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First published online September 17, 2007
British Journal of Radiology (2007) 80, 829-834
© 2007 British Institute of Radiology
doi: 10.1259/bjr/79800547
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Retrospective evaluation of radiotherapy in plantar fasciitis

L Miszczyk, MD, PhD B Jochymek, MD and G Wozniak, MD, PhD

Radiotherapy Department, Centre of Oncology, M. Sklodowska-Curie Memorial Institute, Gliwice Branch, ul. Wybrzeze AK 15, 44-100 Gliwice, Poland

Correspondence: Dr Leszek Miszczyk, Radiotherapy Department, Centre of Oncology, M. Sklodowska-Curie Memorial Institute, Gliwice Branch, ul. Wybrzeze AK 15, 44-100 Gliwice, Poland. E-mail: leszek{at}io.gliwice.pl


   Abstract
Top
 Abstract
Introduction
 Materials
 Methods
 Results
 Discussion
 Conclusions
 References
 
Plantar fasciitis is a common painful syndrome that is usually treated by irradiation with a fraction dose (fd) of 1 Gy up to a total dose (TD) of 6 Gy according to clinical experience. By analysing our experiences with numerous former patients, we have attempted to find the relationship between dose and effect. To evaluate the effectiveness of radiotherapy and assess the impact of fd and TD in plantar fasciitis radiotherapy, we assessed 1624 irradiations (856 patients) performed using a fd of 1–3 Gy and a TD of 1–45 Gy. Analysis was carried out on the 623 irradiations (327 patients) for which complete follow-up data were available. The mean follow-up period was 74 months. The following parameters were evaluated: pain relief level; period of anaesthetic effect preservation after treatment; presence of pain and the timing of its appearance; and the intake of analgesic drugs at the last follow-up. After treatment, 48% of the patients reported a lack of pain, 21% reported pain relief greater than 50% and 17% reported pain relief less than 50%. The mean pain relief duration was 72 months. The last follow-up found that pain at rest afflicted 25% of the patients, and pain during walking afflicted 32%. A dose–effect relationship was not found. In conclusion, radiotherapy is an effective treatment for plantar fasciitis. A fd of 1.5 Gy and TD of 9 Gy should probably not be exceeded.


   Introduction
Top
 Abstract
 Introduction
Materials
 Methods
 Results
 Discussion
 Conclusions
 References
 
Plantar fasciitis is a painful inflammatory syndrome caused by repeated trauma to the plantar fascia insertion to the heel bone, which is the pressure point that bears the whole weight of the body. In the majority of cases, plantar fasciitis coexists with calcaneal (heel) spurs – pathological extraosseus bone formation – at the same location. Chronic inflammation in the soft tissues below the plantar fascia insertion into the heel, intensified by tension bearing on the fascia insert, causes plantar pain. Other causes of plantar fasciitis are repeated trauma (intensive sport activities, obesity), structural deformities of the foot [1, 2] and chronic diseases of the osteoarticular system [3–5].

Because of the high incidence of plantar fasciitis and its chronic and troublesome symptoms, many treatment modalities are available. Oral non-steroidal anti-inflammatory drugs (NSAIDs) as well as oral steroids are ineffective. Short relief is achieved after injections of local anaesthetics and steroids. Other treatment concepts in use are heel pads [6] and specially formed shoe inserts [7]. Surgery is based on spur excision, solely [8] or in combination with plantar fasciectomy [6, 9]; however, results are poor and so other surgical modalities such as resection using a holmium laser [10] or endoscopic decompression [11] are also performed. A new treatment in use is extracorporeal shock wave therapy [1, 12].

A further modality used for the treatment of painful plantar fasciitis is radiotherapy [2, 13–18]. The probable mechanism of action of radiotherapy in non-malignant disease is the anti-inflammatory effect of low-dosage ionising radiation (≤1 Gy) based on the modulation of E-selectin adhesion on endothelial cells, the decrease of leukocyte adhesion [19], the reduction of nitric oxide synthase activity [20] and the reduction of oxidative burst in activated macrophages [21]. Less important are the anti-proliferative and immunomodulatory effects which play a role in irradiation with fraction doses (fd) higher than 2 Gy [22]. The reported results of plantar fasciitis radiotherapy vary from 50% of cases having complete pain relief [13] up to 60% [16] and 70% [17, 18]. Considering the results, the lack of adverse effects, the simplicity of treatment and the relatively low cost, radiotherapy seems to be one of the safest and most effective treatments for painful heel spurs.

