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The Treatment of Plantar Fasciitis with Traditional Chinese Medicine

by Scott R. Smith

Definition

Plantar fasciitisi is the inflammationii of the fascia (fibrous band of connective tissue) that connects the heel bone to the base of the toes. Stretching from the heel bone (calcaneous), the plantar fascia attaches to the bottom of the metatarsal bones around the ball of the foot. Acting as a bowstring, the plantar fascia provides support for the bottom of the foot (arch) (Sauer and Cooper 2007, p478). Pain is usually reported under the medial heel throughout weight bearing (Irving et al, 2007), but may be found along any portion of the plantar fascia. Pain can range from mild to debilitating. Some may use the terms plantar fasciitis and heel spurs interchangeably but this is inaccurate since heel spurs are a result, not the cause of the discomfort (Waller and Maddalo 1995, p351).iii The condition may last a short time, come and go, resolve by itself, or become chronic for unknown reasons. Most cases respond well to conservative treatment eliminating the need for surgery or any other invasive therapy.

Symptoms

Symptoms may develop gradually or come on suddenly and be severe. The classic sign is to feel pain with the first few steps out of bed in the morning due to the fascia tightening overnight. Pain decreases as the fascia loosens up or may hurt more as the day goes on. Pain can be characterized as sharp, stabbing, or burning and most common on the inside bottom of the heel. Pain is not only felt with the first few steps in the morning, but also after long periods of sitting, standing, climbing stairs, and after exercise. If left untreated, plantar fasciitis affects the foot, knee, hip, and back from the change in gait (Wapner and Puri 2004, p189).

Causes

Many causative factors can lead to plantar fasciitis. The most frequent cause is excessive foot pronation (Pribut, 2008). Shoes that are too tight, loose, require arch support, have soles that are too thin and are without sufficient heel cushioning can be the cause and should be changed. Patients should be examined for tight calf muscles as well. A higher risk of developing plantar fasciitis exists for patients with flat feet and high archesiv (AAOS, 2001). Overuse in the form of improper athletic training, certain work or play actions, intense training, prolonged standing, weight bearing for long periods, inactivity, new aggressive training regimens and previous injury can cause plantar fasciitis. Runners and walkers should be aware of the running surface, speed, frequency and distance covered each week particularly if ankle flexion is limited due to tight calf muscles (AAOS, 2001). Also check for limited range of motion of the first metatarsophalangeal joint, ankle dorsiflexion range of motion, leg length incongruity, heel pad thickness and calf strength. Other factors include weight gainv, obesity, elderlyviand pregnancyvii.

Diagnosis

Diagnosis is based on history and symptoms together with a physical examination that involves palpating the foot and observing the patient walk. Reproduction of the pain by palpating the plantar fascia over the medial calcaneal tuberosity or along the course of the plantar fascia is especially important for diagnosis (Richardson 2008, p4816). In severe cases, passive dorsiflexion of the toes may aggravate the symptoms of plantar fasciitis (Foye, 2008). Questions about past and recent injuries, location of pain, when it hurts most, and activities the patient participates in are especially significant. If diagnosis is uncertain then a foot x-ray, bone scan, or nerve conduction test may be performed to rule out a stress fracture or nerve problem (InteliHealth, 2007).

Treatment

Patients must be active participants in treatment. Warn them that failure to do so can result in constant pain when standing or walking. Conservative treatment is recommended for 6 to 8 weeks. Active individuals are encouraged to temporarily eliminate any exercise or sport that has running and jumping. Instead, change to bicycling or swimming to remain active while reducing the strain on the plantar fascia (Jones and Singer 1995, p453). Any delay in treatment or even a lack of compliance by the patient could extend treatment time from 6 months to a year and a half.

