Alternative Management of Plantar Fasciitis: A Case Report
Heather L. Meeks, DC1
1 Staff Chiropractor, VA Central Iowa Healthcare System
Published: December 2020
Journal of the International Academy of Neuromusculoskeletal Medicine
December 2020, Volume 17, Issue 2
The original article copyright belongs to the original publisher. This review is available from: http://ianmmedicine.org ©2020 Meeks and the International Academy of Neuromusculoskeletal Medicine. This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objective To discuss the management of chronic plantar fasciitis in 44 year-old female using a multimodal treatment approach, including cupping therapy.
Clinical Features A 44-year-old female presented to a hospital-based chiropractic clinic with a chief complaint of bilateral plantar fasciitis. Due to the nature of the patient’s occupation, she stood for 12-14 hours at a time and had not found relief with traditional plantar fasciitis management strategies.
Intervention and Outcomes The use of cupping therapy, in combination with instrument assisted soft tissue manipulation and manipulative therapy for plantar fasciitis management provided in a hospital-based chiropractic clinic resulted in subjective improvements in pain during weight bearing and ambulation. Treatment occurred 2 times per month for two months, and then once every 6 weeks for 12 weeks, for a total of 6 visits
Conclusion The use of a non-traditional management strategy, including moving cupping, resulted in symptomatic relief and improved activity tolerance for a 44-year old female with chronic plantar fasciitis. This report provides a case for the use of alternative management strategies and suggests the need for further research in this area.
Key words: plantar fasciitis, chiropractic, manual therapy, cupping therapy
Plantar fasciitis is one of the most common causes of heel pain, affecting approximately 10% of the US population2,5. This condition is usually self-limiting; however, approximately 2/3 of patients with this diagnosis will seek care from an office-based physician3,10, with the other 1/3 seeking care from orthopedic surgeons10. Risk factors for developing plantar fasciitis include obesity, prolonged standing, inappropriate foot overpronation (pes planus) and excessive running3,5. Diagnosis of plantar fasciitis is largely based on history and physical examination, with most patients reporting heel pain during their first steps each morning or upon ambulation following prolonged sitting. Physical examination often demonstrates tenderness to palpation at the medial plantar calcaneal region, where the plantar fascia originates on the calcaneus3, as well as pain with active range of motion of the foot, specifically with dorsiflexion and plantarflexion. Plain film foot imaging is not necessary for diagnosis; however, diagnostic ultrasound and MRI may be obtained to rule out other conditions such as new bone formation or bone pathology3,9. Initial management strategies of this condition include rest, activity modification, ice massage, oral analgesics, and stretching of the plantar fascia and calf1,3,5. If pain persists, secondary management strategies may include physical therapy modalities such as manual therapy and intrinsic foot muscle strengthening11, foot orthotics, night splinting, and corticosteroid injections3,5. It has been suggested that 90% of patients will improve with conservative therapy; however, patients with pain lasting longer than 6 months may consider extracorporeal shock wave therapy or surgical intervention via plantar fasciotomy as a last resort3,4.
Cupping therapy is an ancient therapeutic intervention, with many proposed mechanisms of action12. During a traditional cupping therapy treatment, a glass, plastic or bamboo cup is placed directly on the skin over a painful area or over an acupuncture point14 , and then a suction mechanism is applied to draw the skin into the cup. There are several major types of cupping therapy16 ; descriptions of each type are described in Table 116 .
Basic suction mechanism where the cup is placed directly on the skin and suction is created by either heat or an air-tight pumping mechanism16
(also known as wet cupping)16
A two-step process where a small incision is made in the skin before the suction mechanism is applied to a cup placed over the incision16
The practitioner gently moves the cup along the skin while the suction is applied to the area16
Cups are placed on the skin under suction and then immediately removed16
Acupuncture needle is inserted into the skin at a specific point and then a cup is placed over the inserted needle16
Medicinal (herbal) cupping16
Practitioner uses a bamboo cup and boils the cup with herbal substances for therapeutic benefit before applying the cup to the skin16
There is little evidence demonstrating the use of cupping therapy for the management of plantar fasciitis. This is a case report describing an instance in which symptomatic relief and improved activity tolerance were achieved following a non-traditional treatment plan including moving cupping.
A 44-year-old female presented to a hospital-based chiropractic clinic for evaluation of chronic bilateral plantar fasciitis, beginning 18 months prior with insidious onset. The pain was located at the plantar surface of the feet and calcanei bilaterally, with the right foot notably more painful than left. The pain was described as a constant burning and aching and, worse with the first few steps each morning. The condition was exacerbated by prolonged walking and standing, necessitated by the patient’s occupation as a nurse. Functional limitations included inability to efficiently ambulate to codes in the hospital due to foot pain. Significant past medical history included obstructive sleep apnea, umbilical hernia, mixed hyperlipidemia, low back pain, Vitamin D deficiency, hypothyroidism and obesity. At the time of evaluation, there were no imaging studies pertinent to the patient’s complaint available for review.
Previously trialed interventions included over-the-counter non-steroidal anti-inflammatory medications, compression stockings, Epsom salt bath soaks, as well as rolling her feet on a tennis ball and a frozen water bottle. She also reported a trial of topical camphor and menthol-based creams, none of which provided substantial or long-term symptom relief.
