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Foot & Ankle Specialist
http://fas.sagepub.com/content/4/4/226
The online version of this article can be found at:
DOI: 10.1177/1938640011407320
2011 4: 226Foot Ankle Spec
Panagiotis Karagounis, Maria Tsironi, George Prionas, Georgios Tsiganos and Panagiotis Baltopoulos
Treatment of Plantar Fasciitis in Recreational Athletes : Two Different Therapeutic Protocols
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226
DOI: 10.1177/1938640011407320. From the Laboratory of Functional Anatomy and Sports Medicine (KP, PG, BP), the Department of Sports Medicine and Biology of
Physical Activity (TG), Department of Physical Education and Sports Science, University of Athens, Athens; and School of Nursing, University of Peloponnese, Sparta (TM),
Greece. Address correspondence to Karagounis Panagiotis, MD, MSc, Laboratory of Functional Anatomy and Sports Medicine, Department of Physical Education and Sports
Science, University of Athens, Greece; e-mail: drkaragounis@yahoo.gr.
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Copyright © 2011 The Author(s)
〈 Clinical Research 〉
Treatment of Plantar
Fasciitis in Recreational
Athletes
Two Different Therapeutic
Protocols
Panagiotis Karagounis, MD, MSc,
Maria Tsironi, MD, PhD,
George Prionas, MSc,
Georgios Tsiganos, PhD, and
Panagiotis Baltopoulos, MD, PhD
Treatment protocols in most studies
include the use of ice therapy and
nonsteroidal anti-inflammatory drugs
(NSAIDs).”
“
Abstract: Plantar fasciitis (PF) com-
monly causes inferior heel pain and
occurs in up to 10% of the US popu-
lation. Treatment protocols in most
studies include the use of ice therapy,
nonsteroidal anti-inflammatory drugs
(NSAIDs), and stretching and strength-
ening protocols. The aim of the current
study was to examine the effectiveness
of 2 different therapeutic approaches
on the treatment of PF in recreational
athletes using the Pain and Disability
Scale for the evaluation. A total of 38
participants with PF were randomly
allocated to 2 different groups of 19
male participants in each group. Group
1 was treated with ice, non-
steroidal anti-inflammatory medica-
tion, and a stretching and a strength-
ening program. Group 2 received the
same therapeutic procedures as group
1, reinforced by acupuncture treat-
ment. The primary outcomes, nomi-
nated a priori, were pain description
and mobility-function at 1 and 2
months. Outcomes were measured with
the pain scale for PF. The mean total
score of the acupuncture group at the
third measurement was statistically
minor compared with the mean total
score of the first group. Acupuncture
should be considered as a major ther-
apeutic instrument for the decrease of
heel pain, combined with traditional
medical approaches.
Keywords: age-related
problems; physical ther-
apy; plantar fasciitis;
ankle; pain manage-
ment; sports podiatry
Introduction
Plantar fasciitis (PF) commonly causes
inferior heel pain and occurs in up to
10% of the US population.1 Approximately
600 000 outpatients visit various medical
centers in the United States annually to
receive treatment for PF.2 Both active and
sedentary adults of all ages suffer from
this pathological condition.1 It is more
likely to occur in people who are obese,
spend most of the day on their feet, or
have limited ankle flexion.3 Current
investigation discloses that the pain is
caused by acute or chronic injury to the
origin of the plantar fascia from cumula-
tive and excessive stress.1-3
Diagnosis of PF is based on the
patient’s medical history and on
physical examination test results.4 Patients
typically present with persistent inferior
heel pain on weight bearing for months
or even years.5 Pain is labeled as throb-
bing, searing, or piercing, particularly in
the morning or after periods of inactivity.6
Although discomfort ameliorates after
ambulation, it worsens with continuous
activity, often causing serious disruptions
in daily activities.6 Patients commonly
have tenderness around the medial
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vol. 4 / no. 4 227
calcaneal tuberosity at the plantar apo-
neurosis (Figure 1).7 Numerous other
pathological conditions cause heel pain,
which can be distinguished from PF by
monitoring the medical history of the
patient together with his or her physi-
cal examination (Table 1).5 Diagnostic
imaging is not a preferred test evalua-
tion in diagnosing PF; however, it should
be considered if another diagnosis is
strongly suspected.8 According to several
studies, thicker heel aponeurosis, iden-
tified by ultrasonography, is associated
with PF.9,10 Radiography may display cal-
cifications in the soft tissues around the
heel or osteophytes on the anterior cal-
caneus (ie, heel spurs).11 Bibliographical
evidence suggests that 50% of patients
with PF and up to 19% of patients with-
out PF have heel spurs.11 The presence or
absence of heel spurs may not be asso-
ciated with PF. Bone scans may pres-