Conventional treatment usually begins with recommending rest, ice, compression, elevation (cold compression therapy) and NSAIDs for acute flare-ups. Next, the patient is advised to discontinue any aggravating activity and to stay off the foot to decrease inflammation. Exercises to stretch the Achilles tendon and plantar fascia are shown to the patient and shoes are inspected to consider orthoticsviii, arch support, and heel liftsix (Wapner and Puri 2004, p190). Depending on aetiology, other treatments may include contrast bath therapy, weight loss, physical therapyx, taping, corticosteroid injections, and night splintsxi. When plantar fasciitis does not respond to conservative treatment, extracorporeal shockwave therapyxii (ESWT), surgical release (plantar fasciotomy)xiii, iontophoresisxiv, botulinum toxin type A injection, and cryosurgeryxv (Foye, 2008) maybe used.

Prevention

Maintain a healthy weight. Choose shoes with proper support and discard worn-out athletic shoes. Start all sports activities slow and gradually increase intensity. Wake up with a stretch (see Exercises above) and stretch the calves regularly. Seek treatment with the first signs of pain.

Differential diagnosis

Tendinitis, arthritis, nerve irritation or a cyst (Mayoclinic.com, 2008), calcaneal neuritis, calcaneal stress fracture, lumbosacral radiculopathy of S1 nerve root (Foye, 2008). Heel spur, plantar fascia rupture, nerve entrapment (Pribut, 2008), insertional Achilles tendonitis, calcaneal apophysitis (Sever’s disease)xvii, sciatica, lower back nerve compression or disc origin, IBS, men under the age of 40 with bilateral symptoms should be examined to rule out Reiter’s disease and ankylosing spondylitis (Richardson 2008, p4815), lateral plantar nerve 1st branch entrapment, tarsal tunnel syndrome, neoplasm, gout, infection (Pribut, 2008).

Risk factors

The underlying cause of plantar fasciitis must be remedied regardless of the type of treatment that is sought. That means shoes must be changed, arches must be supported, activity or work must be modified, a healthy weight be maintained, etc. Many sources contend that the correct shoe wear and orthotics are the foundation for successful long-term resolution of plantar fasciitis (FootPhysicians.com, 2008). Patients must be educated about risk factors, exercises, behaviour changes, and preventive measures in order to stop future occurrence. That means relating to the individual’s activity, sport, and work or health issues.

Pattern differentiation

Chinese medicine breaks plantar fasciitis into several patterns:

Wind Cold Damp Obstruction

Weak constitution, intense activity, overuse, trauma; all weaken the channels and involve a deficiency of qi and blood or impair the circulation of qi and blood from the invasion of exterior wind, cold, and damp.

Many outdoor sports are played regardless of the weather condition and can expose athletes to wind, cold, and damp. Intense activity, pre-existing injury and open pores from sweating are possible openings for the invasion of wind, cold, and damp.

Intense or excessive activity or sport leads to strain; standing for prolonged periods without proper rest or footwear; inactivity; certain, unvarying recurring movements.

Symptoms:

Cold feet with a heavy feeling, symptoms worse with cold damp weather and relieved by warmth, aversion to cold, fatigue, and oedema.

Acupuncture points:

Use 0.20mm x 0.25mm needles. Anything less is too flimsy to insert into the foot. The wear on peoples feet varies (some have tougher skin than others) so to make a pain reduced insertion a thicker needle is recommended. That gauge for me is a personal favourite. Insert into Yongquan KID-1 (see figure 1); another approximately 1 cun below Gongsun SP-4 (see figure 2); another approximately 0.5 cun below Jinggu BL-64, all directed towards the centre arch, an ashi point in the proximal heel (perpendicular), an ashi point 3 cun below the tip of the medial malleoulus (perpendicular), and an ashi point approximately 1-1.5 cun below Zhaohai KID-6 (perpendicular). All points should be needled to the depth of 0.5 cun at the minimum. xviii


Figure 1. Acupuncture points on the sole.


Figure 2. Acupuncture points on the sole.

Moxibustion:

Instead of electro-stimulation, moxa cones or press moxa technique may be applied to the appropriate points. Moxa may also be used after electro-stimulation.

