Homoeopathic management of Plantar Fasciitis and Calcaneal Spur

Homoeopathic management of Plantar Fasciitis and Plantar Calcaneal Spur:  Rubrics in various Homoeopathic Repertories

Dr Sowgandhika K N

Abstract:
Most common cause of plantar heel pain is Plantar Fasciitis in which most of the cases are usually associated with Plantar Calcaneal Spur. The treatment for plantar heel pain varies due to the diverse etiologies and unknown pathogenesis of the disease. Therefore therapeutic efficacy of treatments varies, and there is a high relapse rate. Since previous studies have demonstrated that Homoeopathy provides long term solutions and treats the root cause of the disease through law of similar, thus through this article an attempt is made to enumerate the rubrics in different homoeopathic repertories for homoeopathic management of Plantar Fasciitis and Plantar Calcaneal Spur.

Key words: Plantar Calcaneal Spur(PCS), Plantar Fasciitis(PF), Homeopathy, Repertory, Rubrics

Introduction
Plantar heel pain (PHP) is a common musculoskeletal disorder, affecting up to 10% of the population, and is responsible for 15% of all clinical foot symptoms¹. Recent studies have reported the presence of Calcaneal Spur in most of the cases of Plantar Fasciitis and thus frequently coexist². Severe cases can develop chronic plantar heel pain³. Plantar Fasciitis is associated with significant gait related disability⁴. Previous retrospective studies have demonstrated the therapeutic utility of homoeopathy in the treatment of heel pain with or without Calcaneal Spur⁵ thus homoeopathy can play a major role in reducing the burden of this disease in society.

Plantar Calcaneal Spur is a bony outgrowth at the inferior part of the calcaneus, arising from medial or lateral process of calcaneal tuberosity, located on the posterior plantar surface of the calcaneus⁶. Plantar Fasciitis is a chronic degenerative condition causing marked thickening and fibrosis of plantar fascia and collagen necrosis, chondroid metaplasia and calcification⁷ recent studies have reported the presence of Calcaneal Spur in most of the cases of Plantar Fasciitis and thus frequently coexist².”

The Plantar Calcaneal Spurs are not a common cause of the plantar heel pain. Spurs are present in 50% of patients with plantar fasciitis. Over 15% of the general population has a radiologically asymptomatic spur. Repeated corticosteroid injection, for treatment of the Plantar Fasciitis, can lead to heel fat pad atrophy and rupture of the plantar fascia, due to attenuation of the fascia. Physicians should treat the underlying cause of the plantar fasciitis, such as flat feet and ankle instability; otherwise, symptoms will recur shortly after the injection under ultrasound guidance⁸

The burden of conventional symptomatic treatment, surgical intervention and other costly treatment options are difficult to bear by the low socioeconomic group of patients. As observed in previous studies, Homeopathy can play a vital role in alleviating the burden of Plantar Calcaneal Spur associated with Plantar Fasciitis⁵. Homeopathy has a holistic approach in the treatment of diseases that is through individualisation. Repertory is an important tool in selecting the similimum, and is an index of symptoms which are represented in the form of rubrics⁹. Thus in this article rubrics related to Plantar fasciitis and Plantar Calcaneal Spur are represented which can help in the treatment of respective conditions.

^Epidemiology
Plantar heel pain is a common condition that affects ∼10% of the general population and is associated with activity limitation and depression¹⁰.

Plantar fasciitis is most common between 40 and 60 years of age and contributes to 15% of foot injuries in general population without gender difference. The conditions may affect both athletic and non-athletic populations, but the incidence is higher among runners¹¹.

^Anatomy
The plantar fascia is a thick fibrous connective tissue composed of mostly collagen supporting the plantar arch of the foot. It originates on the medial calcaneal tuberosity in the hind foot and inserts onto the bases of the proximal phalanges^12.

 Risk & etiological factors¹²

• Abnormal posture and gait
• Anatomical deformities such as pes planus or flat foot.
• Obesity
• Excessive pronation of the subtalar joint
• Diabetes mellitus
• Weak musculature
• Plantar fat pad atropy

Pathophysiology
The pathophysiology of plantar fasciitis can be either inflammatory due to vasodilation and immune system activation or non-inflammatory involving fibroblastic hypertrophy¹². In latest studies authors found that patients with plantar fasciitis were more likely to have increased plantar fascia thickness, hypoechogenicity, and subcalcaneal spurs primarily identified on ultrasound and X-ray¹³.

 Symptoms¹⁴

• Patients usually complain of pain at the anteromedial prominence of the calcaneum.
• The pain is exacerbated by passive dorsiflexion of the toes.
• The pain is worse when first standing after rest, typically early in the morning.
• Once the patient starts walking, the pain tends to recede.
• The pain eases but never fully resolves throughout the course of the day and is exacerbated by activities such as prolonged walking or exercise, particularly on hard surfaces.

