Plantar fasciitis is a very common condition that is sometimes very difficult to treat. The review I'm bringing you today is titled "Parameters and Effects of Photobiomodulation and Plantar Fasciitis; a Meta-analysis and Systematic Review" was published in 2019 in the Journal of Photobiomodulation, Photomedicine, and Laser Surgery. And it's pretty great because it is a systematic review, which means we've got a lot of studies pooled together to look at the effects of light therapy/laser therapy on plantar fasciitis. This is a pretty common disorder. As a matter of fact, in this study, they say that about 10% of the population will at some point deal with plantar fasciitis. They say that about 2 million people each year seek treatment for it.
Plantar Fasciitis Evaluation
Normally the symptoms are really sharp, intense pains that patients will feel in those first few steps after resting, sleeping, or sitting for a long time. That's the classic sign right there so listen for that in the patient's history. They will say things like "as soon as I get up in the morning, it hurts really bad, but after I've taken a few steps, it starts to get a little bit better." That should perk up your ears right there, because it's one of the hallmarks of plantar fasciitis, but that's not the only thing you need to do for your diagnostics. The next thing you need to do is that physical exam and palpate the heel and the plantar surface of the foot.
Find those tender points. In most cases, you're going to find them around the heel and then just anterior to the heel on the bottom of the foot. One test you can do is a heel squeeze where you don't actually push on the bottom of the foot, but on the sides of the heel in most plantar fasciitis cases, that will be positive. The patient will get a lot of sensitivity, just squeezing on the medial and lateral sides of that calcaneus down towards that heel fat pad.
The next thing you can do is you can shoot x-rays to ensure that you don't have any kind of bone spur formation. Bone spurs will form on the plantar fascia origin after it's been inflamed for a long time, or if patients have had ongoing larger amounts of stress and strain on the plantar fascia. The point of getting that x-ray is to make sure you know what kind of length of time this is going to take to resolve, because in general, if there's bone spur formation, if there is calcification there, it's going to take the patient longer to get better, no matter what treatment you do. On the flip side of that, if there's not a bone spur, then you could expect to see some more rapid changes.
The next test you could choose is a diagnostic ultrasound to look at the thickness of the plantar fascia. The more stress, the more inflamed that plantar fascia is, the more it thickens over time. And that can lead to ongoing disability.
Before I get into treatments and what's out there, once you've gotten the diagnosis of plantar fasciitis, you need to look at the cause, because plantar fasciitis is much more of a symptom than it is a specific disease. In most cases, you need to evaluate the patient's gait and their shoe selection. Make sure they have good foot support. Proper support, not too much, not too little. You need to look for ligament laxity in the ankles, and you need to go all the way up into the knee to look for problems in knee emotion. Look at the patient as they walk barefoot, if they can stand it, but also look at how they walk in shoes, the shoes they've brought into the office that day for their evaluation. That should give you an idea if they have some kind of gait disturbance or biomechanical problem that is loading that plantar fascia too much. You need to know that before you start recommending care, because no matter what kind of care you recommend or you do, if they have a consistent biomechanical strain or stress on the plantar fascia, then the treatment, no matter how great it is, is going to give them some temporary relief, and then there'll be right back into this same situation again. And they'll say, "Oh, the treatment's not working well!" It's not that the treatment isn't necessarily working. It's more that they have this consistent reinjury pattern.
So you need to evaluate what that gait looks like. Do they have the right shoes? Are there other joint biomechanical problems? Look at old ankle injuries especially. Almost everyone's rolled their ankle at some point, that usually means the ligaments have been stretched out. Sometimes the ligaments get stretched enough that they no longer support proper motion in the ankle. And so then the foot has to uptake more of that support function that it's really not designed for. And that's what starts to strain the plantar fascia. It can be strained for a long time before it finally gets inflamed enough for the patient to start picking up on pain signals.
Plantar Fasciitis Treatments
As far as treatment selection goes, these authors say there's a lot of choices. They say you can do stretching exercises, therapeutic ultrasound, NSAIDs (non-steroidal anti-inflammatory drugs), and shockwave therapy. There are the options of a cortisone injection and other injection options too. We know that NSAIDs have significant risk profiles and especially for certain patients that might be already dealing with comorbidities, but also cortisone injections into the plantar fascia have been shown to lead to plantar fascia rupture in some cases, not every time, but it is still a significant risk.
So try to help your patients from a position of minimal risk and maximum gain. There is a lot of evidence out there for things like good stretching exercises and nighttime bracing. In many cases, you need to get into several different methods to get good results. But for the rest of the blog today, I'm going to talk about laser therapy because that's what this we are all about. That's what this particular study is about. The authors say that laser therapy leads to an increase in cell proliferation, microcirculation, vascular neoformation, and collagen production, thus decreasing soft tissue degeneration of the muscle, fascia, ligament, and cartilage.
It also has an anti-inflammatory action that may inhibit and or attenuate the expression of inflammatory mediators and pain markers. Therefore, it's a good way to help out plantar fasciitis.
The authors took all the studies they could find on laser therapy or light therapy or photobiomodulation and plantar fasciitis. They were able to locate over 1300 studies. They pared those down, sorted them, got it down to seven studies that are very high quality. And all of those studies reported beneficial effects from light therapy, whether associated with exercise therapy or not. All those seven studies showed excellent results for patients with plantar fasciitis when laser therapy was used. They further saw that "laser therapy presents no serious side effects like those associated with NSAID therapy." That's exciting because that means that laser therapy can be looked at seriously as another supportive, side effect-free way to treat plantar fasciitis.
Laser Therapy for Plantar Fasciitis
What they saw when they got into the details of all these different studies they looked at was that a good schedule was to treat about three times a week for about four weeks. And I've seen that in clinical practice as well. You can't do a couple of sessions and think the person's going to be better. This is a tough condition. It's the foot, it doesn't get great blood flow. It doesn't get good fluid exchange. And the way that the foot is structured there are pockets that kind of contain and trap inflammatory fluids between the plantar fascia and the rest of the foot, so you need to plan to have some ongoing care. You're not looking for overnight results with laser therapy, but over those four weeks, you should have some good improvement. Now you may need to go further than that. That patient may need some more care past those four weeks, but you should be seeing some improvement. If you're not seeing improvement, then I highly recommend that you rewind back and go, do we have the cause of this thing nailed down? Is the patient wearing shoes that they shouldn't be? Are they going barefoot at home? If that is the case, they're going to be getting worse at the same time that you're trying to help them get better. And that means that over a long time the results are kind of a wash and it looks like laser therapy didn't work. Well, it could be that the patient is unknowingly sabotaging their progress.
Concerning the parameters for laser therapy and plantar fasciitis, they saw excellent results out of 820 and 830 nanometer wavelengths, but also some out of 904 nanometer wavelengths. They saw good effects with doses at five to eight joules per centimeter squared with those wavelengths.
You can get a hold of me by shooting us an email info@lasertherapyinstitute.org.
Our members have protocols for plantar fasciitis. And as a matter of fact, we just this week updated our plantar fasciitis protocol to be even more effective. If you're interested in getting ahold of some of our protocols, for things like plantar fasciitis, go to www.LaserTherapyInstitute.org and check out our programs!