By Mark Callanen PT DPT OCS 10-15 of all foot or ankle pain complaints are due to plantar fasciitis PF 1 Etiology for PF varies however it is a condition that is normally associated with a biomechanical dysfunction that places excessive stress on the soft tissues of the plantar surface of the foot Mechanical overload can be exacerbated by factors such as over pronation obesity over training restricted dorsiflexion ROM and atrophy of intrinsic muscles at the foot 2 PF normally presents with pain located over the plantar surface of the foot specifically at the medial aspect of distal calcaneus where the plantar aponeurosis attaches It is usually reproducible with palpation Subjective pain can be described as burning throbbing and or piercing especially with weight bearing during the initial morning steps Pain can persist from months to years 2 Objective findings include positive Windless Test negative Tarsal Tunnel Test abnormal Foot Posture Index Score and high Body Mass Index 2 Image testing to confirm PF diagnosis can include ultrasound and MRI 3 4 PF normally presents with fascial tissue that has a thickness of 4 mm on ultrasound and is hypoechonic with MRI testing 3 4 A variety of functional tests can be used to quantify functional deficits including the Foot and Ankle Ability Measure FAAM Foot Health Status Questionnaire FHSQ or the Foot Function Index FFI to name a few 2 While acute cases may involve inflammation recent studies emphasize that it is more of a degenerative process 4-6 This should guide treatment decisions to focus on normalizing the stresses being placed on the foot as well as addressing the degenerative nature of the tissue involved at the heel Using modalities that solely focus on decreasing inflammation are not ideal in treating PF 2 The JOSPT practice guideline on Heel Pain Plantar Fasciitis Revision 2014 recommends the following physical agents to help reduce pain and improve function Recommended LLLT Low Level Laser Therapy now referred to as photobiomodulation PBM Phonophoresis Iontophoresis Not recommended General electrical stimulation Dry Needling Ultrasound Also recommended for a PF plan of care manual therapy stretching taping foot orthoses night splints rocker bottom shoes strengthening and neuro reeducation of foot musculature 2 While it is not difficult to understand many of the recommendations made to reduce physical stresses on the foot nor the anti-inflammatory use of phonophoresis and iontophoresis to address acute inflammation the recommendation of PBM laser therapy might not be as clear to all readers PBM has the ability to not only address inflammation and pain but also can help promote tissue healing due to the following factors Increased cell proliferation Increased microcirculation Vascular neoformation Increased collagen production via increased fibroblastic activity 9 With regard to pain and inflammation PBM has the ability to inhibit and or attenuate the expression of several inflammatory mediators and pain markers 7 It is important to understand the differences between helping the body reduce swelling naturally via PBM vs blocking the inflammatory cascades with medication when it comes to muscle repair in the foot While NSAIDs decrease swelling they have been shown to negatively impact tissue repair by diminishing proliferation differentiation and fusion of satellite cells in muscle tissue 8 This can promote intrinsic muscle atrophy via impaired skeletal muscle repair growth and increased fibrosis all of which are components of chronic PF For those clinicians advising the use of NSAIDS for PF these factors should not be overlooked The most current research has further supported the use of laser on PF A 2019 meta-analysis and systematic review on the Parameters and Effects of Photobiomodulation in Plantar Fasciitis concluded that photobiomodulation PBM is effective in treating pain and improving foot function in patients with chronic PF 9 A second meta-analysis paper regarding laser and PF was published in Medicine in December 2018 and had similar findings The researchers concluded that LLLT relieves heel pain with lasting effects for 3 months after treatment 10 Given that PBM can help with pain and inflammation during the initial healing process but can also help promote stronger healthier scar tissue it is a modality that is well positioned to help both acute and chronic PF cases It is not surprising that therapy lasers are being increasingly used in rehabilitation clinics and athletic treatment spaces to complement PF plans of care References Rompe JD Furia J Weil L Maffulli N Shock wave therapy for chronic plantar fasciopathy Br Med Bull 81 183 208 2007 MARTIN RL et al Heel Pain Plantar Fasciitis Revision 2014 Clinical Practice Guidelines Linked to the International Classification of Functioning Disability and Health from the Orthopaedic Section of the American Physical Therapy Association J Orthop Sports Phys Ther 2014 44 11 A1-A23 Akfirat M Sen C Günes T 2003 Ultrasonographic appearance of the plantar fasciitis Clin Imaging 27 353 35 Berkowitz JF Kier R Rudicel S 1991 Plantar fasciitis MR imaging Radiology 179 665 66 Schwartz EN Su J Plantar fasciitis a concise review Perm J 18 105 2014 Tu P Bytomski JR Diagnosis of heel pain Am Fam Physician 84 909 916 2011 Thomas JL Christensen JC Kravitz SR Mendicino RW Schuberth JM Vanore JV Weil LS Sr Zlotoff HJ Bouche R Baker J American College of Foot and Ankle Surgeons Heel Pain Committee The diagnosis and treatment of heel pain a clinical practice guidelines revision 2010 J Foot Ankle Surg 49 1 19 2010 Macias DM Coughlin MJ Zang K et al Low-level laser therapy at 635 nm for treatment of chronic plantar fasciitis a placebo-controlled randomized study J Foot Ankle Surg 2015 54 768 772 Duchesne E Dufresne S Dumont N Impact of Inflammation and Anti-inflammatory Modalities on Skeletal Muscle Healing From Fundamental Research to the Clinic Physical Therapy serial online August 2017 97 8 807-817 Dos Santos et al Parameters and Effects of Photobiomodulation in Plantar Fasciitis A Meta-Analysis and Systematic Review Photobiomodulation Photomedicine and Laser Surgery Volume XX Number XX 2019 Mary Ann Liebert Inc Pp 1 9 Wang et al Clinical efficacy of low-level laser therapy in plantar fasciitis A systematic review and meta-analysis Medicine 2019 98 3