  • Zusanli ST-36 Spleen, tonify qi, nourish blood, reduce atrophy and painful obstruction. (moxa)
  • Sanyinjiao SP-6 influence the Spleen and Liver, resolves damp and moves the blood.
  • Yinlingquan SP-9 resolves damp and painful obstruction. (moxa)
  • Qihai REN-6 moves qi and damp and influences yang. (moxa)
  • Shangqiu SP-5 Damp obstruction of the ankle and foot, influences sinews and muscles.
  • Kunlun BL-60 removes channel obstruction, relaxes sinews.

Qi and Blood deficiency

A deficiency means a lack of nourishment, especially in the channels open to invasion of external wind, cold, and damp. Intense exercise and physical stress without adequate time for recovery depletes the qi and blood as does an intense moment of physical activity in a person who already has a weak constitution. The undernourished tendon, or plantar fascia, becomes overworked resulting in pain and stiffness.

Symptoms:

Stiffness, cramping or numbness of the limbs, fatigue, pallid complexion and lips, insomnia, , dizziness, a pale tongue and a soggy pulse.

Acupuncture points: Using 0.20mm x 0.25mm needles, insert into Yongquan KID-1, (see figure 1); another approximately 1 cun below Gongsun SP-4; another approximately 0.5 cun below Jinggu BL-64, all directed towards the centre arch, an ashi point in the proximal heel (perpendicular), an ashi point 3 cun below the tip of the medial malleoulus (perpendicular), and an ashi point approximately 1-1.5 cun below Zhaohai KID-6 (perpendicular). All points should be needled to the depth of 0.5 cun at the minimum.

  • Zusanli ST-36 Spleen, tonify qi, nourish blood and reduce atrophy.
  • Sanyinjiao SP-6 influence the Spleen and Liver, qi and blood.
  • Pishu BL-20 tonifies the Spleen.
  • Yanglingquan GB-34 relieves pain, swelling and numbness of muscles and sinews.
  • Pucan BL-61 heel pain.
  • Tanzhong REN-17 influential point of qi.

Liver and Spleen

The Spleen is in charge of qi and blood formation and if impaired will not properly nourish the muscles. The blood accessible to the muscles, tendons and sinews is also reliant on the Liver’s ability to store blood.

Symptoms:

Stiffness, spasms, weakness and numbness, decreased muscle and arch strength, atrophy; particularly of the lower limb, impaired ankle joint range of motion from undernourished sinew contraction and relaxation function. Dizziness, dry eyes, fatigue, pallid complexion, hypochondriac pain, irregular menstruation, slightly pale, flabby, dry tongue with pale tapered sides. The pulse is empty, thin, wiry or choppy.

Acupuncture points:

Using 0.20mm x 0.25mm needles, insert into Yongquan KID-1, (see figure 1); another approximately 1 cun below Gongsun SP-4, (see figure 2); another approximately 0.5 cun below Jinggu BL-64, all directed towards the centre arch, an ashi point in the proximal heel (perpendicular), an ashi point 3 cun below the tip of the medial malleoulus (perpendicular), and an ashi point approximately 1-1.5 cun below Zhaohai KID-6 (perpendicular). All points should be needled to the depth of 0.5 cun at the minimum.

  • Taichong LIV-3 nourishes Liver blood and Liver yin.
  • Ququan LIV-8 nourishes blood and yin.
  • Zusanli ST-36 Spleen, tonify qi, nourish blood, reduce atrophy and painful obstruction.
  • Sanyinjiao SP-6 influence the Spleen and Liver, resolves damp and moves the blood.
  • Ganshu BL-18 nourishes Liver blood and benefits the sinews.
  • Pishu BL-20 tonifies the Spleen.

Qi and Blood stagnation

Trauma to the plantar fascia may reduce the flow of qi and blood to the foot and allow external wind, cold, and damp to invade the area. Poor diet and stress can also lead to qi and blood deficiencies which will impact upon the flow of qi and blood in the vessels.

