Featured Case

MODERN DIAGNOSIS: Plantar fasciitis

ABOUT THE DISEASE:

Plantar fasciitis is a common and often disabling condition. Because the natural history of plantar fasciitis is not understood, it is difficult to distinguish between those patients who recover spontaneously and those who respond to formal treatment. Surgical release of the plantar fascia is effective in the small proportion of patients who do not respond to conservative measures. New techniques such as endoscopic plantar release and extracorporeal shockwave therapy may have a role but the limited availability of equipment and skills means that most patients will continue to be treated by more traditional techniques. [1]

Symptoms: Plantar fasciitis, a chronic degenerative process that causes medial plantar heel pain. The heel pain is most intense during the first few steps of the day or after prolonged standing. [2]

Diagnosis and management: Physical examination findings are often limited to tenderness to palpation of the proximal plantar fascial insertion at the anteromedial calcaneus. Ultrasonography is a reasonable and inexpensive diagnostic tool for patients with pain that persists beyond three months despite treatment. Treatment should start with stretching of the plantar fascia, ice massage, and nonsteroidal anti-inflammatory drugs. Many standard treatments such as night splints and orthoses have not shown benefit over placebo. Recalcitrant plantar fasciitis can be treated with injections, extracorporeal shock wave therapy, or surgical procedures, although evidence is lacking. Endoscopic fasciotomy may be required in patients who continue to have pain that limits activity and function despite exhausting nonoperative treatment options.[3] In this case report, the patient was diagnosed on the basis of clinical presentation and examination. Routine blood tests were done to rule out other possible pathologies. X Ray right foot was done at baseline.

Image 1. X Ray right foot dated 6.3.21 added below.

Prognosis- Most reported treatment outcomes rely on anecdotal experience or combinations of multiple modalities. Nevertheless, nonsurgical management of plantar fasciitis is successful in approximately 90% of patients. Surgical treatment is considered in only a small subset of patients with persistent, severe symptoms refractory to nonsurgical intervention for at least 6 to 12 months. In this patient, the symptoms persisted for 3 months and she was not getting relief, inspite of doing physiotherapy.

Reference

1. Cutts S, Obi N, Pasapula C, Chan W. Plantar fasciitis. Ann R Coll Surg Engl. 2012 Nov;94(8):539-42.
2. Thompson JV, Saini SS, Reb CW, Daniel JN. Diagnosis and management of plantar fasciitis. J Am Osteopath Assoc. 2014 Dec;114(12):900-6.
3. Trojian T, Tucker AK. Plantar Fasciitis. Am Fam Physician. 2019 Jun 15;99(12):744-750. PMID: 31194492.

Image 1. X Ray right foot

AYURVEDA DIAGNOSIS: Vatakantaka

ABOUT THE DISEASE:

Vatakantaka [1] is also called as Padakantaka. There is also an opinion as to this disease being called Khuddaka vata or Parshni Ashrita vata. The medical term correlated with this condition is calcaneal spur or heel spur characterized by pain on standing or walking. The 40-year-old female patient was suffering from severe pain in the right foot for 3 months.

Causes: Structural deformities, excess stress on heels, walking on uneven grounds or irregularities, prolonged standing, hard footwear, and pressure over the heel are the general causes. Due to the nidana, the vata gets aggravated and localizes in the ankle, especially in the dependent parts like the heel.

Line of treatment: If the pain is very severe, raktamokshana is carried out. Snehana and svedana help in pacifying pain. Agnikarma is also a treatment choice by some ayurvedic physicians. In this case report, the patient was given oral medications and siravedha was done.

Treatment rationale: In Ayurveda, Siravedha is described as Ardha cikitsa or one of the supreme pain management modalities in Shalya Tantra. Rasna Saptaka Kwatha has a significant role in balancing vitiated Vata and initiate the anulomana. 

Reference

1. Sushruta, Sushruta Samhita with the Nibandhasangraha commentary of Sri Dalhanacharya and Nyayachandrika paanjika of Sri Gayadasacharya on Nidana Sthana edited by V aidya Y adavji Trikamji Achary; Choukhamba Surabharati Prakashan; Varanasi; Reprint – 20o8; Nidana sthana, 1/ 79

OUTCOME MEASURES

The 40-year-old female patient was suffering from pain in the right foot for 3 months associated with difficulty in walking. Pain aggravates during the initial footsteps after rest.
The patient underwent physiotherapy for 3 months. The symptoms persisted and hence approached Dr Dudhmal for Ayurvedic treatment.

Assessment of the treatment was done using VAS, stiffness, tenderness and swelling before, during and after treatment.

Table 1. The assessments recorded before, during and after treatment are listed below

After 1 month,  the symptoms improved with reduced pain. In further follow-ups, the patient could walk without pain in the initial steps after rest. Stiffness- Absent. Tenderness +. 

Swelling- Absent

Windlass test -Negative

VAS was recorded 8 before treatment, which reduced to 5 after 60 days, indicating a significant improvement.

Disease-modifying effect: The patient is in remission.