Her vital signs were grossly within normal limits (temperature: 98.1°F, pulse: 71 beats per minute, blood pressure: 121/81 mmHg, POX: 99%, height: 68 inches, weight: 288.6lbs, BMI 43.97). Physical examination and inspection demonstrated the skin of bilateral lower extremities to be warm, dry, and intact. There was no evidence of pes planus or pes cavus. There was tenderness to palpation along the longitudinal arches of both feet, with heel tenderness noted bilaterally but predominantly right-sided. There was decreased dorsiflexion at the talus bilaterally. Ankle stability testing was not demonstrative of ligamentous laxity. No bruising, edema or erythema was noted. Dorsal pedis and posterior tibial pulses were 2+ bilaterally. Myotomes were graded 5/5 for dorsiflexion (L4), plantarflexion (S1), and great toe extension (L5), bilaterally. Light touch sensation was grossly intact over bilateral lower extremities. Deep tendon reflexes were graded +2 at patellar (L4) and Achilles (S1) bilaterally.
Laboratory testing was significant for triglycerides (high, value: 175 mg/dL, reference range (rr): 0.0 -150.00), LDL (high, value: 113 mg/dL, rr: 0.0-100) , HDL (low, value: 38 mg/dL, rr: 40-110) , CO2 ( low, value: 21 mmol/L, rr: 23-32), Vitamin D (low, value: 19 ng/mL, rr: >/= 30); all other comprehensive metabolic panel (CMP), complete blood count (CBC), and urinalysis (UA) laboratory values were unremarkable.
Treatments, outcome, and subjective report at each clinic visit are listed in Table 2 below.
Subjective Report Prior to Treatment
Patient noted only temporary reduction of bilateral foot pain following visit 1
Patient reported significant relief of foot pain for three days and reported that she was able to reduce frequency and quantity of NSAID consumption following treatment due to reduction of pain and improved ability to ambulate
Patient noted mild plantar fascia pain after working three, 12-hour shifts; however, subjective pain score remained at 8/10, rather than 10/10; frequency of NSAID usage continued to decrease
She was able to walk for longer periods of time at work with less discomfort. She reported that she was able to run to a code in the hospital due significant improvement in her symptoms. Previously she was unable to run due to pain
Patient presented with increase in discomfort after not being seen for 6 weeks due to work schedule. She noted her usual presentation of bilateral heel pain, along with tightness along the tibialis anterior musculature bilaterally
exercise program (HEP) of gastrocnemius and hamstring stretching
Patient presented to clinic after 6 weeks of not being seen. She reported that she continued to do self-care as listed above. She admitted to not routinely doing home exercises. She stated that cupping therapy provided the more substantial relief than self-care measures. First steps in the morning were not nearly as painful
* In the treatment column, treatment listed as “1” was the first treatment performed at the visit, with the outcome of that treatment listed as “1” in the outcomes column. Each additional therapy provided follows numerical value as described in the same manner.
The patient continued to present to clinic on an as needed basis, noting subjective improvement in pain and activity tolerance following each cupping therapy treatment. The relief following treatment lasted as long as several weeks. Lower extremity functional score assessments were not obtained from the patient; however, her subjective report and improvement in function with ADLs were most notable.
This case described the used of cupping as part of a multimodal treatment plan to manage chronic plantar fasciitis. Cupping therapy represents a non-invasive option for management of a condition responsible for approximately 600,000 visits to primary care providers each year, affecting approximately 10% United States of the population5.
Cupping therapy has been used to treat a number of conditions including low back pain, headache and dermatologic conditions7, with the most significant evidence supporting its use for pain management8. It has been proposed that the vacuum created by cupping promotes circulation at the location of cup placement, and that this phenomenon results in symptom modification6. Another theory is that cupping therapy lifts connective tissue and loosens adhesions8, reducing peripheral nociception. Research regarding the use of cupping therapy for plantar fasciitis is limited; however, one group compared dry cupping therapy to electrical stimulation, noting no significant difference between treatments in management of plantar fasciitis pain6. In this case moving cupping was utilized, which consisted of placing PerformanceHealthTM “deep prep” emollient on the skin, applying the suction mechanism to the cup (“MMT Professional 17 Piece Cupping Set with Pump Gun”, 1.37” and 1.18” cup sizes were used) and then actively gliding the cup longitudinally along the plantar surface of the foot and along the medial, posterior and lateral aspects of the calcanei bilaterally. The speed of the glide was consistent throughout treatment. Differential diagnoses of heel pain are discussed in Table 35 and are important to consider when evaluating patients with pain involving the heel. Based on history and clinical presentation, the symptoms of the patient presented in this case best parallel a diagnosis of plantar fasciitis. Traditional management strategies of plantar fasciitis include rest, activity modification, ice massage, oral analgesics and stretching of the plantar fascia and gastrocnemius1,3,5, all of which were trialed by this patient without substantial relief. This patient’s positive response suggests a need for further exploration to evaluate the clinical effectiveness of cupping therapy in the management of plantar fasciitis. Research is needed to assess for both efficacy and safety of cupping therapy; however, the purpose of this report is to highlight a therapy which may provide relief for patients with plantar fasciitis. Future research may include more specific data related to duration of functional improvements and would include data from a lower extremity functional scoring outcome assessment to qualify therapeutic effectiveness. Future research comparing cupping therapy alone to other forms of manual therapy may provide more substantial evidence for the therapeutic benefit of cupping therapy.
This study is limited in that the outcome reported is based on the subjective report of one patient and not on a validated outcome measure. Therefore, the results of this case may not be generalizable to other patients with plantar fasciitis pain. The patient described in this case was not optimally complaint with her home exercise program and presented for treatment at infrequent intervals, sometimes as long as 6 weeks, which may have impacted her outcome. Additionally, the use of multiple treatment modalities throughout may serve as a confounder when attempting to assess the contribution of cupping therapy to the outcome.
Conflict of interest
The author denies competing interests.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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