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Plantar fasciitis is a very common condition among all ages, sexes, races of people. It is a condition where a long ligament-type structure that attaches at the bottom of the heel and travels to the metatarsal head area (also known as the ball of the foot), gets irritated and inflamed. Patients often complain of pain worse in the morning, which goes away slightly as the patient gets up and walks around but does not completely go away. Often if the patient sits down during the course of the day and gets back up they notice a spike in the pain. Quite often by the end of the day the patient’s heels are very sore. The reason for this cycle of pain is that usually there is mechanical stress and strain that is placed on the fibers of the plantar fascia where it attaches to the heel. The key component of understanding this condition is that the cause of this problem is usually the foot type and structure that a patient has. There are two extremes to this. At one end of the spectrum is a person with an excessively pronated (flatfoot) foot type. In this foot type a patient’s arch flattens out excessively and pulls on the plantar fascia, thereby causing microscopic tears and elongation of the fibers. At the opposite end of the spectrum is the rigid high arch foot type. This is a foot type whereby the patient has a very accentuated arch and when they stand the arch does not have any flexibility. Not only can a patient get pulling of the fibers but when a patient puts their foot down as they are walking or running there is no flexible adaptability of the foot to the surface that the person is ambulating on. Again, this results in pain and discomfort. It is also common to have a simultaneous condition of tight muscles in the calf or hamstrings. The tightness in the calf causes a loss of range of motion at the ankle joint and the joint beneath the ankle called the subtalar joint. The tightness in the hamstring muscles causes a person to strike the ground with the knee excessively flexed, causing the heel to "slam" down onto the ground. When joints do not have their full range of motion, mechanical stress and strain is put on surrounding tissue and the proximity of the plantar fascia to the subtalar and ankle joint makes it a perfect anatomic structure to be subjected to this extra mechanical stress and strain.

Henceforth, it is important that a patient understand that an integral part of their treatment plan includes proper support of the foot with the use of a custom molded in-shoe orthotic, minimizing barefoot walking and a proper stretching program for tight muscles.

Secondary to addressing the mechanical causes of the patient’s pain is the pain itself. Since it is an inflammatory condition there is a multitude of options for controlling inflammation. A patient may utilize an oral anti-inflammatory medication, have an anti-inflammatory injection in the area of the plantar fascia where it attaches to the heel, receive physical therapy modalities such as ultrasound, deep tissue massage, electro stimulation with ice therapy or a home program with icing the area down several times per day to help minimize inflammation. It is important for a patient to understand that if they are only receiving treatment for the pain itself and not having any of the mechanical issues addressed, despite the fact that they may see improvement or resolution of the symptoms, they may have a relapse or recurrence of the pain due to the fact that the cause of their pain was never addressed.

Currently the criteria for being medically eligible for ESWT for plantar fasciitis is to have had plantar fasciitis for greater than six months and having failed at least two conservative treatments. Conservative treatments include foot strappings, anti-inflammatory injections, physical therapy, anti-inflammatory oral medications, orthotics or night splints. Due to the fact that this is a mechanical shock wave type of treatment it is best performed in an outpatient surgical setting. Despite the fact that this is a noninvasive procedure patients have found that it is more comfortable to receive IV sedation/twilight sleep combined with a local anesthetic injection to the heel area. The total time of treatment requires approximately 15-20 minutes. The experimental studies with this treatment during FDA trials shows that it can take up to 12 weeks for a patient to derive full benefit from this treatment. During the patient’s post procedure recovery period, at least for the first four weeks, it is recommended that the patients do not engage in high impact activities such as running, heavy weight lifting, heavy housework or yard work. Also, due to the fact that it must be understood that all the ESWT is working on is the inflammatory tissue, the mechanical causes cannot be ignored. What this translates into is that a patient must continue to participate in any type of treatment to address their mechanics, such as using proper shoe gear, use of orthotics, stretching of tight muscles. Our experiences with this to date have shown that a vast majority of patients have rated their treatment as success, where success is indicated by decreased or eliminated heel pain. In the remaining patients who have not experienced success with one treatment some patients have undergone a second treatment to find that they reach clinical success.

If you suffer from chronic plantar fasciitis and are considering shock wave treatment, please consider the factors mentioned within this article. Please understand that in 95-99% of the cases the reason for the plantar fasciitis is mechanical, i.e. flat feet, excessively high arched feet, tight lower extremity musculature. Shock wave therapy only addresses the inflammation. It does not change the mechanics of the foot or lower extremity. In order to experience long-term success a patient must understand that they still must support either a flat foot or rigid high arched foot and maintain proper range of motion and flexibility of lower extremity musculature.

A perfect analogy is a patient who undergoes coronary artery bypass surgery.  That patient has to realize that if their bypass surgery is a success they must make changes in their lifestyle which usually has caused the problem in the first place, i.e. sedentary lifestyle, smoking, alcohol use, poor dietary habits.

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