ent increased uptake at the calcaneus,
and magnetic resonance imaging may
show thickening of the plantar fascia,
but the accuracy of these tests remains
inconclusive.11
In general, PF is a self-limiting condi-
tion.12 Healing time varies from 6 to 18
months, delimiting patients and frus-
trating physicians.13 Treatment proto-
cols in most studies include the use
of ice therapy and nonsteroidal anti-
inflammatory drugs (NSAIDs).14 Other
research supports the use of night
splints to treat patients with pain last-
ing more than 6 months.15,16 Stretching
protocols often focus on the calf mus-
cles and Achilles tendon or on the plan-
tar fascia itself (Figures 2, 3, and 4).17,18
In addition, limited evidence supports
the use of corticosteroid injections and
steroid iontophoresis to manage PF.19
However, physicians should be cautious
when administering corticosteroid injec-
tions because it is associated with plan-
tar fascia rupture, which may bring about
long-term discomfort.20 Further research
focused on the effectiveness of extracor-
poreal shock wave therapy (ESWT) in the
management of heel pain, with inconclu-
sive results.21
Acupuncture has gained increasing
attention in relation to the treatment of
acute and chronic pain.22 Different mech-
anisms explain its effects. Piercing the
skin activates different pain modulating
systems to a nonquantified degree. Local
effects on healing by electrical effects of
skin injury,23 release of vasoactive sub-
stances,24 and trigger point effects25,26 as
well as distant factors such as activation
of a pain-suppressing system in the spi-
nal cord (diffuse noxious inhibitory con-
trols)27,28 have been described.
The aim of the current study is to exam-
ine the effectiveness of 2 different ther-
apeutic approaches on the treatment of
PF in recreational athletes, using the Pain
and Disability Scale (PFPS) of Willis et
al29 for the evaluation of the participants.
This research suggests that one of the
most commonly treated injuries in ath-
letes may be resolved more successfully
by combining traditional therapeutic pro-
cedures with acupuncture.
Table 1.
Differential Diagnoses in Plantar
Fasciitis
Abductor digiti quintri nerve
entrapment
Tarsal tunnel syndrome
Medial calcaneal branch of the
posterior tibial nerve entrapment
Calcaneal stress fracture
Calcaneal apophysitis (Sever
disease)
Paget disease
Tumor
Reiter syndrome
Fat pad atrophy
Bursitis
Sickle cell disease
S1 radiculopathy
Psoriatic arthritis
Bone bruise
Heel contusion
Figure 1.
Area of maximum tenderness in patients with PF.
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228
the study. After signing an informed con-
sent, participants were screened for PF.
Only those who reported pain and ten-
derness over the medial aspect of the
heel/foot were included in the study (38
participants).All participants were clin-
ically examined (with complementary
tests, such as radiography, ultrasonog-
raphy, and bone scan, where necessary,
to exclude other causes of heel pain) to
diagnose and categorize PF versus other
heel pain conditions, such as calcaneal
bursitis or calcaneal fractures (Table 1).
Participants were randomized using
computer-generated numbers into 2 treat-
ment groups. Both the participants and
the researcher who obtained the com-
pletion of the recordings were blinded
to the group status of the participants.
Participants were randomly allocated to
2 different (as far as the therapeutic treat-
ment is concerned) groups of 19 male
participants in each group. Group 1 was
treated with ice, nonsteroidal anti-
inflammatory medication (diclofenac
75 mg, twice per day for 15 days), a
stretching program focusing on calf mus-
cles, the Achilles tendon, and the plan-
tar fascia itself (Figures 2, 3, and 4), and a
strengthening program (consisting of towel
curls, toe taps, and picking up marbles
and coins with the toes) for minimizing
functional risk factors such as weakness
of the intrinsic foot muscles. The ice ther-
apy and the stretching and strengthening
protocols were conducted for the whole
period of treatment. Group 2 received the
same therapeutic procedures as group 1,
reinforced by acupuncture treatment (a
total of 16 sessions, 2 sessions per week).
All procedures described in the current
study were performed after approval had
been granted by the School of Health and
Social Care Ethics Committee with partic-
ipants being informed about the research
procedures and potential risks. All partic-
ipants provided written informed consent
prior to recruitment. The procedure was
conducted at the Laboratory of Functional
Anatomy and Sports Medicine, University
of Athens. Patients who had a clinical
diagnosis of PF and experienced symp-
toms for at least 2 weeks were invited to
participate. They were excluded if they
displayed a history of a major orthopedic
Figure 2.
Stretching exercise focused on gastrocnemius muscle.
Figure 3.
Stretching exercise focused on soleus muscle.
