Strength of evidence

INTRODUCTION

Plantar fasciitis (PF) is a common cause of heel pain, estimated to affect 10% of people over the course of their life.1 Symptoms are typically sharp, stabbing pain in the sole of the foot or heel with pressure, or when standing after periods of rest. Most cases improve with relatively conservative treatment, including home remedies such as stretching, rest, and massage, but when these approaches don’t work, diagnostic imaging and outside therapies may be recommended. Plantar fasciitis is most common in runners, people who are overweight, in occupations requiring prolonged standing or walking, and those with foot alignment issues or who have one leg longer than the other.2

The ‘plantar fascia’, which is the part of the foot that’s inflamed with plantar fasciitis, is a tendon that attaches to the base of the heel bone and extends into five bands that attach to each toe on the bottom of the foot. As a weight-bearing structure, it is affected by over-use through repetitive strain due to too much or too little movement and exercise. Small injuries to the tendon over time cause inflammation and pain. Often, a little bony growth (called a spur) also develops on the heel bone (calcaneus). Plantar fasciitis can also be caused by arthritic conditions, such as ankylosing spondylitis and psoriatic arthritis.3

ACUPUNCTURE FOR PLANTAR FASCIITIS: THE CLINICAL EVIDENCE

A recent systematic review evaluating all clinical trials on acupuncture for plantar fasciitis concluded that acupuncture is an effective treatment for the condition and that the evidence is comparable to other commonly-used interventions, such as stretching, night splints and dexamethasone.4 Accordingly, the US Department of Veteran Affairs5 and the Acupuncture Evidence Project6 concluded that acupuncture has a potentially positive effect for treating heel pain.

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Acupuncture for Plantar Fasciitis PDF

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HOW ACUPUNCTURE TREATS PLANTAR FASCIITIS: BIOLOGICAL MECHANISMS

Acupuncture improves plantar heel pain through several pathways. One way is that the insertion of needles causes a local effect on nerve endings, releasing neuropeptides that help eliminate pain. There is also some excellent research showing that a substance called adenosine is released during acupuncture and has a potent pain-relieving and anti-inflammatory effect as well as promoting blood flow to the area.7 Other local cells, known as fibroblasts, are stimulated by acupuncture promoting tissue healing in the area.8

Researchers have also demonstrated that the body releases its own opioids, the body’s natural ‘pain killer,’ during acupuncture treatment.9 Studies that look at changes in brain activity during acupuncture show that following treatment there is less activity in brain regions associated with pain perception and increased activity in areas that regulate our response to pain.10

KEY RECOMMENDATIONS FOR PRACTICE
THE MAINSTREAM APPROACH TO TREATING PLANTAR FASCIITIS

The standard treatment for plantar fasciitis is typically conservative, as the condition usually resolves within a year. According to the American Family Physician, ‘although several remedies exist for plantar fasciitis, there is little convincing evidence to support these various treatments.’11

Initial recommendations that the patient can do on their own include changing their activity levels, applying ice, stretching, wearing orthotics, weight loss and taking over-the-counter pain killers such as acetaminophen (Tylenol or Paracetamol) or non-steroidal anti-inflammatory drugs (NSAIDs).

Concerns over the safety of taking over-the-counter painkillers have increased in recent years. A new review of safety evidence found an increased risk of cardiovascular complications, gastro-intestinal tract bleeding, kidney toxicity and death from taking Tylenol or Paracetamol.12

The use of NSAIDs also carries significant health risks, even in small doses. A 2017 review of the safety of NSAIDs, which included over 446,000 patients, found an increased risk of heart attack when using any NSAIDs (including over-the-counter ones like Naproxen) at any dose, even for as little as one week.13 NSAIDs have also been shown to increase the risk of gastro-intestinal bleeding,14 a serious and potentially fatal complication, as well as acute kidney injury.15

If plantar fasciitis symptoms do not improve within several weeks, diagnostic imaging such as ultrasound or MRI may be used to rule out any further contributing factors. Modalities such as physical therapy, steroid injections, prolotherapy, platelet-rich plasma injections, Botox, anterior night splinting, and custom orthotics may be included in the treatment plan.16

If there is no improvement after six or more months of treatment, shock wave therapy and plantar fasciotomy may be used next. Extracorporeal shock wave therapy is reported to be a beneficial, non-invasive approach, however it can be painful and lead to numbness and swelling in the region applied. Plantar fasciotomy has been shown in two studies to provide relief in a majority of patients surveyed (80-85%) but also includes the risk of side effects and complications of surgical procedure.

