ARCHES AND HEELS

Also known as Ledderhose’s disease for the German surgeon, Dr. Georg Ledderhose, who first described the condition in 1894, plantar fibromatosis/fibroma (PF) is a benign thickening of the deep connective tissue in the arch of the foot (called the “plantar fascia”).

This is a fibrotic tissue disorder, but non-cancerous. It normally starts as nodules or cords growing along the foot tendons and can be painful. Then, the fibrous knots can thicken, stiffening and bending the toes to make walking an unpleasant, problematic prospect. A similar affliction, Dupuytren’s disease, affects the hand and causes bent hand or fingers.

The excess collagen or fibrotic tissue (referred to as “fibroma”) can collect as a single mass or in clusters, developing in one or both feet and, unlike the related Peyronie’s disease, usually will not go away or get smaller without treatment. Hard in texture, these non-malignant tumors are oftentimes painless until aggravated or enlarged by activities like walking and running, as the fibers of the fascia become further herniated.

Plantar fibromatosis differed from plantar fasciitis in that the former is cyst(s) in the plantar fascia bands, whereas the latter is the chronic swelling and thickening of the plantar fascia.

While no definitive conclusion exists to explain their origin, damage to the tendon is a common reason for their occurrence, and therefore believed to be a primary culprit. Such trauma may be from a puncture through the sole of the foot or from repetitive impact of activities such as running or climbing. In addition, the thickening and tightening of the plantar fascia from plantar fasciitis may lead to tears in the tissue from which plantar fibromatosis then surface.

It may be genetic as well, since PF patients also tend to have a parent or a close relative with the condition. Those with a family history of fibrotic tissue disorders are thought to be genetically predisposed to this disease. The condition is associated with Dupuytren’s disease too, as 5% of the patients with Dupuytren’s have plantar fibromatosis, and historical and ultrastructural evidence support the theory that both afflictions share a common pathological root.

Medications often used for treating high blood pressure in the drug class known as beta adrenergic blocking agents (or beta-blockers) and the drug Dilantin have been reported to cause fibrotic tissue disorders. Anti-seizure medications (such as phenytoin) are suspected to promote the production of excess collagen that can lead to plantar fibromatosis.

Although not conclusively proven, alcoholism, smoking, liver diseases, and thyroid problems may contribute to the cause.

Lastly, some speculations hold that PF could be an aggressive healing response to small tears in the plantar fascia, almost as though the fascia was trying to over-repair itself.

While the condition can strike people of all ages, according to studies it is diagnosed most often in the middle-aged and elderly population, possibly as high as 25% of all folks in that demographic, and men are approximately 10 times more at risk than women. It also follows that juvenile aponeurotic fibroma is more common in boys than in girls. Caucasians of northern European descents tend to fall victim to this and other fibrotic diseases more often than other ethnicities, while Asians are rarely affected.

Patients of chronic liver disease, diabetes, epilepsy and other seizure disorders have a higher rate of contracting the condition as well. In 10% of the cases, those with plantar fibromatosis also demonstrated Dupuytren’s Contracture — similar lumps in the palms of their hands.

The term plantar fibromatosis actually encompassed different conditions:

Ledderhose’s disease (LD) is the most commonly associated condition and a relatively common plantar equivalent of Dupuytren’s Contracture. Often, LD patients also have other fibrotic disorders such as knuckle pads or induratio penis plastica.

Superficial fibromatosis (SF) is uncommon and appears as one or more flat nodules of fibrous consistency and variable size, though some forms have been observed to not be overgrowth but inflammatory myofibroblastic tumors. SF targets children and young adults more so than it does older people.

Juvenile aponeurotic fibroma (JAF) and aggressive infantile fibromatosis (AIF) are considered PF when lesions are present on the sole of the foot. Like SF, JAF occurs most frequently in youths; the hard nodules grow slowly and adhere to deep structures. AIF is an exceptional condition that begins in an infant’s first year of life; it is the only PF with an invasive course, growing rapidly to pervade the tendons and muscles in the foot but fortunately does not spread to other parts of the body.

Hamartomatous plantar fibromatosis lesions are a rarity. They look like raised soft-to-firm masses, covered by pink, slightly dark, or normal-colored skin, and can become large enough to induce disability.