Materials and Methods
The current study examines 38 male
patients who visited the Laboratory of
Functional Anatomy and Sports Medicine
(University of Athens) from May 2008 to
February 2010, experiencing heel pain.
Initially, a total of 45 patients with foot
symptoms visited our laboratory. Of the
45 patients, 41 agreed to participate in
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vol. 4 / no. 4 229
or medical condition (eg, inflammatory
arthritis or diabetes) that may have influ-
enced their condition. In all, 41 patients
with heel pain were screened; 38 were
diagnosed with PF.
The primary outcomes, nominated a
priori, were pain description and mobil-
ity-function at 1 and 2 months
(3 repeated validations for each partic-
ipant, 1 before the treatment, 1 at the
completion of 4 weeks of treatment, and
1 at 8 weeks of treatment). Outcomes
were measured with the pain scale for PF
used by Willis et al.29 The PFPS includes
unique symptomatic questions in dif-
ferentiating PF and control questions as
well, which makes scores of 0 to 100
points. All patients completed the PFPS
before the beginning, at 4 weeks, and at
8 weeks after the initiation of the treat-
ment protocol.
In our laboratory, patients received 16
acupuncture sessions in 8 weeks (2 ses-
sions per week, with an interval time of
2 to 3 days in between sessions). The
acupuncturist (KP) is a well-trained and
experienced professional. Before the
opening session, acupoints were checked
to determine pain on pressure. Painful
points were chosen as well as others
(local and distal points) according to the
symptoms and the final diagnosis
(Figure 5). A combination of up to 12
points was used out of a list of around
20 (Table 2), which have been described
as being effective.30-32 This first combi-
nation of acupoints was used for 6 con-
secutive sessions. If no improvement
was reported, another clinical examina-
tion was performed to choose alternative
points for the next 10 sessions. Treatment
was initiated by disinfecting the area
with alcohol, and the sterile, 1-use nee-
dles (size 0.26 × 25 mm2, Ener-Qi, China)
were inserted perpendicularly through
plaster and skin into deeper tissue lay-
ers, using slight rotation and thrusting
movements to obtain the Deqi sensa-
tion, which was characterized by the par-
ticipants as a dull ache, numbness, or
heaviness. Needles were retained for 20
to 30 minutes, with periodical manual
stimulation.
After PFPS questionnaires were collected
from patients a 1-way analysis of vari-
ance (ANOVA) was used to determine dif-
ferences between baseline measurements
and the first and second measurements of
the 2 groups during treatment. All statisti-
cal tests were performed at an a level
of .05 using SPSS software.
Results
All participants were active amateur rec-
reational athletes, who practiced their
preferred sport 2 to 3 times/wk; 20 (53%)
of the participants were recreational run-
ners, 12 (32%) were recreational basket-
ball players, and 6 (15%) were tennis
players. The mean value of training hours
was 6 h/wk for both groups.
No statistically significant difference was
found between the 2 groups considering
the interval of time between initial man-
ifestation of heel pain and the beginning
of the therapeutic treatment (the average
length of time that the patients experi-
enced the PF symptoms before receiving
treatment was as follows: group 1, 15.8
days versus group 2, 16.3 days of pain.
Also, 3 participants (1 from group 1 and
2 from group 2) reported previous epi-
sodes of heel pain, which were resolved
only with rest. None of the participants
received previous treatments for the PF.
None of the participants presented pes
Figure 4.
Plantar fascia–specific stretch.
Table 2.
Acupoints Used for the Treatment
Trigger Points
Bladder 31, 54, 58, 60, 62
Stomach 36
Large intestine 4
Daling-PC 7
Spleen 5
Kidney 7,8
Triple Burner 5
Liver 2,3
Gallbladder 30, 34, 37, 38
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Foot
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planus (low arch of the feet), pes cavus
(high arch), or other anatomical malfor-
mations (overpronation, discrepancy in
leg length, excessive lateral tibial torsion,
and/or excessive femoral anteversion).
Nonsevere side effects were reported
during the treatment protocols. Three
participants (16%) of group 2 (with acu-
puncture treatment) complained of
headaches and dizziness. Additionally,
1 participant (5%) of the acupuncture
group reported loss of strength in the
legs and mild local edema around the
area of needling. No side effects
(ie, gastric pain) were reported from the
participants that resulted from the use of
diclofenac.
Baseline anthropometric character-
istics (age and BMI) of the 2 different
groups have been subjected to statisti-
cal analysis and revealed no significant
differences (Table 3). Regarding base-
line measurement scores of the PFPS
(before treatment), no statistically signifi-
cant differences were found between the
2 groups (Table 4).
