A retrospective study of homoeopathic treatment in patients
with heel pain with or without calcaneal spur

Heel pain is one of the most common disorders of the foot that causes patients to seek medical care. A variety of soft tissue, osseous, and systemic disorders can cause heel pain, of which calcaneal spur (CS) is the most common cause.

CS is calcification occurring at the insertion of the plantar fascia to the periosteum on the under surface of the calcaneus. It can also occur on the back of the heel at the insertion of the Tendo Achilles.

The most common cause of spur formation is chronic fasciitis which is multifactorial in etiology, both intrinsic and extrinsic. Intrinsic factors include age, excessive foot pronation, obesity, and limited ankle dorsiflexion. Extrinsic factors include occupational prolonged standing, inappropriate shoe wear, and rapid increases in activity level.

Previous studies suggest that CS is more common in those who have decreased elasticity of the plantar heel fat pad that occurs in older people, females, overweight or obese and in illnesses such as diabetes mellitus and osteoarthritis.

These factors combine to create a pathologic overload and micro tears in the fascia at the calcaneal insertion. Tears lead to inflammation where subsequently calcium gets deposited and spur develops.

Furthermore, a recent histological study has indicated that the bony trabeculae of spurs are vertically oriented, suggesting that the stresses responsible for spur formation may be the result of vertical loading. Previous studies suggest that plantar heel pain is common in runners and people who are walking and standing on hard surfaces for long hours in bare feet, such as labourers and housemaid.

A recent survey of members of the American Podiatric Medical Association revealed that plantar fasciitis/heel pain was the most prevalent condition being treated in podiatric clinics, and 80% of patients with plantar fasciitis have plantar heel spurs.

Recent studies have reported that general population between 11% and 16% have also radiographic evidence of CSs.

Clinically, if patient complains of pain over ball of the heel, there is tenderness on plantar aspect of the heel which makes it difficult to walk barefoot on tile or wood floors. The pain appears when patient stands on the foot for walking and pain disappears when patient walks some distance. It is worst when patient gets up in the morning and exacerbates by walking on a hard surface. The condition is usually not completely disabling but limits their routine daily activities

Diagnosis of CS is confirmed by lateral Xray of the ankle, in which the spurs on the inferior and posterior surface of the calcaneus can be seen. They are known as plantar CSs or inferior CSs and posterior or superior CSs or Achilles spurs. The plantar or inferior CSs are located on the medial tuber calcanei or in the middle of plantar aspect of calcaneus, while the posterior or superior calcaneal or Achilles spurs are located on the posterior surface of the calcaneus where the tendocalcaneus or Achilles tendon attaches

In general, patients do not seek care until the symptoms are considered chronic and the pain of CS significantly affects their activities. Despite the high prevalence of plantar heel pain with CS, the optimal treatment remains unclear. Multiple treatment options exist, but no single treatment has emerged as the standard of care. The condition is often selflimiting if the inciting factors are properly taken care, but the time for resolution of symptoms is highly variable.

Most common treatments are symptomatic in the form of analgesic, nonsteroidal antiinflammatory drugs, physical therapy, stretching exercises, and steroids which are effective mostly in acute symptoms. In highly symptomatic patients non-responding to conservative treatment, trial of surgical intervention such as endoscopic plantar fascia release, release of plantar nerve with plantar fascia, and decompression of the first branch of the lateral plantar nerve were found in literature.

Other costly treatment options such as radio frequency therapy, shock wave therapy, and acupuncture are occasionally used but difficult to bear by the low socioeconomic group of patients

The common inciting factors of CS such as prolonged bare feet, occupational heel stress and lack of softpadded shoes are associated with lower socioeconomic strata of patients who prefer lowcost therapeutic options.

Among the lowcost options, analgesics, both steroidal and nonsteroidal, cause systemic side effects on longterm or frequent use. As a result, these patients of heel pain often get frustrated and seek treatment from multiple providers including Homoeopathy.

However, literature review regarding homoeopathic treatment in plantar fasciitis and CS does not reveal many studies. One uncontrolled study was found where 43 patients suffering from plantar fasciitis and CS were treated with homoeopathic medicine Thiosinaminum or Thiosinaminum and Mercurius corrosivus or Thiosinaminum and Mercurius biniodide. The study showed a positive response in resolving the recently developed CS cases. In another recent preliminary study, Ruta graveolens was found to be effective in treating plantar fasciitis.

