HEEL PAIN/ PLANTAR FASCIITIS/ ACHILLES TENDON DISORDERS
The Heel is composed of the heel bone (Calcaneus) with numerous joints and tendons. Heel pain is a common condition causing mild to severe pain that can interfere with the normal daily activities. Common causes of heel pain is from excess pressure on the heel bones and tendons, sprains or strains, a fracture of the heel bone, inflammation of the tendons, tendon sheaths, nerves, bursa, fat pad and arthritis.
Plantar fasciitis is a common condition that causes pain and discomfort in the bottom of the heel. The condition is developed when the attachments of the plantar fascia are inflamed and subsequently get damaged with resultant micro-tears.
Achilles tendinitis (insertional) is another condition that affects the heel bone when the tendons that join the calf muscles to heel bone are inflamed. Inflammation of the Achilles tendons occurs due to overstress on the tendons during intense physical activities. It can also occur in a disease called Enthesitis. Non- insertional tendinosis can occur at a short distance away from the heel bone. Symptoms of this condition include mild or severe pain, tenderness and stiffness on the back of the heel.
Conventional treatment options for heel pain, plantar fasciitis and achilles tendon includes resting, medications, physical therapies such as stretching and strengthening exercises to relax the stretched muscles and to regain normal strength and tone of the heel bone, tendons and ligaments. Surgical procedures include ligament and tendon repair to regain the motility and strength of the heel bone joint.
ALTERNATIVE TREATMENT METHODS AT BETH YEHUWDAH ARTHRITIS CENTRE, PULLAD AND DAYSTAR CLINIC, ALAPPUZHA
1) Platelet Rich Plasma in Heel Pain/ Plantar Fasciitis/ Achilles tendon disorders
Platelet Rich Plasma prolotherapy is the recent trend in treating various joint conditions and is designed to stimulate repair of partially torn/ damaged tendons & ligaments in the affected joint and to reduce pain caused by the condition. This treatment may help a patient who does not want surgery and helps to overcome the disease condition with minimally invasive injection techniques. The treatment method stimulates the natural immune repair mechanisms of the body and delivers the building block essential to build and repair damaged tissues.
How does PRP work? Blood components are of four major types - plasma, platelets, white blood cells and red blood cells. Platelets assist in clotting and are also the “first-responders” of the body post injury; helping repair an injured region and in building up of new tissue and thereby promoting the healing process. Once platelets contact collagen in damaged tissues, the platelets release various biological growth factors (Table 1 as given below) to promote healing in soft tissues locally. Activated platelets commonly release the following growth factors:
Platelet-Derived Growth Factor (PDGF) |
Attracts cells of the immune system to the site and stimulates their proliferation. Also shown to assist in healing of ligaments and tendons. |
Transforming Growth Factor-ß (TGF-ß) |
Similar affects as PDGF. It is Secreted by all major cell types involved in healing. |
Vascular Endothelial Growth Factor (VEGF) |
Helps in formation of new blood vessel, thereby increasing vascularity in injured areas. |
Fibroblast Growth Factor (FGF) |
Promotes the growth of the cells involved in collagen and cartilage formation. |
Table 1: Various biological growth factors released by PRP when activated
PRP injection delivers a high concentration of autologous (patient’s own) platelets to the site of the Heel Pain/ Plantar Fasciitis/ Achilles tendon disorder. Platelets present in the blood are the first responders to an injured area and helps build up new soft tissues. Introducing high concentration of platelets directly into the site using PRP injection stimulates the healing process and faster recovery from the disease condition.
Patient Benefits of PRP Prolotherapy:
2) Prolotherapy for Heel Pain/ Plantar Fasciitis/ Achilles tendon disorders: Prolotherapy is a natural and cost effective alternative method to surgery. Prolotherapy is an almost painless injection technique under local anesthesia where very thin needles are used to inject high concentrations of dextrose solution (sugar similar to glucose) in to the region of Heel Pain/ Plantar Fasciitis/ Achilles tendon disorder. Prolotherapy works by increasing the glucose concentration in the fluid outside the cells. This results in movement of fluid from inside the cells through the cell membrane to the outside of the cells thereby shrinking the cells and causing temporary cell damage (hyperosmolar damage). As the cells are temporarily damaged, they release many biosignals to the body which results in stimulation of the immune system of the body to accelerate the inflammatory process locally resulting in increased local blood circulation, fibroblast (fibrous cell) proliferation, ligament/ tendon regeneration, tightening and repair. This treatment method has the ability to strengthen the existing intact, but weakened, ligamentous and tendinous structures in the area, helping to reduce symptoms of Heel Pain/ Plantar Fasciitis/ Achilles tendon disorder.
Patient Benefits of Prolotherapy:
Neural & Soft Tissue Infilteration Therapy (NESTIT)
Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT): Steroid tablets and injections of the group Corticosteroids, (which are very different from Anabolic steroids misused by some athletes) have been repeatedly proven medically for the last 70 years in the successful treatment of inflammatory conditions due to its potent anti-inflammatory effect. Though corticosteroids are very effective in reducing inflammation, they carry numerous potential side effects, which are undesirable. To circumvent this problem, and in order to utilize the potent anti-inflammatory effects of steroid injections, at the same time taking appropriate measures to considerably lower its side-effects, Dr Tejaz Koshy John in 2010 while working as an Orthopaedician in his private clinic in Guyana, South America developed NESTIT. NESTIT stands for (Juxta) Neural and Soft Tissue Infilteration Therapy. It consists of injecting small amounts of diluted anti inflammatory steroid solution indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb. It is preferably given for those patients who have Rheumatoid Arthritis, Inflammatory Arthritis, Synovitis, Inflammatory Low Back Pain, Spondyloarthropathy & Nerve and Nerve root irritation. It is not a substitute for DMARDS (Disease modifying anti rheumatoid drugs), however when given with low dose DMARDS, in Dr Tejaz John’s clinical experience it may result in significant reduction of local inflammation, pain and improvement of joint function in most cases, also indirectly reducing side effects of high dose DMARDS.
NESTIT involves
In Dr Tejaz John’s clinical experience, the patient benefits of Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT) treatment are:
At Beth Yehuwdah Arthritis Centre, Pullad & Daystar Clinic, Alappuzha we provide a variety of options for patients suffering from Heel Pain/ Plantar Fasciitis/ Achilles tendon conditions. To know more Heel Pain/ Plantar Fasciitis/ Achilles tendon treatment plans and cost, book an appointment now.
Authored by Dr TEJAZ KOSHY JOHNMBBS, MS Ortho (Christian Medical College, Ludhiana), Joint Replacement Fellowship (HOSMAT Hospital, Bangalore), Orthopaedic Trauma Fellowship (Hebrew University Hospital, Jerusalem, Israel)
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