Symptoms:

If qi stagnation predominates, the location of pain may move around the heel and foot and feel distended and sore. In this case the tongue may be pink/purple and the pulse tight. If blood stagnation predominates, the location of pain is fixed, severe and worse with touch. In this case a purple colour is more pronounced on the tongue and the pulse is choppy.

Acupuncture points:

Using 0.20mm x 0.25mm needles, insert into Yongquan KID-1; another approximately 1 cun below Gongsun SP-4; another approximately 0.5 cun below Jinggu BL-64, all directed towards the centre arch, an ashi point in the proximal heel (perpendicular), an ashi point 3 cun below the tip of the medial malleoulus (perpendicular), and an ashi point approximately 1-1.5 cun below Zhaohai KID-6 (perpendicular). All points should be needled to the depth of 0.5 cun at the minimum.

  • Hegu L.I.-4 and Taichong LIV-3: move qi and blood
  • Zhongwan REN-12 moves qi stagnation.
  • Zusanli ST-36 moves qi and blood.
  • Geshu BL-17 painful obstruction and dispels blood stasis.
  • Sanyinjiao SP-6 nourish and move blood.
  • Shuiquan KID-5 promotes blood circulation.

General Acupuncture Points

Using 0.20mm x 0.25mm needles, insert into Yongquan KID-1, (see figure 1); another approximately 1 cun below Gongsun SP-4, (see figure 2); another approximately 0.5 cun below Jinggu BL-64, all directed towards the centre arch, an ashi point in the proximal heel (perpendicular), an ashi point 3 cun below the tip of the medial malleoulus (perpendicular), and an ashi point approximately 1-1.5 cun below Zhaohai KID-6 (perpendicular). All points should be needled to a minimum depth of 0.5 cu.

Points along the Urinary Bladder line as it descends through the calf should be palpated for tenderness; particularly Chengjin BL-56, Chengshan BL-57, Fuyang BL-59 and Kunlun BL-60.

Exercises

Stretching your Achilles tendon and plantar fascia are the foundation of treating the condition and lessening the chance of recurrence.

Towel stretching:

This exercise is best for patients with pain that is most severe with the first steps out of bed in the morning. Set the midpoint of a towel in the arch of the foot, just under the fore foot. Using both hands, gently pull the towel toward you to cause passive dorsiflexion of the ankle. Hold stretch for 30 seconds. Follow with massage or foot roller.

Towel grip:

Place a towel on the floor and with a barefoot, grip the towel underneath the toes and flex the foot. This strengthens the arch. Follow with massage or foot roller.

Foot roller:

A wooden ravioli rolling pinxix is recommended. The notches work especially well for loosening specific tight spots in the arch as well as moving qi and blood stagnation in the heel.

Standing calf/heel stretch:

Face a wall, standing about 3 feet away. Keeping your right foot planted, step forward with your left foot and place both palms on the wall in front of you, shoulder height. Keeping the right leg straight and the heel on the ground, slowly lean forward, bending your elbows, until you feel a stretch in your right calf. Hold 30 seconds and repeat other side.

Other treatments

Electro-stimulation:

Channel 1 connect the black clip (negative) to Yongquan KID-1 and red (positive) to the ashi point in the proximal heel. Channel 2 connects the black clip to the point approximate to Gongsun SP-4 and red to the point approximate to Jinggu BL-64. Channel 3 connect black to the ashi point 3 cun below the tip of the medial malleoulus and red to the ashi point about 1-1.5 cun below Zhaohai KID 6. Use mild stimulation for 20-30 minutes at 2-4Hz.

Massage:

Massage starting at the top of the calf and follow the Urinary Bladder channel to the bottom and sides of the heel. Start light and slow, gradually increasing the depth and strength of each stroke, particularly from the bottom of the heel to Yongquan KID-1.

Exercise:

Patients must incorporate at least two of the stretches described above along with the foot roller into their daily routine.

Foot baths:

Epsom salt foot baths are recommended at the end of the day to decrease inflammation, move qi and blood and promote healing.

