Hindered by Heel Pain: Traditional Chinese Medicine Unlocks the Door to Foot Freedom

Plantar fasciitis? Jogger’s heel? Tennis heel? Policeman’s heel? Gonorrheal heel??? Has life become one big pain in the foot? If so, you’re not alone. In fact, foot pain -- most commonly referred to as plantar fasciitis – affects 10% of individuals in the United States and accounts for 1 million doctor visits per year! And those who don stilettos may not be shocked to learn the most common demographic falling prey to this painful inconvenience is women aged 40-60.  Maybe you’ve tried upping the Ibuprofen. Stretching. Foot massage. Physical therapy. Perhaps you’ve even resorted to considering risky cortisone injections to find relief. Or maybe you’ve already received a cortisone injection, only to find the pain rearing its ugly head once again, a matter of months later. What’s the solution??? Is there a strategy that exists to stop the madness? I’m here to tell you how Traditional Chinese Medicine can help break the cycle of misery, through the strategic placement of needles, a little electricity, and the magic of Tibetan Foot Soaks. But first, let’s take a trip down Physiology Road to learn how inflammation sets the stage for this all-too-common, tragic ailment. 

“Inflammation” is quite the buzzword these days. For the most part, a majority of us are plagued by it at some point in time. But what most don’t know is there are actually two major types of inflammation that lead to pain: Classic Inflammation and Neurogenic Inflammation. Classic Inflammation occurs at the beginning of an acute injury, such as an ankle or wrist sprain, or even due to excessive strain on the tissues (i.e. muscles or fascia) and lasts for 0-72 hours post-injury. This injury leads to an accumulation of white blood cells and macrophages, and the release BradyKinin, whose job it is to send the white blood cells and macrophages into battle to clean up and repair the damage. BradyKinin does have a dark side though. It, in itself, is a noxious (i.e. painful) stimuli, which causes the release of Substance P. We’ll come back to Substance P in a bit. 

So, what’s happening after the initial 0-72 hours of the classic inflammatory response? This is where Neurogenic Inflammation takes center stage. It is essentially the response of the body’s many sensory nerves releasing a new cascade of inflammation. This is triggered by painful stimuli, which could include trauma, repetitive stress (ex: running or jogging), muscle trigger points (which commonly occur in the calf due to improper footwear), or even changes in the structure of the tissue or joint. These stimuli cause the release of Substance P (an inflammatory mediator) and Neurokinin A, which lead to edema (i.e. fluid accumulation within the tissue) and adhesions (i.e. bands of scar-like tissue). 

Neurogenic Inflammation can last for up to 6 months after the onset of painful stimuli unless the painful stimuli is stopped! From six months and beyond, myofibroblasts are released, which leads to shrinking and scarring of the plantar fascia (the fibrous tissue along the bottom of the foot that connects the heel bone to your toes). This is a failed attempt at healing, which ultimately causes the creation of new nerve endings and a resulting increase in pain. To reiterate, once we’ve exceeded 6 months of neurogenic inflammation, pain is no longer due to inflammation! And this is where long-term sufferers of Plantar Fasciitis have been led astray when it comes to treatment options. Ibuprofen, cortisone injections, and other anti-inflammatory measures will not offer relief.

Those who have tried cortisone injections in the past, continue to receive them every few months, or are considering approaching their doctor to ask for one because they can’t stand the pain any longer, should know about the very real and possible side effects. Many are aware that cortisone injections can cause high blood pressure, thinning of the skin, and weight gain, but there are even more crucial side effects that can be observed in those receiving injections specifically for plantar fasciitis. Fascial rupture, which is the tearing of the underlying tissue on the bottom of the foot, can occur due to a 35% decrease in functional strength of the fascia observed for the first two weeks after administration of the injection. Collagen necrosis is the root of this loss of strength and is directly attributed to steroid injection (Kennedy & Willis, 1976). Additional side effects include plantar fat pad atrophy and lateral plantar nerve injury secondary to injection.

While western approaches to intervention offer temporary, partial relief at best and permanent damage to the structure and function of the foot at worst, acupuncture and herbal medicine therapies provide a safe, effective, long-term solution to the treatment of plantar fasciitis! In my practice, I perform a full physical exam, during which I test for inhibition of supporting muscles, range of motion, the flexibility of the foot, and pliability of the tissue surrounding the Achilles heel, before beginning treatment. Though acupuncture may seem like magic to some, in reality, it’s rooted in anatomy and physiology and really shines in the treatment of orthopedic complaints when the practitioner is able to combine the newest research-based modalities – such as electro-acupuncture and trigger point needling – with the classical teachings of Channel Theory. 

When my patients show me exactly which region of their foot is experiencing discomfort, this helps guide me toward the treatment of hidden trigger points in the calf, which are oftentimes responsible for the genesis of foot pain. These trigger points are hyperirritable, taut bands of muscle which cause referred pain patterns in distant spots on the body. For example, trigger points in the soleus muscle refer pain to the heel, while trigger points in the gastrocnemius refer pain to the medial instep of the foot. There are approximately six different muscle groups in the calf that, when tight and trigger point-ridden, can refer pain to distinct areas of the plantar surface of the foot. Precise insertion of ultra-thin acupuncture needles into these trigger points begins a ripple effect of local relaxation of taut muscle fibers, which translates to pain relief at specific sites in the foot. This effect is amplified when combined with electroacupuncture.