Patients suffering from painful plantar fasciitis are usually irradiated using one plantar or lateral field or two lateral fields, with a fd of 1 Gy up to a total dose (TD) of 6 Gy. This schedule was based on clinical experience; however, over time, fractionation schemes have changed and different fraction and total doses have been used. On the basis of numerous retrospective patient groups treated with different regimes, we have tried to find the possible dose–effect relationship and to specify the most effective dose per fraction.

The aim of this study was to evaluate the effectiveness of radiotherapy in patients suffering from plantar fasciitis and to assess the impact of fd used and TD delivered on the irradiation effect.


   Materials
Top
 Abstract
 Introduction
 Materials
Methods
 Results
 Discussion
 Conclusions
 References
 
Our study included 1624 plantar fasciitis irradiations (cases) performed between 1969 and 2003. The number of irradiated plantar fascias (calcaneal spurs) – 1289 – was smaller because some patients received multiple irradiations. In total, 53% of patients were irradiated because of bilateral lesions or were reirradiated (21%), therefore the number of patients included in this study was 856.

To avoid biases in data interpretation and statistical analysis, one planned course of plantar fasciitis irradiation along with the results was considered as one case. Radiotherapy was never delivered in two planned courses, only as unplanned reirradiation, and so each course was considered as a separate case.

The study included 630 women (74%) and 226 men (26%). The right heel was irradiated in 819 cases and the left heel in 805 cases. Spur size ranged from 1 mm to 30 mm (mean 9 mm). In the majority of cases pain appeared after a few steps (1–2 m).

The data available for other previously performed treatments were minimal. In 49 cases, local steroid and anaesthetic injections were administered, and in 7 cases operations were performed. The poor data regarding other previously performed treatment modalities leads us to suppose that such treatments were more frequent.

Because of the retrospective character of the data and the long period during which patients were treated (25 years), the follow-up data were incomplete. Follow-up data were available for only 327 patients (623 cases – 38%) and so the analysis was performed on the basis of this subgroup. The number of irradiated plantar fascias in the subgroup was smaller (527) because of multiple repeated irradiations. In total, 96 cases were reirradiated: 75 heels were irradiated twice, 9 were irradiated 3 times and 1 was irradiated 4 times. Accordingly, because of bilateral and repeated irradiations the real number of treated patients from the analysed subgroup was 327. In the analysed subgroup there were 255 women (78%) and 72 men (22%). In 318 cases, the right plantar fasciitis was irradiated and in 305 cases the left was irradiated. Spur size varied from 1 mm to 30 mm (mean 8 mm). The follow-up ranged from 1 month to 360 months (mean 74 months).

Precise data regarding the ages of the patients, the duration of symptoms before radiotherapy and the duration of the follow-up period for the whole group and for the analysed subgroup are presented in Table 1Go.


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  		Table 1. Patients' age, duration of symptoms before radiotherapy and duration of follow-up period for the whole group and the analysed subgroup

 
Spurs were irradiated using a fd from 1–3 Gy up to a TD of 1–45 Gy, delivered in one planned course. The overall treatment time (OTT) ranged from 2–44 days. Patients were irradiated using one plantar or lateral field comprising the insertion of the plantar fascia with a calcaneal spur and a reasonable margin. The field size varied from 27–150 cm2 (mean 47 cm2). In all cases, doses were specified in the built-up point on the beam axis. Different fds and TDs used for the analysed cases depended on the physician's choice as well as on treatment policy, which changed over time.

The detailed distribution of cases in the analysed subgroup according to fds, TDs and OTT is presented in GoTables 2 and 3Go.


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  		Table 2. Numbers of cases irradiated using a particular fraction dose(fd) and different ranges of total dose (TD), and percentage having complete pain relief after radiotherapy and at last follow-up

 

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  		Table 3. Numbers of cases irradiated for different overall treatment times(OTT) and different ranges of total dose (TD)

 
More than 97% (605) of irradiations were performed using orthovoltage X-ray beams. High-energy photons were used in eight cases, electrons in six cases and gamma beams in four cases. In 374 cases 200 kV was used, in 133 cases 180 kV was used, in 32 cases 205 kV was used, in 4 cases 190 kV was used and in 2 cases 195 kV was used. In 78 cases no data were available regarding the X-ray voltage used. For 483 irradiations 1 mm Cu filters were used and for 21 0.5 mm Cu filters were used. For 119 irradiations no filters were used.


