Crucial Questions About Treating Plantar Fasciitis In Obese Patients

I had the opportunity to speak recently at the American Public Health Association meeting in New Orleans for the podiatry section. I would highly encourage everyone to consider joining this organization as I believe the natural symbiotic relationship between podiatry and public health is an important one. One of the two topics I spoke on was “Obesity and Plantar Fasciitis.” 

There is a definite association between obesity and plantar fasciitis that those who treat heel pain everyday know instinctively. Obesity is the greatest cause of morbidly and mortality worldwide.¹ Research has shown that weight loss reduces this morbidity and mortality.² Approximately 34 percent of the adult population in the United States is obese and 68 percent is overweight.³ The problem is getting worse and is also affecting our youth at historic rates.

Systematic literature reviews suggests that long-term weight loss through changes in eating and physical activity is possible.⁴ Unfortunately, weight loss from behavioral changes typically maximizes approximately six months into the weight loss attempt, followed by a gradual regain of weight in most individuals.⁵ Maintaining weight loss is critical to sustain health benefits so understanding how best to support patients in sustaining weight loss is vital to addressing the obesity epidemic and its consequences.^6,7

There are well-documented gait changes associated with obesity that include shorter steps, slower gait, increased step width, greater ankle joint dorsiflexion, less ankle joint plantarflexion, increased Q-angles, increased hip abduction angles, increased foot abduction angles, increased out-toeing and increased pronation during midstance.^8-11

In 2007, Frey and Zamora examined orthopedic-related foot and ankle pathologies and the influence of obesity in 1,411 patients.¹² They found there was a 1.4 times greater incidence of plantar fasciitis in obese patients, namely those having a body mass index (BMI) = 25. Additionally, Tanamas and colleagues in 2012 showed a statistically significant relationship between increased BMI and foot pain, and between increased fat-mass index and foot pain.¹³ In 2007, Irving and coworkers did a case-matched control study, showing that patients with chronic plantar heel pain were 2.9 times more likely to have a BMI = 30.¹⁴

This evidenced-based medicine supports the intuition that there is a direct correlation between obesity and plantar fasciitis. There are some questions that we must answer in the treatment of obese patients with plantar fasciitis.

1.  Should treatment be more aggressive to resolve the condition as quick as possible?

2.  If so, how does an aggressive, rapid result treatment plan correlate to established treatment protocols?

3.  What is the role of surgical intervention and when should you perform it?

4.  How can we promote exercising with a painful heel(s)?

5.  What is podiatry’s role in obesity counseling and treatment?

6.  What is the role of weight loss in plantar fasciitis treatment?

Prior to answering these questions, we must clarify the goal of treatment. I believe the goal of treatment in the patient is to initiate or continue an exercise regimen that will allow obese patients with plantar fasciitis to lose weight as efficiently as possible and maintain weight loss in the long term.

I do advise a more aggressive approach to treatment in this patient. I believe initial therapy should focus on symptom (oral and/or injected steroids) and etiology (external support via taping and stretching via bracing therapy, appropriate shoe gear) treatment simultaneously, and use the pain scale to monitor therapy. If pain reduction is resolving as expected, continue standard therapies that have been well documented in the literature. If the patient plateaus or regresses, add adjunctive therapies (physical therapy, shockwave, immobilization, platelet rich plasma injection, amniotic membrane injection, etc.) to the treatment plan to aid in pain reduction. Once pain resolution occurs, long-term therapy should start with continued stretching and custom orthoses.

If a patient does not respond to conservative therapy (which research has shown to be effective approximately 85 percent of the time) within an appropriate time period (usually six months), surgical intervention may become an option.¹⁵ Should an obese patient who is trying to lose weight with exercise but is not responding to conservative therapy have to wait six months for surgery? Can waiting be detrimental to a weight loss program? What can this failure mean to the patient’s psyche about his or her weight?