Conversely, studies on acupuncture for plantar fasciitis have shown few to no adverse effects, in addition to overall high levels of effectiveness. While there is a variety of styles of treating plantar fasciitis with acupuncture, each displays a strong ability to reduce pain and improve function, helping people with plantar fasciitis to get back on their feet!

THE AUTHOR

Zaynah Shabo, DACM, LAc is currently in private practice in Palm Desert, CA. Her primary focus is orthopedics but she treats the general population, and hopes to expand to include Functional Medicine once her DACM at PCOM is complete. She graduated from the Pacific College San Diego, MSTOM in 2012 and from Boston University, BA, English Literature, cum laude in 2002. She has experience as an editorial assistant on several publications (Partisan Review, Teleosis Institute’s Symbiosis Journal, and received grant to perform research and draft pieces for an interdisciplinary humanities textbook from BU’s UROP program 2001).

References:
1. Zhiyun L, Tao J, Zengwu S. Meta-analysis of high-energy extracorporeal shock wave therapy in recalcitrant plantar fasciitis. Swiss Med Wkly. 2013;143:w13825. doi:10.4414/smw.2013.13825.
2. Goff JD, Crawford R. Diagnosis and treatment of plantar fasciitis. Am Fam Physician. 2011;84(6):676-682.
3. Narváez JA, Narváez J, Ortega R, Aguilera C, Sánchez A, Andía E. Painful heel: MR imaging findings. Radiographics. 2000;20(2):333-352. doi:10.1148/radiographics.20.2.g00mc09333.
4. Clark, R. J., & Tighe, M. (2012). The effectiveness of acupuncture for plantar heel pain: a systematic review. Acupuncture in Medicine: Journal of the British Medical Acupuncture Society, 30(4), 298–306.
5. Hempel, S., Taylor, S. L., Solloway, M. R., Miake-Lye, I. M., Beroes, J. M., Shanman, R., et al. (2014). Evidence Map of Acupuncture. Washington (DC): Department of Veterans Affairs.
6. McDonald, J. L., & Janz, S. (2017). The Acupuncture Evidence Project, 1–81. Retrieved from http://www.acupuncture.org.au/OURSERVICES/Publications/AcupunctureEvidenceProject.aspx
7. Goldman N, Chen M, Fujita T, et al. Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture. Nat Neurosci. 2010;13(7):883-888. doi:10.1038/nn.2562.
8. Langevin, H. M., Bouffard, N. A., Churchill, D. L., & Badger, G. J. (2007). Connective Tissue Fibroblast Response to Acupuncture: Dose-Dependent Effect of Bidirectional Needle Rotation. The Journal of Alternative and Complementary Medicine, 13(3), 355–360. http://doi.org/10.1089/acm.2007.6351
9. Staud R, Price DD. Mechanisms of acupuncture analgesia for clinical and experimental pain. Expert Rev Neurother. 2006;6(5):661-667. doi:10.1586/14737175.6.5.661.
10. Huang W, Pach D, Napadow V, et al. Characterizing acupuncture stimuli using brain imaging with FMRI–a systematic review and meta-analysis of the literature. PLoS ONE. 2012;7(4):e32960. doi:10.1371/journal.pone.0032960.
11. Goff, 2011
12. Roberts E, Delgado Nunes V, Buckner S, et al. Paracetamol: not as safe as we thought? A systematic literature review of observational studies. Ann Rheum Dis. 2016;75(3):552-559. doi:10.1136/annrheumdis-2014-206914.
13. Bally, M., Dendukuri, N., Rich, B., Nadeau, L., Helin-Salmivaara, A., Garbe, E., & Brophy, J. M. (2017). Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data. BMJ (Clinical Research Ed.), 357, j1909–13. http://doi.org/10.1136/bmj.j1909
14. Lanas A, Carrera-Lasfuentes P, Arguedas Y, et al. Risk of upper and lower gastrointestinal bleeding in patients taking nonsteroidal anti-inflammatory drugs, antiplatelet agents, or anticoagulants. Clin Gastroenterol Hepatol. 2015;13(5):906–12.e2. doi:10.1016/j.cgh.2014.11.007.
15. Ungprasert P, Cheungpasitporn W, Crowson CS, Matteson EL. Individual non-steroidal anti-inflammatory drugs and risk of acute kidney injury: A systematic review and meta-analysis of observational studies. Eur J Intern Med. 2015;26(4):285-291. doi:10.1016/j.ejim.2015.03.008.
16. Goff, 2011