   Methods
Top
 Abstract
 Introduction
 Materials
 Methods
Results
 Discussion
 Conclusions
 References
 
Directly after completion of radiotherapy, the level of pain relief was evaluated on a scale of one to four. The first group had complete pain relief; the second group saw their pain reduced by at least 50%; the third experienced pain relief but by less than half of pre-radiation pain levels; and the fourth group was without analgesic effect. The period of anaesthetic effect preservation was also recorded.

During the last follow-up, the presence of pain, the timing of its appearance and the analgesic drug intake were evaluated. The timing of pain appearance was expressed as the distance travelled in metres at which the patient started to feel pain.

The use of other treatment modalities for calcaneal spurs during the follow-up period was noted.

All data were derived from forms sent to patients and from interpretations of chart notes. All forms were sent in the same time period and so the time from treatment to form completion differed from patient to patient.

The observation of patients was completed in June 2004.

Statistical analysis
The character of data distribution for different analysed variables was checked using the Shapiro–Wilk test.

Correlations between duration of pain relief after radiotherapy and certain physical (fraction and total dose, field size, treatment time) and biological (age, spur size, symptom duration before the treatment) factors were evaluated using the Spearman test.

The impact of previous treatments (steroid injections, surgery, radiotherapy), sex and spur location on duration of pain relief was checked using the Mann–Whitney test.

The ANOVA Kruskal–Wallis range test was used to assess the impact of the roentgen beam filtration effect on the duration of pain relief.


   Results
Top
 Abstract
 Introduction
 Materials
 Methods
 Results
Discussion
 Conclusions
 References
 
The percentages of cases exhibiting complete pain relief after radiotherapy and during the last follow-up are presented in Table 2Go.

The percentage of cases having particular degrees of pain relief after radiotherapy and the mean total dose delivered are presented in Table 4Go.


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  		Table 4. Percentages of cases having particular degrees of pain relief after radiotherapy and the mean total dose(TD) delivered

 
The rate of pain relief as a function of TD, restricted to the 529 treatments with a fd of 1.5 Gy, is presented in Figure 1Go. No gain in pain relief was found when the TD exceeded 9 Gy.


Figure 1
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  		Figure 1. The rate of pain relief as a function of total dose delivered restricted to treatments performed with a fraction dose of 1.5 Gy.

 
The rate of pain relief as a function of fd, restricted to the 233 cases irradiated to a TD of 6–7 Gy, is presented in Figure 2Go. The graph does not show an improvement in anaesthetic effect with a fd bigger than 1.5 Gy.


Figure 2
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  		Figure 2. The rate of pain relief as a function of fraction dose restricted to the cases irradiated to a total dose of 6–7 Gy.

 
For the analysed subgroup the median duration of pain relief was 24 months (upper quartile, 133; lower quartile, 5). This period varied from 0.5 to 354 months (mean 72 months) for first-time irradiated cases and from 1 to 320 months (mean 70 months) for reirradiated cases; however, data regarding this feature were available for only 252 cases.

The data available for other treatments used in the follow-up period are poor. In 2 cases, spurs were operated on; 236 cases did not undergo surgery during this period; and for the remaining 1386 cases no data are available. In 25 cases, perilesional blocks after radiotherapy were carried out. In 219 cases, no local injections were performed and for the remaining 1380 cases data are not available.

The percentages of cases having different treatment results evaluated during the final follow up and the means of the total delivered doses for these groups are presented in Table 5Go.


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  		Table 5. Percentages of cases having different treatment results evaluated during final follow up and mean total dose(TD) delivered for these groups

 
The distance at which pain appeared, evaluated during the final follow up, varied from 1–5000 m (mean 1220 m, median 200 m, upper quartile 2000 m, lower quartile 10 m).

In only 7% of cases were analgesic drugs necessary, as evaluated during the final follow up. Tramadol was used in 3 cases and NSAIDs in 17. In 208 cases, analgesics were not used. We have no data regarding the analgesic intake of the remaining patients.

The Spearman test confirmed a statistically significant but weak correlation between the duration of pain relief after radiotherapy completion and the TD delivered (p = 0.04, R = 0.1) and duration of radiation treatment (p = 0.001, R = 0.2). There was no other correlation between the duration of pain relief and the analysed physical and biological factors.