The most conspicuous signs of plantar fibromatosis are the firm nodular masses you can feel just under the skin on the bottom of the foot or on the medial border of the sole, near the highest point of the arch, and perhaps cause pain when standing, walking, or running.

These noticeable lumps can remain the same size or become larger over time, or additional fibromas may develop. They are not always painful, but when they are, it is usually because the knots are rubbing against the shoes worn or on the floor (when barefoot). The agony can stay constant or even intensify while standing or walking. At the early stages, the overlaying skin can move freely and contracture of the toes does not happen until later.

To diagnose a plantar fibromatosis, the foot-and-ankle surgeon will examine the foot and press on the affected area. Occasionally this can produce pain that runs down to the toes.

MRI (magnetic resonance imaging) and sonography (diagnostic ultrasound) have traditionally been useful in detecting plantar fibromatosis. The fibroma typically appears as a poorly defined, infiltrative mass in the layer of flat, broad tendons next to the foot muscles. The images will reveal the extent and depth of the invasion, which often penetrates layers of tendons. Biopsy of the masses, however, is not recommended, since the act may cause the fibroma to enlarge.

Many different treatments for plantar fibromatosis have been used and can be categorized as either invasive or noninvasive. Given the high rate of recurrence from surgery, most doctors agree that a non-invasive approach should be considered first, reserving surgery and other invasive options for the most severe cases. Professional treatments include functional foot orthotics, corticosteroid injections, and surgery to remove the mass. Non-surgical treatments will help relieve the pain of PF, but they will not make the nodules disappear.

Because in most cases the only pain found with PF is when the nodule is irritated by direct pressure from the shoe or floor, alleviation and avoidance will serve as the initial treatment. Soft inner soles on footwear and padding should cushion the cyst from agitation and lighten the contact.

Calf stretching is a common treatment method, especially when the condition is due to heavy pressure from the calf to the foot: Put your forefoot on a wedge or small block and the heel on the ground, then lean forward, stand up, straighten the knee and hold the position for 60 seconds. Repeat it for 4-6 times a day on separate occasions. Wearing night splints or a heel lift that raises the heel and consequently reduces the forces applied by the calf to the foot should also enhance the result.

Custom foot orthotics will also take the strain off of the plantar fascia ligament and sometimes shrink the nodules in size.

No medical care, even professional, is thought to be completely effective against plantar fibromatosis. Early treatments have included anti-inflammatory medication, orthotics, and physical therapy.

Doctors have tried cortisone injections with triamcinolone and clobetasol ointments, a painful, invasive approach that has shown to stall the condition temporarily, but the results are largely subjective and the long-term prospect remains questionable.

Radiotherapy, on the other hand, has recorded successes on Ledderhose nodules.

Some podiatrists may suggest transdermal verapamil gel. However, it has not yet been approved by the FDA, is quite expensive, and you must apply it for several months with no guarantee of it working.

Wear comfortable footwear and maintain the proper walking posture to minimize irritation of the sole and heel, especially when you already noticed lumps and bumps on a foot.

Check with your podiatrist or doctor at the earliest opportunity, who can diagnose and confirm a plantar fibromatosis, and advice you on the proper care.

Exercise and stretch your calves to reduce the forces exerted on your feet. Regular reflexology, shiatsu and foot massage can also keep the foot tissue flexible.

Dietary problems may be a cause for excessive nodular collagen build-up, so consult a nutritionist as well.

Plantar fasciitis (pronounced “plantar fash-eee-eye-tiss”, from the Latin, “plantar” meaning “sole” and “fascia” meaning “band”) is the most common type of heel pain. The plantar fascia is the long fibrous fascia ligament tissue band that serves as shock absorber designed to support the arch of the foot. Plantar fasciitis occurs when the plantar fascia develops tears causing pain and inflammation.

The pain of plantar fasciitis is usually located close to where the fascia attaches to the calcaneous—the heel bone. Plantar fasciitis causes stabbing pain that usually occurs with your very first steps in the morning because of the tightening that occurs overnight while you sleep. Once your foot loosens up, the pain often decreases, but it may return after long periods of standing or remaining in a seated position.