The first group presented a statisti-
cally significant (P < .05) decrease of the
mean total score values (55.1 vs 62.6) of
PFPS on the second measurement (after
4 weeks of treatment) compared with the
first validation, with additional significant
decrease of the mean total score (46.2)
on the third measurement (after 8 weeks
of treatment).
The second group (including acupunc-
ture treatment) showed a statistically sig-
nificant (P < .05) decrease of the mean
total score values (54.2 vs 64.8) of PFPS
on the second measurement (after
4 weeks of treatment) compared with the
first validation, with an additional signif-
icant decrease of the mean total score
(34.3) on the third measurement (after
8 weeks of treatment).
No statistically significant difference
(P > .05) was reported between the mean
total score of the 2 groups at the second
measurement (group 1 mean total score
of 55.1 vs group 2 mean total score 54.2).
In contrast, the mean total score of the
acupuncture group at the third measure-
ment was statistically minor compared
with the mean total score of the first
group (group 1 mean total score of 46.2
vs group 2 mean total score of 34.3).
Discussion
Although plantar heel pain generally
affects older adults, some other groups
are also vulnerable. Furthermore, it is
common among the athletic population,
being estimated to contribute to 25%
of all foot injuries related to running.33
Evidently there are numerous interven-
tions used to treat plantar heel pain;
however, the Clinical Practice Guidelines
for plantar heel pain proposed by the
Orthopaedic Section of the American
Physical Therapy Association do not pin-
point to one treatment over another.34
A complementary treatment for plantar
heel pain involves dry needling and/or
injections (local anesthetics, steroids, bot-
ulinum toxin A, and/or saline) of myofas-
cial trigger points within the lower limb
and foot areas.35,36 However, the bibliog-
raphy consulted does not identify any
clinical trials that have investigated exten-
sively the effectiveness of dry needling
and/or injections of myofascial trigger
points.
Figure 5.
Acupoint large intestine 4 (L.I. 4).
Table 3.
Participant Anthropometric and Training Characteristics
Group 1 (n = 19) Group 2 (n = 19)
Mean age = 37.4 (±4.3) years Mean age = 36.8 (±3.9) years
BMI = 23.74 BMI = 23.21
Training (h/wk): 6.3 Training (h/wk): 6.5
Sports: 12 runners, 7 basketball players,
4 tennis players
Sports: 8 runners, 5 basketball players,
2 tennis players
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PF often produces heel pain in adults.4
The pain is mostly caused by collagen
degeneration at the origin of the plan-
tar fascia at the medial tubercle of the
calcaneus.4 This degeneration is simi-
lar to the chronic necrosis of tendonosis,
which features loss of collagen continu-
ity, increases in ground substance (matrix
of connective tissue) and vascularity,
and the presence of fibroblasts rather
than the inflammatory cells that usually
coexist with the acute inflammation of
tendonitis.37
The main cause of the degeneration is
repetitive microtears of the plantar fas-
cia that overcome the body’s ability to
repair itself.4 The plantar fascia is a thick-
ened fibrous aponeurosis that originates
from the medial tubercle of the calcaneus
and runs forward to form the longitudi-
nal foot arch. The principal function of
the plantar fascia is to provide static sup-
port of the longitudinal arch and dynamic
shock absorption.4 Overuse rather than
anatomy is the most common cause of
PF in athletes.4 A training history of an
increase in weight-bearing activities is
common, especially those involving run-
ning, which causes microtrauma to the
plantar fascia and exceeds the body’s
capacity to recover.4
Treatment protocols in most stud-
ies include the use of ice therapy and
NSAIDs.14,38 However, none has thor-
oughly examined the effectiveness of
these treatments alone and assessed the
effectiveness of taping or strapping for
managing PF.
An alternative treatment for the man-
agement of PF is the use of shoe inserts.39
The results of randomized controlled
trials showed that magnet-embedded
insoles were less effective than placebo
insoles in alleviating heel pain.39 Another
study40 that compared custom orthotics
and prefabricated shoe inserts combined
with a stretching activity showed that the
use of prefabricated insoles plus stretch-
ing was significantly more effective than
custom orthotics plus stretching activity.
Furthermore, the use of posterior-
tension night splints maintains ankle dor-
siflexion and toe extension, creating a
stable mild stretch of the plantar fas-
cia that allows it to heal at a functional
length.41 According to a review,41 limited
evidence supports the use of night splints
to treat patients with pain lasting more
than 6 months. Patients treated with
custom-made night splints exhibited con-
siderable improvement, but patients treated
with prefabricated night splints did not.
Physicians favor stretching protocols
focusing on the calf muscles and Achilles
tendon or on the plantar fascia itself.18
Evidence related to the comparison of
these 2 similar stretching protocols con-
cludes that patients who stretched the
plantar fascia showed a greater decrease
in maximum pain levels and a
similar pain decrease in morning
activities.18 Both protocols present an
overall decrease in pain.