AIM
To collect some systematic retrospective data on patients with heel pain presented to an homoeopathic setup.

OBJECTIVE
To find the extent of CSs among the patients of heel pain; location of the CSs in Xray; collect data regarding different sociodemographic and available healthrelated information of those patients; and finally to evaluate the outcome of homoeopathic treatment in terms of symptomatic relief of pain as recorded by the treating physicians over a period of at least 6 months.

METHODOLOGY

This study was a retrospective study conducted at Dr. Anjali Chatterjee Regional Research Institute for Homoeopathy (DACRRIH), Kolkata. In DACRRI(H), outpatient department (OPD) runs every Monday to Saturday with provision of dispensing medicine, pathological test, and non-digital Xray facilities at free of cost.

In general, patients from low to middle socioeconomic status families come for the treatment.

Register of OPD attendance, other facilities, and treatment cards are preserved for record.

The study population was selected from the Xray register, patients who were referred for lateral Xray of ankle due to heel pain other than acute traumatic origin were selected as sample of heel pain patients. The study sample was retrospectively selected from such patients undergoing X-ray during 1year period from August 2014 to July 2015.

The lateral X-rays of the ankle were reviewed by the investigator with the help of the radiologist. CS and its exact site were noted on the files from the reports of X- ray films.

Files of all these patients of heel pain with or without CS were traced from the OPD record.

Different patient and treatment related data(such as socio-demographic information; general built related information such as height, weight, body mass index (BMI = weight in kg/height in m2); and co-morbidities such as overweight/obesity (BMI >23 and 27), diabetes mellitus, osteoarthritis, hyperuricemia, and hypothyroidism were noted from the record) as noted in the OPD treatment cards were picked up.

Treatment related data such as selection of medicines, symptomatic response to medicines, changes of medicines, and follow-up pattern of patients were collected from the available clinical notes of the treating physicians.

Clinical notes were reviewed for 6 months after the radiological diagnosis of spur in each case. Descriptive analysis was done for all the obtained data in both groups of patients.

RESULTS
Total 92 patients had undergone lateral X-ray of the ankle for heel pain other than acute traumatic origin during the stipulated 1year period.

Out of the 92 patients of heel pain, 76 (82.61%) were found to be positive with CS and 16 (17.39%) were without CS.

Usual duration of heel pain in both the groups was more than 3 months in most of the cases with progressive difficulties in day today functional activities.

Among socio-demographic features, data were available only regarding sex, age, and occupation in the treatment card.

Regarding general built related factors, weight and height were universally recorded in treatment cards, out of which BMI was calculated. Patients were divided into different groups i.e. normal, overweight, obese, and below normal as per South Asian standard of the WHO. Some of the patients were seeking treatment for different metabolic and musculoskeletal co morbidities from this institute parallel to their heel pain. Data regarding those conditions were also obtained from the treatment cards.

However, there was no universal screening for those conditions in all patients with heel pain.  Among the 76 patients with CS, location of CS was in the right heel in 38 (43.42%) patients, left heel in 39 (43.42%) patients, and bilateral in 10 (13.16%) patients.

Majority of CS (61, 80.26%) were under the plantar/inferior surface of calcaneus.

STEPS OF HOMOEOPATHIC INTERVENTION
All the patients (92) of heel pain were treated with homoeopathic medicines in the OPD by different physicians.

Selection of medicine
Selection of homoeopathic medicines was found to be based on the individualization, totality of symptoms, particular symptoms, and keynote symptoms.

Total 19 homoeopathic medicines were used in 92 patients with heel pain.

In the DACRRI(H) OPD, Rhus toxicodendron was the most common medicine used in both the groups (CS = 35, 46.05% and nonCS = 7, 43.75%).

It was observed that the higher potencies of 10M and 50M were used more in CS patients than that of nonCS patients

In CS patients, positive response was found mostly with Calcarea flouricum (n = 28, 36.84%) followed by Rhus toxicodendron (n = 22, 28.94%), while in nonCS patients, it was found in Rhus toxicodendron (n = 6, 37.5%) followed by Ledum palustre (n = 5, 31.25%) [Table 2].