I certainly believe in appropriate conservative therapy but I think it becomes a more individualized patient-physician decision with lack of progress. A time period for one patient may not be adequate for another patient. Prior to any surgical intervention, I get a magnetic resonance image (MRI) to rule out Baxter’s nerve entrapment. If this is negative, I have gone to a gastrocnemius recession in lieu of a plantar fasciotomy. The plantar fascia is critical to arch stability and cutting it comes with consequences such as lateral column pain due to pronatory changes. This is particularly concerning in the obese patients and avoidance of cutting of the plantar fascia is of utmost importance. There is evidenced-based medicine to support gastrocnemius recession for plantar fasciitis.¹⁶

There are some even larger considerations that must accompany treatment of this patient, either conservatively or surgically. Consider several referrals including primary care physician, nutritionist/dietitian, bariatric surgery, personal trainer and physiatrist consultations. Any of these consultations require open, honest, compassionate conversation with the patient about obesity.

It is our job to aid the obese patients with plantar fasciitis in recovering as quickly as possible to aid in their weight loss, which will decrease their morbidity and mortality.

References

1. Haslam DW, James, WP. Obesity. Lancet. 2005; 366(9492):1197–209.

2. Poobalan AS, Aucott LS, Smith WC, et al. Long-term weight loss effects on all cause mortality in overweight/obese populations. Obesity Rev. 2007; 8(6):503-513.

3. Available at

https://www.hivehealthmedia.com/world-obesity-stats-2010/ .

4. Avenell A, Broom J, Brown TJ, et al. Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement. Health Technol Assess. 2004; 8(21):1-182.

5. Dombrowski SU, Avenell A, Sniehott FF. Behavioural interventions for obese adults with additional risk factors for morbidity: systematic review of effects on behaviour, weight and disease risk factors. Obesity Facts. 2010; 3(6):377-396.

6. Penn L, White M, Lindstrom J, et al. Importance of weight loss maintenance and risk prediction in the prevention of type 2 diabetes: analysis of European Diabetes Prevention Study RCT. PloS One. 2013; 8(2):e57143.

7. Dombrowski SU, Knitt K, Avenell A, et al. Long term maintenance of weight loss with non-surgical interventions in obese adults: systematic review and meta-analyses of randomised controlled trials. BMJ. 2014; epub ahead of print.

8. Petrella RJ, Bartha C. Home based exercise therapy for older patients with knee osteoarthritis: a randomized clinical trial. J Rheumatol. 2000; 27(9):2215-2221.

9. Sharma L, Lou C, Cahue S, Dunlop DD. The mechanism of the effect of obesity in knee osteoarthritis: the mediating role of malalignment. Arthritis Rheum. 2000; 43(3):568-575.

10. Toda Y, Segal N, Kato A, et al. Correlation between body composition and efficacy of lateral wedged insoles for medial compartment osteoarthritis of the knee. J Rheumatol. 2002; 29(3):541-545.

11. Toda Y. The effect of energy restriction, walking, and exercise on lower extremity lean body mass in obese women with osteoarthritis of the knee. J Orthop Sci. 2001; 6(2):148-54.

12. Frey C, Zamora J. The effects of obesity on orthopaedic foot and ankle pathology. Foot Ankle Int. 2007; 28(9):996-999.

13. Tanamas SK, Wluka AE, Berry P, et al. Relationship between obesity and foot pain and its association with fat mass, fat distribution, and muscle mass. Arthritis Care Res. 2012; 64(2):262-268.

14. Irving DB, Cook JL, Young MA, Menz HB. Obesity and pronated foot type may increase the risk of chronic plantar heel pain: a matched case-control study. BMC Musculoskel Disord. 2007; 8(1):41.

15. DiGiovanni BF, Moore AM, Zlotnicki JP, Pinney SJ. Preferred management of recalcitrant plantar fasciitis among orthopaedic foot and ankle surgeons. Foot Ankle Int. 2012; 33(6):507-512.

16. Maskill JD, Bohay DR, Anderson JG. Gastrocnemius recession to treat isolated foot pain. Foot Ankle Int. 2010; 31(1):19-23.