There is little evidence supporting the
use of corticosteroid injections to treat
PF. Study41 results show that cortico-
steroid injections improved PF symp-
toms at 1 month after injection but not
at 6 months once compared with con-
trol groups. However, physicians should
be alert when administering this treat-
ment because corticosteroid injections
are strongly associated with plantar fas-
cia rupture, which may cause long-term
discomfort.42
Other reviews41,43 concentrate on the
effectiveness of ESWT in the manage-
ment of acute and chronic heel pain. The
overall estimate pinpoints that the quality
of the studies is poor and that no conclu-
sive evidence supports the effectiveness
of ESWT in reducing night pain, resting
pain, and pressure pain short term (ie,
within 6 and 12 weeks).
Concerning surgical treatment, 5 retro-
spective case series,44-48 which included
278 patients who experienced heel pain
for an average duration of 14 months
before surgery, showed that 75% to 95%
of patients had long-term improvement
as measured by various criteria. Up to
27% of patients still manifested significant
pain, up to 20% had some activity restric-
tion, and up to 12% had moderate pain
that impaired foot function. Recovery
time ranged from 4 to 8 months.
No evidence strongly supports the
effectiveness of any treatment for PF, and
most patients show improvement without
specific therapy or by using conservative
measures.12 If conservative measures fail,
physicians have to consider surgical treat-
ment. The American College of Foot and
Ankle Surgeons recommends49 surgery if
pain persists after 3 consecutive months
of treatment. The effectiveness of surgery
compared with conservative measures
remains unproved, but many patients
who have not benefited from conserva-
tive treatment report long-term improve-
ment following surgery.
The current study uses the PFPS29
for the evaluation of heel pain. It was
selected because it can be administered
in any setting and effectively illustrates
the difference between PF patients versus
patients with other pathologies causing
heel pain. The PFPS allows physicians a
more descriptive and exclusive analysis
of PF pain for the evaluation of therapeu-
tic treatment than the 100-point Visual
Analog Scale (VAS) scale.
In China acupuncture has been used
in the treatment of several diseases for
at least 5200 years.50 In Europe and the
Table 4.
Mean Total Score Values of PFPS Questionnaire in the 3 Measurements
Participants
First
Measurement
(Before
Treatment)
Second
Measurement
(4 Weeks of
Treatment)
Third
Measurement
(8 Weeks of
Treatment)
Group 1 62.6 (±11.2) 55.1(±10.7) 46.2(±10.3)
Group 2 64.8(±11.4) 54.2(±10.9) 34.3(±10.8)
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United States, acupuncture has increas-
ingly become a complementary com-
ponent of the health delivery system
and has steadily claimed its usefulness
assisting Western traditional medicine.50
The extensive application of acupunc-
ture includes the treatment of infections,
inflammatory diseases such as rheuma-
toid arthritis, neurological diseases like
migraine, pain, cardiovascular diseases,
pulmonary diseases like asthma, drug
and alcohol abuse, psychological dis-
orders, and numerous other illnesses.51
Improvement of local blood circulation,
distribution, and bloodletting could be
the main aspects to which acupuncture-
derived effects on inflammatory diseases
could be attributed.52 In acupuncture,
the insertion of a needle induces various
changes close to the needle in all the dif-
ferent tissues that are penetrated.50 These
peripheral events may improve tissue
function through vasodilation in the skin
as a result of axon reflexes, which cause
an immediate flare reaction.53 This vaso-
dilative effect is generated by the release
of calcitonin gene-related peptide on
stimulation of Ad or C fibers.54,55 As bibli-
ographical evidence50 suggests, the local
release of b-endorphin is responsible for
the short-term analgesic effect, whereas
the neuropeptide-induced release of anti-
inflammatory cytokines derives from lym-
phocytes and secondary activating cells,
such as macrophages. In addition, sub-
stance P is not likely to contribute to this
biological phenomenon but plays a regu-
lating role in calcitonin gene-related pep-
tide release from nerve endings.56,57
Four major contributing factors improve
the symptoms once acupuncture treat-
ment is followed: the impulsive resolution
of the condition; the placebo or psycho-
logical effect; a general, nonspecific phys-
iological reaction to needling irrespective
of site; and finally, a definite effect of
needling at an appropriate location.58
Two treatment approaches are com-
monly used in acupuncture: local and
distal acupoints.32 In our current study,
treatment acupuncture is considered as
a principle therapeutic tool for the man-
agement of PF. In our laboratory, we fre-
quently use acupuncture for the treatment
of various musculoskeletal diseases, such
as tennis elbow, ankle sprains, rotator
cuff injuries, and low back pain, with sat-
isfying short- and long-term results. The
acupuncture impact was statistically sig-
nificant after 8 weeks of treatment, with
no differences between the 2 groups of
participants in 4 weeks. The improvement
of the analysis of the conclusive impact of
acupuncture on PF should be considered
in future approaches with a focus on the
differences in time resolution of PF pain
using the acupuncture technique.
