Indian Journal of Research in Homeopathy

ORIGINAL ARTICLE
Year
: 2017  |  Volume : 11  |  Issue : 1  |  Page : 64--73

A retrospective study of homoeopathic treatment in patients with heel pain with or without Calcaneal Spur


Suraia Parveen 
 Dr. Anjali Chatterjee Regional Research Institute (H), Kolkata, West Bengal, India

Correspondence Address:
Suraia Parveen
Dr. Anjali Chatterjee Regional Research Institute (H), 50, Rajendra Chatterjee Road, Kolkata - 700 035, West Bengal
India

Abstract

Background: Heel pain is a common clinical condition which significantly affects the quality of life. It is frequently associated with calcaneal spur (CS). Despite its high prevalence, the optimal treatment remains unclear. The aim and objective of this study is to evaluate the extent of CS in heel pain; correlation of CS with some sociodemographic and health-related factors; and outcome of homoeopathic treatment over a period of 6 months. Methodology: It was a retrospective study done at Dr. Anjali Chatterjee Regional Research Institute for Homoeopathy, Kolkata. Samples were selected from the patients referred for ankle X-ray from August 2014 to July 2015 for nontraumatic heel pain. Their files were traced from outpatient department, and treatment records were reviewed over the next 6 months. Results: Totally 92 patients, 70 women and 22 men, had undergone lateral X-ray of ankle for nontraumatic heel pain, of which 76 (82.6%) patients had CS. Extent of CS was found to be higher in case of females, older age, overweight, and profession of housemaid or manual labor. Homoeopathic treatment showed positive response in nearly 75% of the CS patients. The most useful medicines were Calcarea flouricum, Rhus toxicodendron, Ledum palustre, and Aranea diadema. Conclusion: CS was found in nearly 80% of patients presenting with heel pain, which showed association with female sex, overweight, increasing age, and profession requiring heel stress. Homoeopathic treatment was effective in 3/4th of CS patients, and Rhus toxicodendron and Calcarea flouricum are the two most commonly used medicines.



How to cite this article:
Parveen S. A retrospective study of homoeopathic treatment in patients with heel pain with or without Calcaneal Spur.Indian J Res Homoeopathy 2017;11:64-73


How to cite this URL:
Parveen S. A retrospective study of homoeopathic treatment in patients with heel pain with or without Calcaneal Spur. Indian J Res Homoeopathy [serial online] 2017 [cited 2019 Oct 21 ];11:64-73
Available from: http://www.ijrh.org/text.asp?2017/11/1/64/200844


Full Text

 Introduction



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.[1] 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.[2] 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,[3] females,[4] overweight or obese,[5] and in illnesses such as diabetes mellitus [6] and osteoarthritis [7]. 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.[8] 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.[9] 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 laborers and housemaid.[10]

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.[11] Recent studies have reported that general population between 11% and 16% have also radiographic evidence of CSs.[12]

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.[13]

Diagnosis of CS is confirmed by lateral X-ray 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.[14]

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 self-limiting 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 anti-inflammatory drugs, physical therapy, stretching exercises, and steroids which are effective mostly in acute symptoms. In highly symptomatic patients nonresponding 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.[14]

The common inciting factors of CS such as prolonged bare feet, occupational heel stress and lack of soft-padded shoes are associated with lower socioeconomic strata of patients who prefer low-cost therapeutic options. Among the low-cost options, analgesics, both steroidal and nonsteroidal, cause systemic side effects on long-term or frequent use. As a result, these patients of heel pain often get frustrated and seek treatment from multiple providers including Homoeopathy.[15]

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.[15] In another recent preliminary study, Ruta graveolens was found to be effective in treating plantar fasciitis.[16]

The aim of the current study was to collect some systematic retrospective data on patients with heel pain presented to an homoeopathic setup. The objective of this study was to find the extent of CSs among the patients of heel pain; location of the CSs in X-ray; collect data regarding different sociodemographic and available health-related 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 nondigital X-ray 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 X-ray register of the institute. Approval of the institutional head was taken for the study. From the X-ray register, patients who were referred for lateral X-ray 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 1-year 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 as noted in the OPD treatment cards were picked up. Patient-related data such as sociodemographic information; general built-related information such as height, weight, body mass index (BMI = weight in kg/height in m 2); and comorbidities such as overweight/obesity (BMI >23 and 27, respectively, as per Asian standard),[17] diabetes mellitus, osteoarthritis, hyperuricemia, and hypothyroidism were noted from the record. 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 1-year period. This constitutes 10.97% of the total patients undergoing X-ray for different clinical conditions over the same period of time in this institute. 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-to-day functional activities [Chart 1].[INLINE:1]

Among sociodemographic 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 [Table 1] as per South-Asian standard of the WHO.[17] Some of the patients were seeking treatment for different metabolic and musculoskeletal comorbidities [Table 1] 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.{Table 1}

