Plantar fasciitis

BMJ 2012; 345 doi: (Published 10 October 2012)
Cite this as: BMJ 2012;345:e6603

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Dear Editor,

Although benign in nature, plantar fasciitis pulls down nearly all the activities, and it might be difficult to perform the routine chores. Various modalities are in use, invasive & non-invasive, including surgery, but the results are variable. Possibly this problem could be quite common in the armed forces around the world, with long and forced marches, regular drills, using boots for prolonged hours, prolonged standing, changing into new boots / shoes once the previous ones have worn out or damaged, getting back into business after leave, etc.

Some other common predisposing causes could be :

• Tight, and ill fitting shoes
• Hard heel pad of shoes or sandals
• Overweight
• Reiter’s syndrome (reactive arthritis), and incomplete Reiter’s syndrome
• Chapped feet
• Deformities of feet, like
o pes planus
o pes varus
o pes calcaneus
o pes cavus
o pes valgus, etc.

By also having the first hand knowledge of military medicine, with additional interest in sports medicine, and internal medicine, I have been taking into consideration all these above factors. Our results have been good, and the management usually varies from one patient to another. In cases we suspect a reactive arthritis or an incomplete Reiter’s syndrome, or where we find external signs of inflammation over or around an affected heel, we use antibiotics as well, and once the inflammation has settled down after regulating activity and avoiding boots/ shoes/ sandals, we use a combination of SWD (short wave diathermy), ultrasonic therapy, IR therapy (infra red therapy), and the pain is gone in one hour. Precautions are advised in the form of avoiding using tight fitting shoes/ boots, avoidance of prolonged standing, and a padded cushion is advised depending on the deformity of foot, so as to correct it. Warm soaks for few minutes daily for a few days, weight loss, taking care of chapped feet, are some of the other things that we suggest to our patients. A few patients may have to be given another two or three consults, but that’s all.

Through you BMJ, maybe our new technique developed and mastered over the years, could help spread smiles across patients all over the world as they start getting relief from this problem of plantar faciitis, by totally non-invasive, painless technique, that does not use any steroids or needles, and the relief if not permanent, is for pretty long period, and comes within an hour, yes.

Best regards.

Dr (Lt Col) Rajesh Chauhan
Faculty IMA CGP
& Honorary National Professor

Dr. Ajay Kumar Singh Parihar
MBBS, MD Medicine (Second Year)

Competing interests: None declared

Dr (Lt Col) Rajesh Chauhan, Consultant Family Medicine

Dr. Ajay Kumar Singh Parihar

Family Healthcare Centre, 154 Sector 6-B, Awas Vikas Colony, Sikandra, AGRA - 282007. INDIA, 154 Sector 6-B, Awas Vikas Colony, Sikandra, AGRA - 282007. INDIA.

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A simple early therapeutic intervention, which is more experience based than evidence based, is the use of a heel raise from the local cobbler. It certainly seems to be useful in alleviating the symptom. It is more cost effective than orthoses whether OTC or custom made. Explaining the natural history and addressing other associated problems such as weight are useful, in addition to symptomatic treatment.

Competing interests: None declared

Sidha Sambandan, GPwSI Orthopaedics

Norwich Community Hospital, 44 Brettingham Ave, Cringleford, Norwich NR4 6XQ

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25 October 2012

Many thanks to Adrian Pace for the Rapid Response. Although there are space limits, a brief mention of the documented associations between plantar fasciitis and rheuamtological diseases would have been worthwhile in the article and his response redresses this omission. However, when studied with control groups the association is present but weak (1-3) (i.e. many cases of plantar fasciitis without spondyloarthitis and vice versa; overlap is mild). My interpretation is that the two diseases probably share a common risk factor but they are not likely to be causally linked.

1. Falsetti P, Frediani B, et al. Sonographic study of calcaneal entheses in erosive osteoarthritis, nodal osteoarthritis, rheumatoid arthritis and psoriatic arthritis. Scand J Rheumatol. 2003;32(4):229-34.

2. Gerster JC, Vischer TL, et al. The painful heel. Comparative study in rheumatoid arthritis, ankylosing spondylitis, Reiter's syndrome, and generalized osteoarthrosis. Ann Rheum Dis. 1977 Aug;36(4):343-8.

3. McGonagle D, Marzo-Ortega H, et al. The role of biomechanical factors and HLA-B27 in magnetic resonance imaging-determined bone changes in plantar fascia enthesopathy. Arthritis Rheum. 2002 Feb;46(2):489-93.

Competing interests: None declared

John W. Orchard, Sports Physician

University of Sydney, Western Ave Uni of Sydney 2006 Australia

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Occupation, constitutional features and sporting activities are considered to be important aetiological factors for plantar fasciitis in Orchard’s article.1

The Assessment of Spondyloarthritis International Society (ASAS) includes heel enthesitis (defined as ‘past or present spontaneous pain or tenderness at examination at the site of insertion of the Achilles tendon or plantar fascia at the calcaneus’) as one of the classification criteria for axial spondyloarthritis.2 More recently, enthesitis, together with arthritis and dactylitis, was included as a major classification criterion for peripheral spondyloarthritis by the same group.3

The incidence of spondyloarthritis tends to peak at middle age which overlaps greatly with the age that the occupational and sporting activities mentioned in Orchard’s article mostly occur (policemen on patrol, athletes etc).

It is important to point out therefore, that the clinical evaluation of plantar fasciitis should include a full enquiry about other spondyloarthritis features, particularly inflammatory back pain.

1. Orchard J. Plantar fasciitis. BMJ 2012;345:e6603

2. Sieper J, Rudwaleit M, Baraliakos X, Brandt J, Braun J, Burgos-Vargas R et al. The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis. Ann Rheum Dis 2009;68(Suppl II):ii1-ii44.

3. Rudwaleit M, van der Heijde D, Landewe R, Akkoc N, Brandt J, Chou CT et al. The Assessment of SpondyloArthritis international Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis 2011;70:25-31.

Competing interests: None declared

Adrian V Pace, Consultant Rheumatologist

Dudley Group NHS FT, Dudley, West Midlands DY1 2HQ

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