In 2009, Zhang et al32 assessed the spec-
ificity of the acupoint Daling (PC 7) for
heel pain using a nearby acupoint Hegu
(LI 4) as control. The dominant purpose
of this study was to determine the effi-
cacy and specificity of acupuncture treat-
ment for PF. Participants were randomly
assigned to the treatment group (n = 28)
or control group (n = 25). The treatment
group received needling at the acupoint
PC 7, which is considered to have a spe-
cific impact on heel pain. The control
group received needling at the acupoint
Hegu (LI 4), which has analgesic proper-
ties. Acupuncture treatment was adminis-
tered 5 times per week for 2 weeks, with
an identical method of manual dry nee-
dling applied to the 2 acupoints. The
primary outcome measure was morn-
ing pain on a 100-point VAS at 1 month
posttreatment. Secondary outcome mea-
sures included a VAS for activity pain,
overall pain rating, and pressure pain
threshold using algometry. Statistically
significant differences in the reduction of
pain scores, favoring the treatment group
of PC 7, were recorded at 1 month post-
treatment for morning pain (22.6 ± 4.0 vs
12.0 ± 3.0), overall pain (20.3 ± 3.7 vs 9.5
± 3.6), and pressure pain threshold (145.5
± 32.9 vs -15.5 ± 39.4). Similar to our
research conclusions, these results indi-
cate that acupuncture can provide pain
relief to patients with PF; according to
the authors, PC 7 is a relatively specific
acupoint for heel pain.
The statistical power of our study was
81% (estimates based on means and SD
of morning pain, overall pain, and pres-
sure pain threshold at 8 weeks of follow-
up). A limitation of the current study is
that it does not include a control group
because it is practically difficult to sus-
tain patients without any medication and/
or acupuncture treatment. Therefore, no
assessment of the efficacy of the intended
acupuncture treatment compared with
placebo can be found. In a future study,
a control group is suggested to include
follow-up measurements for the impact
of acupuncture treatment on the resolu-
tion of pain.
In conclusion, acupuncture should be
considered as a major and nonalternative
therapeutic instrument for the decrease
of heel pain as early as possible during
the first sessions, combined with the tra-
ditional medical approaches. We recom-
mend that acupuncture sessions should
last a minimum of 4 weeks, with a maxi-
mum of 20 sessions for each patient.
Acknowledgments
No sources of funding were used to assist in
the preparation of this article. The authors
gratefully acknowledge all the patients and
the medical personnel who voluntarily
participated in the study. We would also
like to thank Dr Kleoniki Karagouni for her
editing assistance.
References
1. Cole C, Seto C, Gazewood J. Plantar
fasciitis: evidence-based review of
diagnosis and therapy. Am Fam Physician.
2005;72:2237-2242.
2. Riddle DL, Schappert SM. Volume of ambu-
latory care visits and patterns of care for
patients diagnosed with plantar fasciitis:
a national study of medical doctors. Foot
Ankle Int. 2004;25:303-310.
3. Riddle DL, Pulisic M, Pidcoe P, Johnson RE.
Risk factors for plantar fasciitis: a matched
case-control study. J Bone Joint Surg Am.
2003;85:1338.
4. Young CC, Rutherford DS, Niedfeldt MW.
Treatment of plantar fasciitis. Am Fam
Physician. 2001;63:467-475.
5. Lui E. Systemic causes of heel pain. Clin
Podiatr Med Surg. 2010;27:431-441.
6. Aldridge T. Diagnosing heel pain in adults.
Am Fam Physician. 2004;70:332-338.
7. Werner RA, Gell N, Hartigan A,
Wiggerman N, Keyserling WM. Risk factors
for plantar fasciitis among assembly plant
workers. PM R. 2010;2:110-116.
8. McNally EG, Shetty S. Plantar fascia: imag-
ing diagnosis and guided treatment. Semin
Musculoskelet Radiol. 2010;14:334-343.
at University of Athens on September 14, 2011fas.sagepub.comDownloaded from
Foot
&
Ankle Specialist
vol. 4 / no. 4 233
9. Cardinal E, Chhem RK, Beauregard CG,
Aubin B, Pelletier M. Plantar fascii-
tis: sonographic evaluation. Radiology.
1996;201:257-259.
10. Kamel M, Kotob H. High frequency ultra-
sonographic findings in plantar fasciitis and
assessment of local steroid injection.