Plantar fasciitis is particularly common in runners, people who are overweight, women who are pregnant and those who wear shoes with inadequate support.

There are many risk factors that plantar fasciitis suffers should look out for. Rigorous exercise and sports can significantly stress the heel tissue. In addition, High arches or flat feet can cause stress because of the abnormal mechanics of the foot.

Additionally, as we age, tissue can become weaker and more susceptible to damage, causing plantar fasciitis.

Structural misalignment is the number one cause of heel pain. Either a flat foot or a highly arched foot can cause heel pain; most people have one of these two problems. Flat feet or high arches are caused in part by the sedentary lifestyle that most people lead. We sit for too long and don’t walk enough. When we sit for too long, our body stays bent forward, which moves our center of gravity in front of us. This puts tension on the calf muscles, which in turn flattens the arches. And when your arches are flattened, you put tension at the insertion site of the heel, causing plantar fasciitis as described above. Think about your car: when you have a flat tire it puts pressure on the axels. You sure don’t want to run on rims alone.

When you have the other extreme foot type, the high-arched foot, you have to deal with an extremely rigid foot. This foot type is not very flexible; it causes too much shock to be absorbed in your foot with every heel strike. If you were a car, high arches would mean that you would have too much tire pressure, so you would feel every bump on the road. Your shock absorbers wouldn’t be working either, meaning there would be too much tension on the plantar fascia, leading to inflammation.

The next common cause of heel pain is increased weight. Back to the car metaphor: if you put too much cargo in your small-tired car, your car will not be able to handle the load and will break down eventually. As a nation, we don’t walk enough. Our lack of walking causes a weakening of the foot and leg muscles. In addition, more than 60 percent of our population is overweight. The combination of insufficient walking and obesity is detrimental to the heel, which gets pressure with every step you take. Plantar fasciitis occurs when there is a strain on the ligament that supports your arch. Repeated strain will cause tiny tears in the ligament that can lead to pain and swelling in the fascia.

Plantar fasciitis most commonly occurs in people between age 40 and 60. Plantar fasciitis can occur from injury or may be related to underlying diseases that cause arthritis. Sometimes plantar fasciitis occurs for unknown reasons.

If feet roll inward when walking (pronation), which will cause abnormal stress on the plantar fascia and heel, this can lead to inflammation and pain in the foot. Having an abnormal gait (the way in which the foot hits the ground) can overwork or abnormally stretch the fascia tissue, resulting in tears and inflammation.

Improperly fitting or unsupportive shoes are damaging to the tendons, muscles, ligaments, bones, and nerves in your feet. Wearing supportive shoes may be the easiest action you can take in your foot health.

There are a number of factors that can contribute to developing plantar fasciitis. The plantar fascia ligament is similar to a rubber band and loosens and contracts with movement. It absorbs the weight and pressure of your body.

Athletes who put excessive or strenuous physical activity on the feet can cause plantar fasciitis.

Arthritis is another common cause of plantar fasciitis. This cause is particularly common among elderly patients.

Diabetes and obesity is also a factor that can contribute to heel pain and damage, particularly among the elderly. Weight plays a factor in many foot conditions, so it is important to see a podiatrist if you are overweight

The hormonal changes and sudden onset of excessive weight in pregnant women can also cause ligaments and other tissue to relax and become more strained, which can lead to plantar fasciitis.

The most common factor that contributes to plantar fasciitis is wearing improperly fitting shoes for long periods of time. This is why it affects women because they so often wear shoes that either do not fit properly, or provide inadequate support or cushioning, such as high heels. While walking or exercising in improperly fitting shoes, weight distribution becomes impaired causing stress to be added to the plantar fascia ligament.

There are three conditions related to plantar fasciitis:

• Mild: Strain and/or tears to the plantar fascia; discomfort upon waking.
• Moderate: More intense pain upon waking, additional pain throughout the day, including heel pain.
• Severe: Very intense pain, especially in the heel, which is indicative of a heel spur—a pointed bony fragment that stems from the heel bone— that has resulted from the plantar fasciitis, making it more painful and even difficult to walk.