Case study

Main complaint: Plantar fasciitis of the right foot. 51 year-old male. Severity: 6-7/10. Chronic pain from the time he steps foot on the floor in the morning up until bedtime. The heel is stiff; the arch is painful, all worse in the morning. He does a lot of forefoot movements at work and during after work activity. Pain is relieved when shoes are off and when he is off his feet. He reports that stepping on the foot feels like stepping on a marble located lateral to the middle of the arch (perhaps a Morton’s neuroma). Numbness, tingling or any shooting sensations throughout the foot are not present, only pain and stiffness. He reports no other significant health concerns.

History: Since 2004 (4 years duration). Patient is in law enforcement and is on his feet 8-12 hours at a time. A podiatrist administered a cortisone injection which provided 3-4 months relief. A 2nd cortisone injection provided the same results. A custom orthotic insole was added to provide arch support.

Other: Foot pain has decreased the patients’ quality of life due to the severity and duration.

Observations: I noticed that upon standing to walk to the treatment room, he was slow to rise and put weight on the foot. Limping proceeded until he reached the chair in the examining room. Mood was slightly irritated due to annoyance of the right foot pain.

Pulse: Sluggish.

Tongue: Pink red with white coat.

Diagnosis: Qi and blood stagnation, Spleen qi deficiency, Wind, Cold, Dampness painful obstruction.

First Treatment: Acupuncture and electro-stimulation described above plus Zusanli ST-36, Yanglingquan GB-34, Yinlingquan SP-9, Hegu LI-4, Taichong LIV-3.

Post-treatment: Reported immediate improvement.

Advice: Avoid activities that aggravate the condition, use the foot roller every day, towel grip exercise, Epsom salt foot baths and schedule a second treatment for no more than one week.

Second treatment: (5 days later)
60-80% improved overall. Emotions improved as well. He was doing exercises every night, but no foot baths as advised; he just found no time. He reported that the custom orthotics now felt better in his shoes. Decrease in tenderness, marble feeling, stiffness and morning pain.

Treatment: Same protocol as first treatment.

Advice: Continue exercises and schedule another treatment for no more than one week.

Third treatment: (5 days later)

Patient reports feeling improved. Reports a 0/10 pain scale. He has continued with exercises and foot roller but still no foot baths. “Everything has improved and holding” he says. Patient reported that the foot roller was initially painful but has now gotten to be tender with a “good pain” feeling.

Treatment: Same protocol as the first and second treatment.

Outcome

At a three month follow-up with the patient he reports that plantar fasciitis has resolved. No reoccurrences of pain but occasional tenderness that he now knows how to manage with stretching, foot baths and the foot roller.

Conclusion

Chinese medicine provides lasting relief for a common foot problem with the specific use of acupuncture, electro-stimulation and the appropriate points based on pattern discrimination.

Here is a review of a few points to consider for a successful treatment outcome:

  • Plantar fasciitis acupuncture protocol with electro-stimulation and appropriate points based on the pattern.
  • Patient advised that they need to have active participation in treatment and to follow advice given in order for the condition to resolve.
  • Modify exercise if that is a causative factor.
  • Engage in a daily stretching regimen combined with foot baths and the foot roller.
  • Schedule weekly visits.

Biography

Scott R. Smith is a licensed acupuncturist and herbalist (Dipl. OM, NCCAOM) practicing in Rapid City, SD. He can be emailed at srsmithom@gmail.com.