The word “electroacupuncture” may sound quite shocking, but in reality, it’s a soothing, efficient addition to the practice of traditional acupuncture, and bio-hacks both our functional and neuroanatomy. When applying electroacupuncture, small clips are placed on specific needles – in this case, at the site of trigger points in the calf – and a safe, gentle, slow-pulse electric current is transmitted into the belly of the muscle. Current research has shown that low-frequency electroacupuncture delivers an analgesic effect by way of releasing opioids from the brain, and inhibits the release of substance P, thus resulting in the downregulation of inflammation (Zhang, Zhang, Yung, & Zhang, 2004). Using this technique, we can successfully neuromodulate the pain, thus turning it off and putting a stop to the cycle of neurogenic inflammation. When inflammation is interrupted, the body is allowed the opportunity to begin the healing process. 

Once pain is reduced, we can focus on improving the movement and flexibility of the Achilles tendon, which directly attaches to the heel bone and influences the tension of the plantar fascia. This is accomplished through the use of electroacupuncture in conjunction with gua sha therapy. Gua sha, in this case, involves gentle, targeted scraping of the tissue surrounding the Achilles. A specialized tool, usually made from jade or surgical steel, is used to stimulate microcirculation and break up adhesions. Manual therapy can also be used in place of or in addition to gua sha. With increased movement comes decreased strain and tension on the neighboring plantar fascia. 

When proper movement is restored, attention can then be directed to the Paratenon, an oft-overlooked piece of the anatomy of the plantar fasciitis pie. The Paratenon, which attaches to the heel and the plantar fascia, is located under the Achilles tendon and the Keger’s fat pad and consists of type 1 and 3 collagen fibers, fibrin, elastin, and nerve endings. It has a rich blood supply and secretes synovial fluid. Studies have demonstrated that an intact Paratenon promotes healing of the Achilles heel (Müller, Evans, Heisterbach, & Majewski, 2018). In this instance, when high-frequency electroacupuncture is applied, local perfusion of the Paratenon is increased, and thus allows for maximal gliding action of the Achilles tendon. 

The above modalities: 1) Neuromodulation of pain 2) Improving movement of the Achilles tendon 3) Targeting the Paratenon, are performed in sequence, two times a week for three weeks. When the prescribed treatment frequency is adhered to, one can expect an initial 50% reduction in pain! This is music to the ears of anyone who’s suffered from prolonged foot agony. An additional three-week course of treatment is usually sufficient in eliminating plantar fasciitis pain.

In my practice, I also like to deploy the secret weapon of herbal medicine in the treatment of plantar fasciitis. Traditional Chinese Medicine states that where there is pain, there is no flow. In this case, our focus turns to blood flow. Many Chinese herbs are tried and true when it comes to increasing systemic circulation, and these herbs can be used in the form of foot soaks to not only sooth aching extremities, but improve the flow of blood throughout the body, nourishing the tendons and ligaments in the process. The Tibetan herbal foot soaks I prescribe, formulated by leading herbal pharmacologists at Botanical Biohacking, consist of Grade-A sourced blood-moving herbs such as Hong Hua, Qiang Huo, and Du Yi Wei. Patients can utilize these soaks, while relaxing in the comfort of their home, experiencing immediate relief while also resting easy in the knowledge they’re working on their pain at a systemic level between acupuncture treatments. 

Traditional Chinese Medicine operates in an elegant manner, with its focus set on getting to the root of a physical problem, rather than simply relying on the treatment of the branch (i.e. the symptom) and hoping for the best. Plantar fasciitis is merely a branch of a root problem, which is inflammation and poor blood flow to the muscles, tendons, and ligaments. As demonstrated through our journey here together, acupuncture, gua sha, and herbal medicine combine forces to dig deep into the root and provide patients with some of the safest, most effective, longest-lasting results available for the treatment of foot pain. So get off your seat, say goodbye to temporary fixes, and make your way to your local, friendly acupuncturist to regain the bounce in your step!

References

Kennedy, J. B., & Willis, R. B. (1976). The effects of local steroid injections on tendons: a biomechanical and microscopic correlative study. The American Journal of Sports Medicine, 4(1), 11–21. doi: 10.1177/036354657600400103

Müller, S. A., Evans, C. H., Heisterbach, P. E., & Majewski, M. undefined. (2018). The Role of the Paratenon in Achilles Tendon Healing: A Study in Rats. The American Journal of Sports Medicine, 46(5), 1214–1219. doi: 10.1177/0363546518756093

Zhang, S. P., Zhang, J. S., Yung, K. K., & Zhang, H. Q. (2004). Non-opioid-dependent anti-inflammatory effects of low frequency electroacupuncture. Brain Research Bulletin, 62(4), 327–334. doi: 10.1016/j.brainresbull.2003.10.002

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