 Examination & evaluation⁸

Laboratory
The laboratory tests include acute phase reactants, Rheumatoid factor, Anti-Cyclic Citrullinated Peptide Antibodies, HLA-B27 For systemic causes of the plantar heel pain.

Plain Radiographs and Computed Tomography

Clinicians can order them to diagnose stress fractures and plantar calcaneal spurs.

Musculoskeletal Ultrasound
In patients with plantar fasciitis, the investigators may find thickening of the plantar fascia (greater than 4 mm) on the medial tuberosity of the calcaneus. An increase in vascularity under power Doppler ultrasound is not a common finding in plantar fasciitis.

Prevention^8,15 

• Weight reduction
• Shoe modification
• Foot flexion and extension using hands
• Exercises on the foot flexion and extension under the controlled load
• Exercises with a massage ball
• Lifting and lowering to the tiptoes when sitting and standing.

Related rubrics in various repertories
Some of the rubrics related to Plantar fasciitis and Plantar Calcaneal Spur from “Boenninghausen’s Therapeutic Pocket Book” (BTPB)¹⁶.

SECTION	CHAPTER	RUBRIC	SUB RUBRIC	PAGE NO
parts of the body and organs	lower extremities	Heels	–	138
parts of the body and organs	lower extremities	back of foot	–	138
parts of the body and organs	lower extremities	soles	–	138
parts of the body and organs	lower extremities	Tendo achilles	–	138
sensations and complaints	bones	painfulness in general	of periosteum	202
sensations and complaints	bones	swelling	of periosteum	203
sensation and complaints	bones	inflammation	of periosteum	201
Aggravation and amelioration	amelioration	motion in general	continued	316
Aggravation and amelioration	Aggravation	motion at the beginning of	after	292
Aggravation and amelioration	Aggravation	walking	walking, beginning of	307

B) Some of the rubrics from Kent’s “Repertory of the Homoeopathic Materia Medica” with respect to Plantar Fasciitis and Plantar Calcaneal Spur¹⁷.

CHAPTER	RUBRIC	SUB RUBRIC	PAGE NO
Extremities	PAIN, foot	morning, rising on	1079
Extremities	PAIN, foot	walking while	1079
Extremities	PAIN, foot	sole	1080
Extremities	PAIN, foot	sole, walking while	1080
Extremities	PAIN, foot	heel, walking	1080
Extremities	PAIN, foot	heel, morning	1080
Extremities	PAIN, foot	heel, bone	1081
Extremities	PAIN, foot	sole, stepping when	1080
Extremities	PAIN, foot	heel, splinter as if	1081

C) Some of the rubrics from “Boger Boenninghausen’s Characteristics & Repertory” (BBCR) with respect to plantar fasciitis and plantar calcaneal spur¹⁸.

CHAPTER	RUBRIC	SUB RUBRIC	PAGE NO
lower extremities	heels	–	547
lower extremities	soles	–	548
lower extremities	bones	–	549
lower extremities	boring	foot, heels	551
lower extremities	bruised pain	foot, heels	551
lower extremities	cutting	foot, heels	553
lower extremities	darting	foot, heels	554
lower extremities	pain, simple	feet, heels	559
lower extremities	sensitiveness	feet, heels	561

D) Some of the rubrics from William Boericke’s “Pocket Manual of Homoeopathic Materia Medica & Repertory”¹⁹

CHAPTER	RUBRIC	SUB RUBRIC
Locomotor system	heels	Os calcis , pain
Locomotor system	heels	burning
Locomotor system	heels	pains, aching, bruised
Locomotor system	heels	pains, soreness
Locomotor system	heels	pains, tendo Achilles, pain
Locomotor system	heels	pains, ulcerative

E) Some of the rubrics from “A Concise Repertory of Homoeopathic Medicines by DR. S R. Phatak”²⁰

CHAPTER	RUBRIC	SUB RUBRIC
Heels	bone would push through as if	–
Heels	Os calcis painful	–
Heels	painful	–
Heels	painful	standing long after
Heels	painful	walking, amel
Heels	stand	can not on
Heels	tearing	–
Heels	piercing	–

F) Some of the rubrics from “Synthesis 1.3 Android app” created by Archibel SA based on Synthesis Repertory version 2009, Editor: Dr Frederick Schroyens²¹.