The most common complaint associated with plantar fasciitis is a burning, stabbing, or aching pain in the heel of the foot. Most sufferers will be able to feel it in the morning because the fascia ligament tightens up during the night. The first pressure on the foot in the morning after the ligament becomes taut is when pain is particularly acute. Over the day, pain usually decreases as the tissue loosens up, but may return again after long periods of standing, physical activity, or after getting up after long periods of sitting.

For most people, heel pain is at its worst with the first steps in the morning. When you are asleep, your foot rests in a downward relaxed position. In this position, your calf muscles and plantar fascia are tight. Therefore, when you take your first steps in the morning, you are stretching the plantar fascia, which causes an extreme amount of pain.

When you get up from a sitting down position, you could also feel heel pain. In this scenario, your plantar fascia is in a tightened position while sitting down; when you get up from being seated, you feel the stretch of the fascia.

After prolonged standing and walking, you will also feel heel pain. That’s why many people complain of sore heels after a long day on their feet. You may be surprised to hear that most people feel more pain after standing than walking. This is because you have more tension on the plantar fascia while standing than during the actual movement of walking. People with flat feet have an especially hard time withstanding.

When your body is more inflamed, you will feel more heel pain. Therefore, if you have cold, fever, or infection in your body, you will feel more pain. Any generalized swelling of the body can exacerbate heel pain.

You may be suffering from plantar fasciitis if you regularly suffer from any of these symptoms:

• Pain starts as dull and sporadic in the heel or arch, progressing to a sharp, persistent pain.
• Sharp, piercing pain through heel and foot that usually occurs in the morning or after resting and gradually disappears with walking.
• Inflammation is present in the heel, ankle, and arch or sole of the foot.
• Tightness in calf muscles or Achilles tendon.
• Noticeable heel pain after long periods of standing or walking.
• Heel pain worsens when climbing stairs or standing on the toes.
• Heel pain lessens with normal daily activity, but returns during rest when the plantar fascia tightens up.

Exam: Your doctor will check your feet and watch you stand and walk and observe your symptoms, such as where the pain is and what time of day your foot hurts most and ask about your daily activities.

X-ray: An X-ray of your foot may be necessary if the physician suspects a problem with the bones of your foot, such as a stress fracture or a heel spur.

n most cases, plantar fasciitis does not require surgery. Conservative treatments are usually all that is required. However, every person’s body responds to plantar fasciitis treatment differently and recovery times may vary.

Conservative Treatments

• Orthotic devices: Your doctor may recommend and fit you for an orthotic insert to be placed in your shoes to help reduce pain. Orthotics can also help promote healing to reverse plantar fasciitis.
• Night splints: These devices are worn during the night while you sleep, helping to keep the plantar fascia stretched to promote healing.
• Physical therapy: Another powerful way to decrease heel pain is through physical therapy. Ultrasound, electro-stimulation and deep tissue massage are very effective techniques for resolving inflammation. In addition, stretching and strengthening exercises can be lifesavers. I also recommend using a night splint, which keeps the foot in a straight position to help stretch the plantar fascia during sleep. This prevents the morning pain when you first step out of your bed.
• Corticosteroids: Injections of corticosteroids deliver medicine into the injured fascia to reduce pain. This treatment may weaken the plantar fascia and result in further damage.
• Extracorporeal shock wave therapy (ESWT): Treatment with sound waves is used to stimulate the damaged tissue and encourage healing. This is a relatively new method in treating plantar fasciitis.

Autologous Platelet Concentration ( APC ) Treatment: Some doctors have begun injecting APC (Autologous Platelet Concentrates) into chronically inflamed areas with great success. It has been known for many years that your blood’s platelets contain growth factors (specifically, PDGF, TGF, VEGF, and EGF). The doctors who injected APC isolated the platelets from each patient’s own blood and re-injected it into the area of chronic inflammation. So far, this technique has been utilized for many different kinds of chronic inflammation, such as chronically inflamed wounds, bones, tendons, and fascia.