J Rheumatol. 2000;27:2139-2141.
11. DiMarcangelo MT, Yu TC. Diagnostic imag-
ing of heel pain and plantar fasciitis. Clin
Podiatr Med Surg. 1997;14:281-301.
12. Wolgin M, Cook C, Graham C, Mauldin D.
Conservative treatment of plantar heel
pain: long-term follow-up. Foot Ankle Int.
1994;15:97-102.
13. Toomey EP. Plantar heel pain. Foot Ankle
Clin. 2009;14:229-245.
14. Neufeld SK, Cerrato R. Plantar fasci-
itis: evaluation and treatment. J Am Acad
Orthop Surg. 2008;16:338-346.
15. Petrizzi MJ, Petrizzi MG, Roos RJ. Making
a tension night splint for plantar fasciitis.
Phys Sportsmed. 1998;26:113-114.
16. Powell M, Post WR, Keener J, Wearden S.
Effective treatment of chronic plantar fasci-
itis with dorsiflexion night splints: a cross-
over prospective randomized outcome
study. Foot Ankle Int. 1998;19:10-18.
17. Healey K, Chen K. Plantar fasciitis: current
diagnostic modalities and treatments. Clin
Podiatr Med Surg. 2010;27:369-380.
18. DiGiovanni BF, Nawoczenski DA, Lintal ME,
et al. Tissue-specific plantar fascia-stretching
exercise enhances outcomes in patients
with chronic heel pain: a prospective, ran-
domized study. J Bone Joint Surg Am.
2003;85:1270-1277.
19. Saxena A, Fullem B. Plantar fascia rup-
tures in athletes. Am J Sports Med.
2004;32:662-665.
20. Pribut SM. Current approaches to the
management of plantar heel pain syn-
drome, including the role of injectable
corticosteroids. J Am Podiatr Med Assoc.
2007;97:68-74.
21. Chow IH, Cheing GL. Comparison of dif-
ferent energy densities of extracorpo-
real shock wave therapy (ESWT) for the
management of chronic heel pain. Clin
Rehabil. 2007;21:131-141.
22. Patel M, Gutzwiller F, Paccaud F,
Marazzi A. A meta-analysis of acupunc-
ture for chronic pain. Int J Epidemiol.
1989;18:900-906.
23. Gunn CC. Transcutaneous neural stimula-
tion, acupuncture and the current of injury.
Am J Acupunct. 1978;3:191-195.
24. Ernst M, Lee MHM. Sympathetic vasomotor
changes induced by manual and electrical
acupuncture of the HOKU Point visualized
by thermography. Pain. 1985;21:25-33.
25. Ghia JN, Mao W, Toomey TC, Gregg JM.
Acupuncture and chronic pain mecha-
nisms. Pain. 1976;2:285-299.
26. Lewit K. The needle effect in the relief of
myofascial pain. Pain. 1979;6:83-90.
27. Bing Z, Villaneuva L, Le Bars D.
Acupuncture and diffuse noxious inhibitory
controls: naloxone-reversible depression of
activities of trigeminal convergent neurons.
Neuroscience. 1990;37:809-818.
28. Carlsson C. Acupuncture mechanisms for
clinically relevant longterm effects recon-
sideration and a hypothesis. Acupunct
Med. 2002;20:82-99.
29. Willis B, Lopez A, Perez A, Sheridan L,
Kalish S. Pain scale for plantar fasciitis.
Foot Ankle Online J. 2009;2:3. http://faoj
.files.wordpress.com/2009/05/pain_scale
_for_plantar_fasciiits.pdf. Accessed
April 11, 2011.
30. Cheng XN. Chinese Acupuncture and
Moxibustion. Beijing, China: Foreign
Languages Press; 1987.
31. Vangermeersch L, Pei-Lin S. Bi-syndromes
or Rheumatic Disorders Treated by
Traditional Chinese Medicine. Brussels,
Belgium: Satas; 1994.
32. Zhang SP, Yip TP, Li QS. Acupuncture
treatment for plantar fasciitis: a randomized
controlled trial with six months follow-
up. Evid Based Complement Alternat Med.
2009;10:1-10.
33. Clement DB, Taunton JE, Smart GW,
McNicol KL. A survey of overuse running
injuries. Phys Sportsmed. 1981;9:47-58.
34. McPoil TG, Martin RL, Cornwall MW,
Wukich DK, Irrgang JJ, Godges JJ.
Heel pain-plantar fasciitis: clinical prac-
tice guidelines linked to the international
classification of function, disability, and
health from the orthopaedic section of the
American Physical Therapy Association.
J Orthop Sports Phys Ther. 2008;38:1-18.