End notes

i Being the most common cause of heel pain, plantar fasciitis is the focus of this article, however etiology and treatment cross into the broader classification of other plantar heel pain conditions.
ii One article suggests that current studies of plantar fasciitis show a loss of blood circulation rather than inflammation of the plantar fascia. (Pribut, 2008)
iii Heel spurs (soft, bendable calcium deposits) are not the cause of pain, rather the result of tension and inflammation in the plantar fascia attachment to the heel. Surgery was once common to remove a bone spur but is rare today.
iv Flat feet and high arches provide inadequate shock absorption during activity. One increases the strain on the plantar fascia while the latter has a tighter plantar fascia.
v An increased body mass index (BMI) causes excessive wear on the tissue under the calcaneous.
vi The arch begins to drop as we age putting more stress on the plantar fascia.
vii Pregnancy results in increased weight and swelling. This can cause the foot ligaments to relax leading to inflammation of the plantar fascia.
viii May be custom fitted or purchased over the counter.
ix This inexpensive insert should be recommended at the first treatment as a way to alleviate symptoms, especially if they are returning to work.
x Along with stretches and exercises, the physical therapist can instruct the patient how to properly apply athletic taping to the foot.
xi Worn overnight, night splints keep the plantar fascia and Achilles tendon in a stretched position.
xii ESWT is a non-surgical treatment that increases blood flow to the area by re-inflammation. It may take a long as 6 months post-procedure to see the results. It is typically recommended for patients who have not responded to conservative treatment of more than 6 months.
xiii This treatment is usually done as a last resort. Complications include lowering of the arch and foot pain.
xiv The use of electric current to pull anti-inflammatory medication into the area of discomfort.
xv Cryosurgery uses a handheld probe to destroy pathological tissue. Having gained acceptance in plastic surgery, dermatology and pain management, Cryosurgery is now being used to help plantar fasciitis.
xvii Commonly seen in patients between the ages of 10 to 14, Sever’s disease is the combination of an activity and a growing heel bone. Pain is from inflammation of the calcaneal growth plate.
xvii The purpose of this article is to provide an effective acupuncture protocol for the treatment of plantar fasciitis no matter what pattern is involved. It is the other points that will specifically address the underlying cause. Even though electro-stimulation is mentioned under ‘other treatments’, I personally recommend it be used on each patient. The points added to each pattern are just very general suggestions.

References

American Academy of Orthopaedic Surgeons (AAOS), (2001). Plantar Fasciitis. http://orthoinfo.aaos.org/topic.cfm?topic=A00149 (Accessed 6 June 2008)

Irving, D.B., Cook, J.L., Young, M.A., Menz, H.B. (2007). Obesity and Pronated Foot Type May Increase the Risk of Chronic Plantar Heel Pain: A Matched Case-Control Study. http://www.medscape.com/viewarticle/559871 (Accessed 19 May 2008)

FootPhysicians.com (2008). Heel Pain. http://www.footphysicians.com/footankleinfo/heel-pain.htm (Accessed 5 June 2008)

Foye, P.M. (2008). Plantar Fasciitis. http://www.emedicine.com/pmr/topic107.htm (Accessed 5 June 2008)

InteliHealth.com (2007). Plantar Fasciitis. http://www.intelihealth.com/IH/ihtIH/WSIHW000/9339/10550.html (Accessed 5 June 2008)

Jones, Donald C., Singer, Kenneth M. (1995). The Lower Extremity & Spine in Sports Medicine: Soft Tissue Conditions of the Ankle and Foot. (2nd ed). St. Louis: Mosby.

Mayoclinic.com (2008). Plantar fasciitis. http://www.mayoclinic.com/health/plantar-fasciitis/DS00508 (Accessed 5 June 2008)

Pribut, S.M. (2008). Heel Pain: Plantar Fasciitis and Plantar Heel Pain Syndrome. http://www.drpribut.com/sports/heelhtm.htm (Accessed 9 June 2008)

Richardson, E. Greer. (2008). Campbell’s Operative Orthopaedics. (11th ed). Philadelphia: Mosby Elsevier.

Sauer, Scott T., Cooper, Paul S. (2007). Essentials of Orthopedic Surgery. (3rd ed). New York: Springer.

Waller Jr., John F., Maddalo, Anthony V. (1995). The Lower Extremity & Spine in Sports Medicine: Foot and Ankle Linkage System. (2nd ed). St. Louis: Mosby.

Wapner, Keith L., Puri, Rajeev D. (2004). Orthopaedic Surgery Essentials: Heel and Subcalcaneal Pain. Philadelphia: Lippincott Williams & Wilkins.

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