30cc Blood put into each tube

In 2004, the first scientific paper was published about the use of APC for plantar fasciitis and heel pain by Drs. Barrett and Erredge. The paper was titled “Growth Factors for chronic plantar fasciitis?” The publication demonstrated excellent results using APC in a nine-patient study targeting chronic heel pain. In response to this paper, our group of doctors at Kim Foot and Ankle took on the challenge of gathering a larger group of patients for a follow-up study. We collected data for the study from December 2006 to October 2008, and we just finished writing a paper called “Use of APC in Plantar Fasciosis and Achilles Tendinopathy”.

If you’d like to read about the study, you may request a copy of this paper from our office. Our paper will be submitted for publication in the next few months. It details the study of 62 patients who have gone through the treatments with APCs.

Based on our research, we found that APC can be great treatment option for chronic heel pain. The wonderful thing about APC therapy is it has no side effects since it is the patient’s own blood that we are re-injecting. Obviously, we need to do more research on APC therapy, but for many of our patients, it has worked well as an alternative to surgical intervention.

Centrifuge for 10 minutes

The beauty of the APC procedure is its simplicity. It takes around 15 minutes to complete the whole procedure. We draw about 30cc of a patient’s blood and centrifuge it for 10 minutes. Then, we isolate around 3cc of platelets, which are re-injected into the heel. A local anesthetic is used on the injection site, so there is minimal pain involved. After APC therapy, patients are required to wear a CAM walker for a week. The therapy can be repeated once a month. Within our experience so far, about two or three injections eliminated chronic heel pain.

Changing physical activities to lessen standing, running or putting excessive pressure on the foot can decrease stress on the plantar fascia, relieving pain.

Resting the foot to avoid stress is especially helpful if you stand or run on hard surfaces regularly. Taking breaks and rests will decrease pain.

Ice treatments to the area for 15-minutes at a time with a 15-minute break will reduce inflammation and speed recovery. Gently massage the ice over the affected area, rather than leaving it to sit in one place.

Massage the arch and heel daily to loosen the tightness and pressure.

Stretching the foot gently several times daily is one of the most effective and easiest ways you can relieve pain and tightness to the affected area, while also loosening the tight muscles, ligaments and tendons. Stretch before you get out of bed in the morning. Take a stretch band, belt or towel and place it around the ball of your foot and pull your toes towards you with your leg extended. Stretch like this for a few minutes every hour throughout the day, or whenever you can. A plantar fascia specific stretch requires that you place your foot on you opposite knee. Grab your heel with the opposite hand. Use the other hand to pull back at the toes, especially the big toe. You should be able to feel the plantar fascia, which will be the tense band on the inside of the arch. Hold the stretch for 10 seconds and repeat 10 times. Perform this exercise 3 times a day or whenever you can.

NSAIDS Taking over the counter medications such as ibuprofen (Advil) or naproxen sodium (Aleve) can help reduce pain and inflammation.

Losing weight will relieve pressure put on the foot causing plantar fasciitis and other foot problems. It is advised to always consult with your primary care physician before starting any weight loss or diet programs.

Wearing properly fitting shoes will support your foot and ankle, providing the assistance needed to avoid further damage to the foot. Supportive shoes will also reduce the risks of developing other serious foot conditions.

Surgery may be recommended for patients who are not finding relief through conservative treatments. Generally, only about 5% of plantar fasciitis sufferers have surgery. The majority of surgery patients make a full recovery; however, there is always a possibility that complications develop. Candidates for surgery will typically have symptoms for at least 9 months with little benefit from conservative treatment.

Athletes afflicted with plantar fasciitis might also elect for surgery when performance becomes significantly impaired by their condition.

Like with any type of surgery, plantar fascia surgery certainly has its risks. However, the majority of patients who undergo this procedure enjoy a full recovery so it is important to decide with your orthopedic surgeon if the procedure is right for you.

1. Traditional plantar fascia release surgery involves open surgery. In this procedure, a cut is made into part of the plantar fascia ligament, relieving accumulated tension. The incision is made around the heel pad and then into the fascia ligament to release strain. If a heel spur is present it may be removed along with any damaged tissue.