Based on clinical notes made in some of the treatment cards, indications of some of the commonly chosen medicine are shown in Table 3.

Selection of potency
The indicated medicine’s potency selection (30C–50M, as shown in Table 2) depends on the patient’s susceptibilities, duration of diseases, and nature of medicines.

Dose
Each dose of individual medicine consisted of 4 globules; size number 30 in sugar with milk to be taken on tongue. Repetition of doses depends on the nature of disease, medicine, and potency. Polycrest deep medicines with higher potency were used with minimum dose (1 or 2), and in acute exacerbation of heel pain, short acting medicines were used in frequent doses.

Changes in the medicines, potencies, and repetitions were done according to the homoeopathic principle. In the treatment cards, it was found that most of the patients were treated with two or more than two medicines in both the group of patients. However, comparatively, non CS group had better response on single medicine than CS group.

Regarding changeover of medicine (n = 86), there were 14 (16.28%) cases where medicines were changed within 1–2 weeks due to aggravation of symptoms. In rest of the patients, change of medicine was done due to either minimal improvement even after observation for about 6–8 weeks with progressive increment of potency up to 1M (n = 39, 45.35%) or use of complementary medicine after plateauing of initial improvement (n = 33, 38.37%). Complementary medicines were used in cases of prescriptions of more than two medicines [Table 4].

Source of medicine
All the medicines were provided to the patients from the dispensary of OPD, DACRRI(H), Kolkata, in homoeopathic centesimal potencies.

Dispensing of medicine
Medicines were dispensed by the pharmacist posted at DACRRI(H) as per directions of OPD physicians in treatment card.

Follow-up
Follow-up advice was usually given at 15day interval at lower potency and in the acute symptomatic stage. After stabilization of improvement or during use of higher potency medicines, the follow-up duration was after 1 month. However it was seen that patients come after there was 7–10 days for follow-up in most of the patients at some point of the observation over 6 months.

There were about twenty cases where patients have re-consulted within 1 week due to either aggravation or appearance of new symptoms.

Follow-up was less than 6 months in case of 25 patients. Out of them (25), poor improvement was in case of five patients, no improvement in case of five patients, three patients had early remission, and the rest (12) patients did not report.

OUTCOME
Treatment outcome was assessed on the basis of the symptomatic improvement of heel pain and the functional activities of the improvement of target symptom of heel pain along with improvement in functional activities.

Complete remission of heel pain with no difficulties in functional activities was considered as marked improvement;  significant improvement in heel pain with residual impairment in functional activity as moderate improvement;  some improvement in heel pain with significant difficulties in functional activities as mild improvement.

The “status quo” category included patients whose heel pain sustained or worsened during treatment over 6 months or left treatment in-between [Table 5].

There was a positive response in terms of both symptomatic improvements in heel pain as well as improvement in functional activity (marked and moderate improvement group in Table 4 and Chart 2) in majority of both the CS patients (71.04%) and the nonCS (75%) patients. However, there was no radiological followup of the CS. In the status quo group, most of the patients had comorbidities of diabetes mellitus, obesity, and osteoarthritis.

DISCUSSION
In this study, total 92 patients had undergone lateral Xray heel due to chronic heel pain (other than acute traumatic origin).

This number was 10.97% of the total Xray investigations for different clinical conditions in this institute over the same period of time.

This signifies that heel pain cases were quite common in the OPD. Out of the 92 patients of chronic heel pain, 76 (82.6%) were positive for CS. This matches with the survey of members of the American Podiatric Medical Association which revealed that 80% of patients with plantar fasciitis have plantar heel spurs.

From the data regarding sociodemographic factors, it was observed that the majority (37, 53.49%) of heel pain patients with CS were older people (34, 44.74%). There was no patient below 18 years of age. More than 40% of CS patients have their age above 50 years while 81.25% of nonCS patients have their age below 50 years.

This indicates that pathology of CS increases with advancing age among patients of heel pain as also found in previous studies.

It was seen that majority of heel pain patients were female (70, 76.08%). While comparing patients with or without CS, female preponderance was relatively higher in patients with CS (59; 77.63%) as in a previous study.