No differences in duration of pain relief with respect to previous steroid injections, previous surgery, spur location, sex and filtration of roentgen beams were found.


   Discussion
Top
 Abstract
 Introduction
 Materials
 Methods
 Results
 Discussion
Conclusions
 References
 
Radiobiological rationale
Several explanations have been given for the effects of radiation in non-malignant disease. According to Trott and Kamprad [22], four mechanisms can be distinguished: anti-proliferative and immunomodulatory effects, which play a role in cases of irradiation using a fd of 2 Gy up to a TD of 10 Gy or higher; poorly defined functional effects achieved by modulation of autonomous nervous system activity and/or gene activation processes, which occur with a TD below 2 Gy; and anti-inflammatory effects, which are probably the main role of radiotherapy in the treatment of plantar fasciitis. This phenomenon appears mainly when low fds (0.5–1 Gy) and TDs (2–6 Gy) are used.

Because the majority of analysed cases were irradiated with fds of 1.5 Gy (85%) and 2 Gy (13%), both the anti-proliferative and the anti-inflammatory effects probably influenced the treatment results obtained.

Anaesthetic effect
In the largest survey published to date [2], comprising 7947 patients irradiated because of heel spurs, the percentage of cases achieving complete pain relief for 3 months was 70% and thus was much higher than the 49% obtained in our work. A small percentage of cases (17%) achieving complete pain relief directly after the completion of treatment was also reported by Schafer et al [16] as well as by Mucke et al (23%) [14]. In other publications, the percentage of patients having complete pain relief varied from 36% to 84% [23].

Pain relief duration
There are no clear published data available on the duration of pain relief after radiotherapy and so the result obtained in this study (mean duration of pain relief of 72 months) is not directly comparable with other data. The only similar data are published by Schafer et al [16], in which 58% of patients had complete pain relief through the mean follow-up period of 41.5 months. The response rate of 75% during the final control (mean follow up of 74 months) is better than that reported by Micke and Seegenschmiedt [2] after 12 months. A higher response rate (86%) was achieved by Mucke et al [14] in a study of 100 patients with a median follow up of 20 months.

Dose–response relationship
Significant dose–response relationships for TD and fd were not found in this study and this is also the case in other publications [2, 13].

The lack of a direct dependency between fd and the probability of pain relief is often described [17, 18, 23]. The most common fd used in plantar fasciitis radiotherapy is 1 Gy [2, 14, 16–18, 24], and only in a small number of these publications is it suggested that higher doses may be useful [25].

Side-effects
No acute or late toxicity in cases of plantar fasciitis patient irradiation has been reported in the literature [2, 13, 14, 16, 26] and no adverse effects appeared in the analysed group in this study. Taking into account the relatively small TD used in this kind of radiotherapy, acute and/or late side-effects are not usually expected.

Critical analysis of obtained results
The retrospective character of this study might account for the various ambiguities and potentially false results. It does not allow for a precise and clear interpretation of the results obtained and might generate unintentional biases. Poor data also created difficulties for the analysis. Fewer than half of the irradiated cases (623 out of 1624) were analysed. Moreover, some data derived from forms sent to patients and from chart notes were incomplete.

The first unclear result is the discrepancy between the high percentage of cases having complete pain relief (70%) after 3 months reported by Mick and Seegenschmiedt [2] and the quite low percentage – 49% – obtained by us. However, our data were concerned only with the situation at the time of radiotherapy completion, and it is possible that the percentage of cases having complete pain relief could increase during the following weeks.

The second unexpected finding was a lack of improvement with higher TD, which might be the result of an intentional increase of TD by the physician because of a more intensive and fixed painful syndrome in some patients who appeared to be non-responders.


   Conclusions
Top
 Abstract
 Introduction
 Materials
 Methods
 Results
 Discussion
 Conclusions
References
 
The following conclusions can be made based on the results and discussion presented above:

  1. radiotherapy is an effective, easy and safe modality for the treatment of painful plantar fasciitis;
  2. a fd of 1.5 Gy and TD of 9 Gy should probably not be exceeded in the radiotherapy of plantar fasciitis.


   Acknowledgments
 
Special thanks to Dr Krystyna Rozek-Lesiak from the Silesian Medical Academy for her support with the clinical material.

Received for publication February 21, 2006. Revision received October 1, 2006. Accepted for publication December 14, 2006.


   References
Top
 Abstract
 Introduction
 Materials
 Methods
 Results
 Discussion
 Conclusions
 References
 

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