Pathological mechanics and treatment of plantar fasciitis: future prospects of platelet-rich plasma therapy

doi:10.3969/j.issn.2095-4344.2014.42.023

Abstract

Abstract:

BACKGROUND: The treatments of plantar fasciitis as an important cause of calcaneodynia are different in medical institutions, as well as the therapeutic results.
OBJECTIVE: To summarize various treatments of plantar fascia, and based on the pathogenesis and pathological mechanics of plantar fasciitis, to investigate the effect of various treatment methods and indications.
METHODS: A computer-based online search of PubMed database and Wanfang database was performed for articled related to plantar fasciitis published between January 1993 and January 2014. The keywords were “plantar fasciitis, mechanism, treatment” in English and Chinese, respectively, by screening the titles and abstracts. Finally, 34 articles were included in result analysis.
RESULTS AND CONCLUSION: The treatment of plantar fasciitis needs to follow the principle from noninvasive to invasive treatment. Stretching the plantar fascia and heel cord, using prefab-ricated orthotics, and wearing night splints are crucial for the treatment of plantar fasciitis. Local hormone injection can be used as first-line therapy for patients with acute plantar fasciitis if they can tolerate the adverse reactions due to hormone therapy. Platelet-rich plasma therapy has a promising prospect, but there is lack of experimental evidences. Extracorporeal shock wave therapy can be a choice for recurrent chronic intractable plantar fasciitis. Surgical intervention remains the last line of therapy, for which, rigorous screening is important, but it is not always effective at reducing pain.

中国组织工程研究杂志出版内容重点：组织构建；骨细胞；软骨细胞；细胞培养；成纤维细胞；血管内皮细胞；骨质疏松；组织工程

全文链接：

Key words: fasciitis, traction, hormones

CLC Number:

R318

Pan Zhang-yi, Yin Feng. Pathological mechanics and treatment of plantar fasciitis: future prospects of platelet-rich plasma therapy[J]. Chinese Journal of Tissue Engineering Research, 2014, 18(42): 6844-6848.

Figures/Tables 1

2.1 跖筋膜炎的机制 1954年，Hicks[3]提出了里程碑式的“绞盘(起锚机)理论”(图1)，提示跖筋膜炎是引起跟骨结节内测疼痛的重要因素。理论阐述了跖筋膜作为足底静态支持结构的重要性，并且由此解释了跖筋膜炎的部分发病机制。他将足弓比作连接杆，跖骨头比作绞盘，远端趾骨比作手柄。当手柄上抬(趾骨背伸)时，因为绞盘的存在，带动连接杆向远端延伸(足弓伸长，高度降低)。此时，连接于跖骨头与跟骨结节内侧缘的跖筋膜张力增加，并且牵引跟骨结节向远端移动，由此将足弓长度缩短、高度恢复。作为足弓稳定结构之一，跖筋膜在跟骨结节处及跖骨头处受力最集中，这也解释了为何临床上跖筋膜炎好发于此两处位置，同时也揭示了跖筋膜炎的病理力学，阐述了跖筋膜炎运动损伤修复与局部炎症共同存在但彼此分开的理论，提出了“网球跟”的概念。但跖筋膜炎的病理力学依旧存在疑问(病程中跖筋膜的受力来源于弯曲、剪切或者压缩)，同样对于跖筋膜炎的病理机制也并未达成共识，相关的研究需要进一步落实。跖筋膜炎的诱发因素包括过度的训练、肥胖、扁平足、各种原因引起的足踝背伸功能受限以及不合脚的鞋具[4]。 2.2 跖筋膜炎的治疗跖筋膜炎治疗分为保守治疗及有创治疗。保守治疗跖筋膜炎治愈率可达85%-90%[5-6]。2010年美国足踝外科协会推荐的保守治疗方法包括体质量的控制、非类固醇药物、跖筋膜特殊拉伸训练以及矫形支具的佩戴。此外，近年来在临床广泛使用的包括体外震波治疗、肌内效布贴。足踝外科协会建议以上保守治疗至少持续6个月，基本能缓解大部分患者的症状[7]。 2.2.1 体质量控制对于正常足弓的个体，跖筋膜在站立情况下需要承受足弓负重的15%，这个数值在扁平足等足弓高度较低的个体更高[8-9]。行走时随着步态变化，足底跖屈肌腱及韧带共同参与足弓伸缩运动[10]。所以控制体质量是减小跖筋膜应力行之有效的方法。 2.2.2 非类固醇类药物非类固醇类药物临床上被广泛应用于跖筋膜炎的治疗。事实上，在部分高龄以及久坐的跖筋膜炎患者中，炎症并不是主要的病因。至今仍没有有效的大样本的证据表明非类固醇类药物对跖筋膜炎的疼痛缓解及足部功能恢复有显著作用，但是，如果患者无明显的用药禁忌证，非类固醇类药物仍可作为尝试性治疗[11]。 2.2.3 跖筋膜特殊牵引治疗 DiGiovanni等[12]比较了跖筋膜特殊牵引治疗与传统跟腱复合体拉伸治疗的效果(图2)，在8周的试验观察后得出结论，非负重状态下的跖筋膜特殊牵引治疗相比传统负重状态下的拉伸治疗，对于足底疼痛的缓解疗效更好。并且在2006年对慢性跖筋膜炎研究中报道称相较于传统的足底筋膜拉伸治疗[13]，跖筋膜特殊牵引治疗对减轻足底疼痛效果更好。非负重情况下跖筋膜拉伸有助于增加纤维组织的韧性，从而提高跖筋膜的痛阈。因为跖筋膜炎有其反复发作的特性，故跖筋膜特殊牵引治疗对于慢性反复发作的顽固性跖筋膜炎是首选治疗。同时，美国足踝外科协会也推荐跖筋膜特殊牵引治疗作为急性期跖筋膜炎的治疗手段之一，一般辅以非类固醇类药物。因跖筋膜炎的发病群体广泛且以中老年人居多，对于跖筋膜的康复锻炼花样繁多。诸多文献报道如离子渗透疗法、深部足底组织按摩，但样本量有限且多结合多种治疗方法，单一治疗效果缺乏强有力的证据。另外诸如制动、冰敷、热敷、离子导入治疗等均无明确询证医学证据支持。但根据临床经验，急性期必要的制动及冰敷可有效缓解软组织的肿胀，为其他保守治疗提供良好的平台。"

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