Regarding healthrelated factors, increased body weight in terms of obesity and overweight influences heel pain in both CS and nonCS groups. Together they constituted 57.89% in CS and 50% in nonCS patients.

A positive association between increased body weight and CS in previous studies gets reflected in this study. Excess body mass causes a local pressure effect which accelerates the degenerative processes occurring in the plantar heel region which causes inflammation and heel pain and few of them progress further to produce local spur formation.

In this study, two patients from CS population and one in nonCS group were even below normal weight (BMI <17). They were elderly females from low socioeconomic status and two of them were working as housemaid. In the normal body weight group of CS (39.47%) patients, majority were housemaid.

In the nonCS normal body weight group, patients were heterogeneous; either elderly or having associated metabolic complications and one was housemaid.

Nearly 20% of the CS patients have different comorbid metabolic and musculoskeletal conditions, of which > 10% had osteoarthritis which match with previous studies. However, in comparison, those complications were more common (37.50%) in the nonCS group.

Thus, in the CS group, increasing age, female sex, increased body weight, and occupation requiring prolonged heel stress were the common causative factors. While in the nonCS group, female sex, increased body weight, and associated medical conditions were commonly found.

Regarding occupation, it was found that nearly 65% of the patients of CS were engaged in occupations that require marked heel stress such as housemaid, laborer, and prolonged standing (security and traffic control personnel). This population hails from low socioeconomic condition and cannot afford to buy soft silicon shoes. This suggests that there is a need for lowcost therapy in long run.

In this study, regarding homoeopathic treatment, Rhus toxicodendron (Rhus tox) was the most common medicine used in both CS (n = 35, 46.05%) and nonCS (n = 7, 43.75%) groups, followed byCalcarea flouricum (Calc flour) in CS group (n = 33, 43.42%) and Ledum palustre (Led pal) in nonCS group (n = 6, 37.5%).

In CS group, Calcarea flouricum (n = 28, 36.84%) was the most useful medicine followed by Rhus toxicodendron and Ledum palustre. While in nonCS group, Rhus toxicodendron was the most useful medicine followed by Ledum palustre and Hypericum perforatum [Table 2].

It has been found that useful potencies were higher (200M, 1M, 10M, and 50M) in CS patients compared to nonCS (30, 200, and 1M) heel pain patients. In CS group of patients, the most effective medicine was Calcarea flouricum (1M and 10M, 50M), whereas in the nonCS group of patients, Rhus toxicodendron (200, 1M) was most effective.

The pathology of plantar fasciitis in CS group is more progressed than nonCS group, making the CS group more recalcitrant to treatment. Thus, relatively higher potency of medicines was used by the treating doctors in CS group of patients.

The final outcome of homoeopathic treatment was quite satisfactory in both CS and nonCS patients. More than 50% (CS = 39, 51.31%, nonCS = 9, 56.25%) of the patients of both the groups achieved symptomatic remission of pain and complete functional recovery. Percentagewise improvement was more pronounced in the nonCS group, probably because the pathology of plantar fasciitis in the CS group was more progressed in nature. Associated medical comorbidities have made the cases more treatment refractory.

LIMITATIONS

This study was a retrospective study.

No data was collected directly from the patients.  Data recoded in patients treatment cards by treating physicians were the only source of information.

No predesigned tools for collecting socio-demographic and health related information were available.

Since there was no universal screening, relevant socio-demographic and health related data may be missing in some of the patients.

Detailed notes on repertorization regarding selection of medicines were not available

Treatment outcome was not systematically evaluated with rating scales; only the clinical impression of the treating doctors was the source of information

Endpoint radiological evaluation was also not done in the study. Only simple descriptive statistics (frequency and percentage) have been presented

No comparative or correlative statistical analysis was done between the two groups of CS and non CS patients because of highly unequal group size and inadequate sample.

FUTURE DIRECTIONS

  • A future systematic trial of homoeopathic medicine should be conducted in patients of heel pain with CS
  • It is a common clinical condition, so there would be no dearth of patients
  • There should be demand of homoeopathic treatment for safe, effective, and low-cost sustainable remedy

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