35. Crawford F. Plantar heel pain and fasciitis.
Clin Evid. 2005;13:1533-1545.
36. Landorf KB, Menz HB. Plantar heel
pain and fasciitis. Clin Evid (Online).
2008;pii:1111.
37. Khan KM, Cook JL, Taunton JE, Bonar F.
Overuse tendinosis, not tendinitis: a new
paradigm for a difficult clinical problem
(part 1). Phys Sportsmed. 2000;28:38-38.
38. Middleton JA, Kolodin EL. Plantar
fasciitis-heel pain in athletes. J Athl Train.
1992;27:70-75.
39. Winemiller MH, Billow RG, Laskowski ER,
Harmsen WS. Effect of magnetic vs
sham-magnetic insoles on plantar heel
pain: a randomized controlled trial. JAMA.
2003;290:1474-1478.
40. Pfeffer G, Bacchetti P, Deland J, et al.
Comparison of custom and prefabri-
cated orthoses in the initial treatment of
proximal plantar fasciitis. Foot Ankle Int.
1999;20:214-221.
41. Crawford F, Thomson C. Interventions
for treating plantar heel pain. Cochrane
Database Syst Rev. 2003;(3):CD000416.
42. Acevedo JI, Beskin JL. Complications of
plantar fascia rupture associated with
corticosteroid injection. Foot Ankle Int.
1998;19:91-97.
43. Boddeker R, Schafer H, Haake M.
Extracorporeal shockwave therapy
(ESWT) in the treatment of plantar fasci-
itis: a biometrical review. Clin Rheumatol.
2001;20:324-330.
44. Brown JN, Roberts S, Taylor M, Paterson
RS. Plantar fascia release through a trans-
verse plantar incision. Foot Ankle Int.
1999;20:364-367.
45. Davies MS, Weiss GA, Saxby TS. Plantar
fasciitis: how successful is surgical inter-
vention? Foot Ankle Int. 1999;20:803-807.
46. Fishco WD, Goecker RM, Schwartz RI. The
instep plantar fasciotomy for chronic plan-
tar fasciitis: a retrospective review. J Am
Podiatr Med Assoc. 2000;90:66-69.
47. Boyle RA, Slater GL. Endoscopic plantar
fascia release: a case series. Foot Ankle Int.
2003;24:176-179.
48. Vohra PK, Giorgini RJ, Sobel E, Japour CJ,
Villalba MA, Rostkowski T. Long-term
follow-up of heel spur surgery: a 10-year
retrospective study. J Am Podiatr Med
Assoc. 1999;89:81-88.
49. American College of Foot and Ankle
Surgeons. The diagnosis and treat-
ment of heel pain. J Foot Ankle Surg.
2001;40:329-340.
50. Zijlstra FJ, van den Berg-de Lange I,
Huygen FJ, Klein J. Anti-inflammatory
actions of acupuncture. Mediators
Inflamm. 2003;12:59-69.
51. Sato A, Li P, Campbell JL, eds.
Acupuncture: Is There a Physiological
Basis? Excerpta Medica International
Congress Series 1238. Amsterdam, the
Netherlands: Elsevier Science; 2002.
52. Kaptchuk TJ. The placebo effect in alter-
native medicine: can the performance of
a healing ritual have clinical significance?
Ann Intern Med. 2002;136:817-825.
53. Kaptchuk TJ. Acupuncture: theory,
efficacy, and practice. Ann Intern Med.
2002;136:374-383.
at University of Athens on September 14, 2011fas.sagepub.comDownloaded from
August 2011
Foot
&
Ankle Specialist
234
54. Brain SD, Williams TJ, Tippens JR, Morris HR,
MacIntyre I. Calcitonine gene-related
petide (CGRP) is a potent vasodilator.
Nature. 1985;313:54-56.
55. Brain SD, Newbold P, Kajekar R.
Modulation of the release and activity of
neuropeptides in the micro-circulation.
Can J Physiol Pharmacol. 1995;73:995-998.
56. Franco-Cereceda A, Rudehill A,
Lundberg JM. Calcitonin gene-related
peptide but not substance P mimics
capsaicin-induced coronary vasodi-
latation in the pig. Eur J Pharmacol.
1987;142:235-243.
57. Brain SD, Williams TJ. Substance P
regulates the vasodilator activity of
calcitonin gene-related peptide. Nature.
1988;335:73-75.
58. Langevin HM, Hammerschlag R, Lao L,
Napadow V, Schnyer RN, Sherman KJ.
Controversies in acupuncture research:
selection of controls and outcome mea-
sures in acupuncture clinical trials. J Altern
Complement Med. 2006;12:943-953.
at University of Athens on September 14, 2011fas.sagepub.comDownloaded from