2. Endoscopic surgery may also be an option. This procedure takes 20 minutes to an hour and does not require a stay in the hospital. It works by locating the damaged portion of the fascia through instruments that are fed through a small incision. The surgeon cuts a portion of the plantar fascia from the heel and a slotted tube is inserted through two small incisions made in the skin on each side of the heel. A knife inserted down the tube pokes out of the slot, cutting the fascia tissue band. An endoscopic camera is inserted into the tube to allow the surgeon to see what he is cutting. The cut fascia usually relieves pain and pressure in the area. New fascia tissue grows into the gap created by the cut.

Many patients are able to wear their regular shoes in less than a week and can return to work after the first week. Other factors such as age, weight, and occupation can contribute to healing times.

You are about to have surgery. As you may already know, nutrition plays a very important role in proper healing. One of the most important benefits of proper nutrition is maintaining the right pH balance in your body. pH is the measurement of acidity and alkalinity. pH ranges are from one to fourteen with fourteen representing most alkaline. Seven is neutral. The most optimal pH level for humans is slightly more alkaline than acidic at around 7.36.

Undergoing surgery can increase acid levels in the body. Emotional and physical stress from both the surgery and recovery time changes your metabolism, which increases acid production. The use of both general and local anesthesia, pain medication, anti-inflammatory medications and other medications such as antibiotics will also introduce more acid to your system, lowering the alkalinity. This will delay healing and prolong recovery time.

To maintain your body’s proper pH, keep yourself well hydrated prior to and after surgery. Water helps to dilute the acid build up in your body and release it through urination. Eating alkaline rich foods such as dark, leafy green vegetables will add alkalinity. Avoid acidic foods such as meats, fried foods, coffee (and other caffeinated drinks), carbonated beverages, cigarettes, and alcohol.

• Many people may need medical clearance through their Primary Care Physician, especially if taking medications such as Coumadin.
• Stop using anti-inflammatory medication 5 – 7 days before surgery. These include aspirin, ibuprofen, Advil and Aleve.
• Arrange for a ride home from surgery and for someone to look after you for at least the first 24 hours.
• Avoid long trips for at least two weeks after surgery.
• Avoid eating and drinking anything after midnight the night before surgery.

Most foot and ankle surgeries are day surgeries, which means you will go home the day of surgery. You will generally be given a local anesthetic and anesthesia. After surgery, you will receive pain medication and care instructions.

Post-op Recovery

• The best results and quickest healing is achieved when patients follow after surgery instructions.
• Keep your foot elevated as much as possible for the first week after surgery.
• Keep your foot dry for at least 2 weeks after surgery.
• One week after surgery you will have your dressing changed by coming to see your attending physician.
• The sutures will be removed after the second week.
• Your doctor will advise you when you can increase weight and activities on the foot.
• Take pain and anti-inflammatory medications as prescribed by your physician.
• Following plantar fascia surgery, a cast or brace may be used to reduce weight on the heel of the foot to allow the tissue to heal. It may take a few weeks before weight bearing can be applied. In most cases, it will take at least three months to regain full activity of the foot.
• Vitamin C is important to heal scar tissue. It is vital in aiding in collagen formation. Take 4,000 mg spread out over each day in 500 mg doses taken for several days to several weeks after surgery.
• Omega 3 fatty acids, such as flax or fish oil, vitamin A and beta-carotene aid in the skin healing and lessen the appearance of scars.

Preventing plantar fasciitis is optimal and can be easy.

One of the most important factors is maintaining a healthy weight in order to reduce tension on the plantar fascia. Work with a nutritionist or your physician to develop a plan if you have a problem with your weight.

Shoes should fit well and provide cushioning and support throughout the heel, arch, and ball of the foot so that weight is distributed evenly. Make sure to replace old or worn out shoes. A podiatrist may be able to recommend a brand or type of shoe best suited to your foot.

Avoid walking barefoot on hard surfaces and replace old shoes before they wear out, especially shoes that you run or exercise in.

When exercising, start off slow and ease into new routines to prevent sudden or excessive stress on the tissue.

Keep your calf muscles and the tissue of your feet stretched. Greater flexibility in the tissue makes them less susceptible to damage.

Treat pre-existing foot conditions such as high arch, flat feet or pronation. These foot problems can lead to abnormal stress on the plantar fascia leading to fasciitis.

Regularly visit your podiatrist to manage your foot health.