CHAPTER	RUBRIC	SUB RUBRIC
Extremities	feet, complaints of	heels
Extremities	pain,	feet, Os calcis, motion continued, amel
Extremities	pain	feet, heel, stitching pain
Extremities	pain	feet, heel, excoriated as if
Extremities	pain	feet, heel, putting it down when
Extremities	pain	feet, heel, stepping agg
Extremities	pain	feet, heels, walking, agg
Extremities	pain	feet, heels, extending to, foot
Extremities	pain	feet, heels, shooting pain
Extremities	pain	feet, heels, pressure, amel
Extremities	pain	feet, heels, pressure, slightest, agg

Discussion
A retrospective study was conducted at Dr Anjali Chatterjee Regional Research Institute (H), Kolkata, West Bengal,  to evaluate the extent of Calcaneal Spur in heel pain and to study the correlation of Calcaneal Spur with some socio-demographic and health related factors. It was found that out of 92 patients who undergone X-ray for heel pain, 76 (82.6%) had calcaneal spur. Extent of Calcaneal spur was highest in females, older age, overweight and profession of housemaid or manual labor. Homoeopathic treatment showed positive response in nearly 75% of cases and the most useful medicines were Calcarea flourica, Rhus toxicodendron, Ledum palustre and Aranea diadema.⁵

 In a double blind randomised placebo controlled trial conducted at Mahesh Bhattacharyya Homoeopathic Medical College and Hospital, Howrah, patients with Plantar Fasciitis were randomized to receive either Individualised Homeopathic Medicines or identical-looking placebo in the mutual context of conservative non-medicinal management. The Foot Function Index (FFI) questionnaire, as an outcome measure, was administered at baseline, and every month, up to 3 months. Significant results were also observed on three FFI sub-scales (pain%, disability%, and activity limitation %). Natrum muriaticum, Rhus toxicodendron and Ruta graveolens were the most frequently prescribed medicines.⁷”

An unrandomized, prospective, open, controlled, comparative, observational study was carried out at two centres, the Centre Hospitalier, Troyes, and Institut Godinot, Reims, France. This preliminary observational study suggests that joint pain linked to the treatment of hormone-receptor positive breast cancer with aromatase inhibitor can be prevented or improved by concomitant homeopathic treatment combining Ruta graveolens 5CH and Rhus toxicodendron 9CH ²² . Though following drugs are found to be useful in the treatment of PHP associated with PF and PCS, efficacy of these drugs and other drugs indicated under the related rubrics in different homoeopathic repertories has to be explored.

Conclusion
Thus homeopathic management with reportorial approach has a wider scope in the treatment of heel pain associated with Plantar Fasciitis and Plantar Calcaneal Spur, which can be widely made use of to treat the sufferings of the patient based on his or her individuality of symptoms.

