Plantar fasciitis is the most common cause of inferior heel pain in adults. The patient typically complains of gradual onset pain along the medial side of the heel, with pain worse when first standing in the morning which lessens after walking a few steps.[i]
The plantar fascia has a fundamental role in the biomechanics of the foot, supporting the medial longitudinal arch and in the mechanisms of propulsion, as it can dissipate the forces and stresses involving the foot during gait.[ii] It was recently shown that it can store strain energy and convert this energy into propulsive force, behaving like a quasi-elastic tissue.[iii]
Plantar fasciitis is an irritation and swelling of the band of tissue that extends from the heel to the toes and can cause both heel pain as well as pain in the bottom of the foot. It is a common condition in people of middle age but can occur in all age groups.
Plantar fasciitis accounts for about 10% of injuries in runners, and about 15% the general population seeking medical care for foot problems. 83% patients are active working adults between the ages of 25 and 65 years old. Presentation is typically unilateral; however, it may present bilaterally in a third of the cases. The average plantar heel pain episode lasts longer than 6 months.[iv]
Approximately 90% of cases are treated successfully with conservative care. In the United States, plantar fasciitis generates up to 2 million patient visits per year, and accounts for 1% of all visits to orthopedic clinics.[v] Plantar fasciitis is diagnosed on clinical grounds, sometimes with the support of imaging to rule out other diseases and confirm a thickening of the fascia. The presence of heel spurs in patients with plantar fasciitis is still debated, as it is not settled whether they cause or co-exist with plantar fasciitis.[vi]
Plantar fasciitis care historically has consisted of the following, in order from non-invasive to invasive: rest (which can be a challenge for the active runner); application of ice, either via ice pack or ice cup massage; anti-inflammatory agents and non-steroidal anti-inflammatory drugs (NSAIDS); stretching; foot orthotics; extra-corporeal shock wave therapy (ESWT); a walking boot and/or night splints; autologous platelet rich plasma injection (PRP); steroid injections and finally, surgery.[vii]
The application of ice, especially on acute injuries is falling out of favor. “Inflammation is an essential mechanism in human health and disease.”[viii] The healing response, with its stages of inflammation, proliferation, remodeling, and maturation in necessary for proper repair of injured and damaged tissues. It is now recognized that anything that reduces or suppresses inflammation (including ice, NSAIDs, and corticosteroids) will delay healing.[ix]
One study recommended treating plantar fasciitis with radial extracorporeal shockwave therapy. But it also indicated laser therapy (defined later in this article) may potentially be a better alternative.[x]
PRP has been shown to provide better pain relief and improved function compared to steroid injection.[xi] Steroid injections compared may slightly reduce heel pain for up to one month but not thereafter. And steroids are falling into disfavor with their inherent side effects and related tissue damage.[xii]
Laser therapy, more formally known as photobiomodulation (PBM) is a treatment that utilizes nonionizing lasers (red and infrared) and is a nonthermal process by which endogenous chromophores absorb photons of light, eliciting photochemical events at various biological scales. This treatment results in beneficial therapeutic outcomes including, but not limited to, the alleviation of pain or inflammation, immunomodulation, and promotion of wound healing and tissue regeneration.[xiii]
Photobiomodulation has been used in both human and veterinary medicine for more than 30 years. The last decade has seen a significant increase in its use, as a better understanding of mechanisms of action has guided laser therapy equipment manufacturers to build more clinically effective devices. Early therapeutic lasers were simply too low in power, and today both scholars and clinicians agree that class 4 therapeutic laser devices are necessary for significant and dependable outcomes.[xiv]
The evidence suggests that PBM resolves and does not inhibit inflammation, as it can reduce or inhibit production of important inflammatory mediators such as IL-1, IL-6, PGE2, and MMPs and significantly reduce leukocyte infiltration in different inflammatory conditions.[xv] In addition, PBM has been shown to preserve mechanical behavior of inflamed tendons, whereas NSAIDs did not.[xvi]
Patients with myofascial trigger points in the gastrocnemius and soleus muscles will experience chronic shortening of those muscles, which will either cause or contribute to the problem of plantar fasciitis. Laser therapy is clinically indicated for myofascial trigger points and should be a part of the treatment plan for plantar fasciitis patients.[xvii]
Photobiomodulation treatments with a class 4 therapy laser are inherently safe, due to the non-ionizing (red and infrared) wavelengths being used. Treatments are non-invasive and there is no pain during treatment so patients do not need a local anesthetic or sedative as can be the case with shockwave therapy.
Patients are drawn to the high-tech nature of laser therapy treatments. Any health care provider caring for patients suffering from plantar fasciitis should consider adding photobiomodulation with a class 4 therapy laser to their treatment services.
[i] Stecco, et al. Plantar fascia anatomy and its relationship with Achilles tendon and paratenon, J Anat. 2013 Dec; 223(6): 665–676.
[ii] Hicks, JH. The mechanics of the foot; The plantar aponeurosis and the arch. J Anat. 1954 Jan; 88(1):25-30
[iii] Natali AN, Pavan PG, Stecco C. A constitutive model for the mechanical characterization of the plantar fascia. Connect Tissue Res. 2010 Oct; 51(5):337-46.
[iv] Plantar Fasciitis. https://www.ncbi.nlm.nih.gov/books/NBK431073/
[vi] Onwuanyi ON. Calcaneal spurs and plantar heel pad pain. The Foot. 2000;4:182–185.
[viii] Freire and Van Dyke. Natural resolution of inflammation. Periodontol 2000. 2013 Oct; 63(1): 149–164.
[ix] Mirkin. Why Ice Delays Recovery. https://www.drmirkin.com/fitness/why-ice-delays-recovery.html
[x] Xian Li, et al. Comparative effectiveness of extracorporeal shock wave, ultrasound, low-level laser therapy, noninvasive interactive neurostimulation, and pulsed radiofrequency treatment for treating plantar fasciitis. Medicine (Baltimore). 2018 Oct; 97(43): e12819.
[xi] Khurana, et al. Comparison of midterm results of Platelet Rich Plasma (PRP) versus Steroid for plantar fasciitis: A randomized control trial of 118 patients. J Clin Orthop Trauma. 2021 Feb; 13: 9–14.
[xii] David, et al. Injected corticosteroids for treating plantar heel pain in adults. Cochrane Database Syst Rev. 2017 Jun; 2017(6): CD009348.
[xiii] WALT/NAALT. Photobiomodulation: mainstream medicine and beyond. September 9–12 2014; WALT Biennial Congress and NAALT Annual Conference; Arlington Virginia USA.
[xiv] Anders, Arany, Baxter, Lanzafame. Light-Emitting Diode Therapy and Low-Level Light Therapy Are Photobiomodulation Therapy. Photobiomodulation, Photomedicine and Laser Surgery. 2019 Feb;37(2):63-65.
[xv] Lopes, et al. Photobiomodulation: Inhibition or Resolution of the Inflammatory Process?. Photobiomodulation, Photomedicine, and Laser Surgery, 2020 Aug;38(8):453-454.
[xvii] CCGPP. Chiropractic Management of Myofascial Trigger Points and Myofascial Pain Syndrome: Summary of Clinical Practice Recommendations. https://clinicalcompass.org/clinical-guidelines/chiropractic-management-of-myofascial-trigger-points-and-myofascial-pain-syndrome-summary-of-clinical-practice/