunct Med. 1998;16:66-8. https://doi.org/10.1136/aim.16.2.66.
    CrossRef
  18. Deadman P, Al-Khafaji M, Baker K. A Manual of Acupuncture. 2nd ed. Hove, East Sussex, England; Vista, Calif., USA: Journal of Chinese Medicine Publications, 2007.