 References

1. Burton I, Cooper K, Alexander L, Swinton PA. Effectiveness of combined shockwave therapy and plantar fascia stretching interventions in treating plantar heel pain: a systematic review and meta-analysis protocol. JBI Evidence Synthesis. 2021 May 1;19(5):1186-92.https://journals.lww.com/jbisrir/Fulltext/2021/05000/Effectiveness_of_combined_shockwave_therapy_and.13.aspx [Accessed on 15th July 2023]
2. Kuyucu E, Koçyiğit F, Erdil M. The association of calcaneal spur length and clinical and functional parameters in plantar fasciitis. International Journal of Surgery. 2015 Sep 1;21:28-31. https://www.sciencedirect.com/science/article/pii/S1743919115003611 . [Accessed on 15th July 2023]
3. Tahririan MA, Motififard M, Tahmasebi MN, Siavashi B. Plantar fasciitis. Journal of research in medical sciences: the official journal of Isfahan University of Medical Sciences. 2012 Aug;17(8):799.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3687890/ [Accessed on 15^th July 2023]
4. Palomo-López P, Becerro-de-Bengoa-Vallejo R, Losa-Iglesias ME, Rodriguez-Sanz D, Calvo-Lobo C, López-López D. Impact of plantar fasciitis on the quality of life of male and female patients according to the Foot Health Status Questionnaire. Journal of pain research. 2018;11:875. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5931202/ [Accessed on 15^th July 2023]
5. Parveen S. A retrospective study of homoeopathic treatment in patients with heel pain with or without Calcaneal Spur. Indian Journal of Research in Homoeopathy; 2017. https://www.ijrh.org/article.asp?issn=0974-7168;year=2017;volume=11;issue=1;spage=64;epage=73;aulast=Parveen    [Accessed on 15th July 2023]
6. Kirkpatrick J, Yassaie O, Mirjalili SA. The plantar calcaneal spur: a review of anatomy, histology, etiology and key associations. Journal of anatomy. 2017 Jun;230(6):743-51. https://doi.org/10.1111/joa.12607 [Accessed on 15th July 2023]
7. Shahid S, Ghosh S, Chakraborty AS, Maiti S, Sadhukhan S, Koley M, Saha S. Efficacy of individualized homeopathic medicines in plantar fasciitis: double-blind, randomized, placebo-controlled clinical trial. Homeopathy. 2022 Feb;111(01):022-30https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0041-1731383. [Accessed on 15^th July 2023]
8. Allam AE, Chang KV. Plantar Heel Pain. InStatPearls [Internet] 2021 Nov 21. StatPearls Publishing https://www.ncbi.nlm.nih.gov/books/NBK499868/  [Accessed on 15^th July 2023]
9. Tiwari SK. Essentials of repertorization: A comprehensive textbook on case taking & repertorization: 4th edition. 4th ed. New Delhi, India: B Jain; 2023.
10. Menz HB, Thomas MJ, Marshall M, Rathod-Mistry T, Hall A, Chesterton LS, Peat GM, Roddy E. Coexistence of plantar calcaneal spurs and plantar fascial thickening in individuals with plantar heel pain. Rheumatology. 2019 Feb 1;58(2):237-45. https://academic.oup.com/rheumatology/article/58/2/237/5094550 [Accessed on 15^th July 2023]
11. Rhim HC, Kwon J, Park J, Borg-Stein J, Tenforde AS. A Systematic Review of Systematic Reviews on the Epidemiology, Evaluation, and Treatment of Plantar Fasciitis. Life. 2021 Dec;11(12):1287. https://www.mdpi.com/2075-1729/11/12/1287 [Accessed on 15^th July 2023]
12. Rabadi D, Seo S, Wong B, Chung D, Rai V, Agrawal DK. Immunopathogenesis, early detection, current therapies and prevention of plantar fasciitis: A concise review. International Immunopharmacology. 2022 Sep 1;110:109023. https://www.sciencedirect.com/science/article/abs/pii/S1567576922005070 [Accessed on 15^th July 2023]
13. Aradhya S, Tiwari V, Bakde AM, Dwidmuthe S, Roy M, MATH SA. Ultrasonographic Assessment of Indian Patients With Plantar Fasciitis and Its Clinical Correlation: A Prospective Observational Study. Cureus. 2023 Mar 4;15(3). https://assets.cureus.com/uploads/original_article/pdf/59627/20230404-703-10ylcfi.pdf [Accessed on 15^th July 2023]
14. Cutts S, Obi N, Pasapula C, Chan W. Plantar fasciitis. The Annals of The Royal College of Surgeons of England. 2012 Nov;94(8):539-42. https://publishing.rcseng.ac.uk/doi/full/10.1308/003588412X13171221592456 [Accessed on 15^th July 2023]
15. Bakayev VV, Bolotin АЕ. Plantar fasciitis prevention technique based on data aggregation from computer diagnostics. InicSPORTS 2018, Proceedings of the 6-th International Congress on sport sciences research and technology support.(20-21 September, 2018, Seville, Spain) 2018 (pp. 106-110). https://www.researchgate.net/profile/Vladislav-Bakayev/publication/327910138_Plantar_Fasciitis_Prevention_Technique_based_on_Data_Aggregation_from_Computer_Diagnostics/links/5bae9076a6fdccd3cb7b9ab5/Plantar-Fasciitis-Prevention-Technique-based-on-Data-Aggregation-from-Computer-Diagnostics.pdf [Accessed on 15^th July 2023]
16. Allen TF. Boenninghausen’s Therapeutic Pocket Book. B Jain Publishers; 2003.
17. Kent JT. Repertory of the Homoeopathic Materia Medica. Enriched Indian ed. New Delhi. B Jain Publishers; 2017.
18. Boger CM. Boger Boenninghausen’s Characteristics Repertory with corrected Abbreviations and word index. USA. B. Jain publication; 2015.
19. Boericke W. Pocket manual of Homoeopathic Materia Medica and Repertory. 9/e. New Delhi. Jain Publishers; 2012.
20. Phatak SR. Concise Repertory of Homoeopathic Medicines. B Jain Publishers;2004
21. Archibel SA. Synthesis 1.3 Android app based on Synthesis Repertory  Dr Frederick Schroyens; 2009.
22. Karp JC, Sanchez C, Guilbert P, Mina W, Demonceaux A, Curé H. Treatment with Ruta graveolens 5CH and Rhus toxicodendron 9CH may reduce joint pain and stiffness linked to aromatase inhibitors in women with early breast cancer: results of a pilot observational study. Homeopathy. 2016 Nov;105(04):299-308. https://thieme-connect.com/products/ejournals/abstract/10.1016/j.homp.2016.05.004[Accessed on 15^th July 2023]

Dr Sowgandhika K N
PG Scholar
MD Part 1- Repertory
Under the guidance of
Dr Munir Ahmed R
Professor, Department of Repertory
Government Homoeopathic Medical College and Hospital, Bengaluru