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 non-CS = 7, 43.75%). It was observed that the higher potencies of 10M and 50M were used more in CS patients than that of non-CS 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 non-CS patients, it was found in Rhus toxicodendron (n = 6, 37.5%) followed by Ledum palustre (n = 5, 31.25%) [Table 2].{Table 2}

However, the OPD treatment notes in most of the occasions did not contain adequate information pertaining to the rationality behind selection of a particular medicine. Doctors in busy OPD practice elicit the necessary symptoms required for prescription, but in most of the occasions, do not make detailed record of it. Therefore, based on clinical notes made in some of the treatment cards, indications of some of the commonly chosen medicine are shown in [Table 3].{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 dry in 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, “Twelve observations” and “Second prescription” of Kentian Philosophy [18],[19],[20],[21],[22] based on the response of medicines and changes in the presenting symptoms and signs over 6 months of follow-up.

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].{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 15-day 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 reconsulted 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 patients as noted by respective physicians in the treatment card. It was not systematically evaluated with any rating scale.

The outcome status was categorized as “marked/moderate/mild improvement and status quo” based on the clinical 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; and 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].{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 non-CS (75%) patients. However, there was no radiological follow-up of the CS. In the status quo group, most of the patients had comorbidities of diabetes mellitus, obesity, and osteoarthritis.[INLINE:2]

 Discussion



In this study, total 92 patients had undergone lateral X-ray heel due to chronic heel pain (other than acute traumatic origin). This number was 10.97% of the total X-ray 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.[11]

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 non-CS 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.[3] 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.[4] Regarding health-related factors, increased body weight in terms of obesity and overweight influences heel pain in both CS and non-CS groups. Together they constituted 57.89% in CS and 50% in non-CS patients. A positive association between increased body weight and CS in previous studies [5] 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.[8],[9] In this study, two patients from CS population and one in non-CS 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 non-CS 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.[6],[7] However, in comparison, those complications were more common (37.50%) in the non-CS 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 non-CS 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 low-cost 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 non-CS (n = 7, 43.75%) groups, followed byCalcarea flouricum (Calc flour) in CS group (n = 33, 43.42%) and Ledum palustre (Led pal) in non-CS 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 non-CS 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 non-CS (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 non-CS group of patients, Rhus toxicodendron (200, 1M) was most effective. The pathology of plantar fasciitis in CS group is more progressed than non-CS 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 non-CS patients. More than 50% (CS = 39, 51.31%, non-CS = 9, 56.25%) of the patients of both the groups achieved symptomatic remission of pain and complete functional recovery. Percentage-wise improvement was more pronounced in the non-CS 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, and no predesigned tools for collecting sociodemographic and health-related information were available. Since there was no universal screening, relevant sociodemographic 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. End point 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 direction

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 and there should be demand of homoeopathic treatment for safe, effective, and low-cost sustainable remedy.

Acknowledgments

The author would like to thank Dr. D. B. Sarkar, A.D.(H), DACRRI(H), for providing necessary permission for conducting the study; Dr. R. N. Saha, Radiologist, for helping in the radiological evaluation of CS; Devnarayan Shing, X-ray technician, and other OPD staffs of DACRRI(H) for their great help in the collection of data for this study.

Financial support and sponsorship

Nil.

Conflict of interest

None declared.

References

1Aldridge T. Diagnosing heel pain in adults. Am Fam Physician 2004;70:332-8.
2Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for Plantar fasciitis: A matched case-control study. J Bone Joint Surg Am 2003;85-A: 872-7.
3Ozdemir H, Söyüncü Y, Ozgörgen M, Dabak K. Effects of changes in heel fat pad thickness and elasticity on heel pain. J Am Podiatr Med Assoc 2004;94:47-52.
4Riepert T, Drechsler T, Urban R, Schild H, Mattern R. The incidence, age dependence and sex distribution of the calcaneal spur. An analysis of its X-ray morphology in 1027 patients of the central European population. Rofo 1995;162:502-5.
5Irving DB, Cook JL, Young MA, Menz HB. Obesity and pronated foot type may increase the risk of chronic plantar heel pain: A matched case-control study. BMC Musculoskelet Disord 2007;8:41.
6Aydoğan A, Halil A., Tolga E, İlker T, Derun E, Muhittin S. et al. Increased calcaneal spur frequency in patients with obesity and type-2 diabetes mellitus. Original article; Turk J Phys Med Rehabil 2014;60:12-6.
7Bassiouni M. Incidence of calcaneal spurs in osteo-arthrosis and rheumatoid arthritis, and in control patients. Ann Rheum Dis 1965;24:490-3.
8Shenoy RM. Miscellaneous conditions of calcaneal spur, in essentials of orthopaedics. 2nd ed., New Delhi, Jaypee Brothers Medical Publishers (P) Ltd.; 2014. p. 280.
9Menz HB, Zammit GV, Landorf KB, Munteanu SE. Plantar calcaneal spurs in older people: Longitudinal traction or vertical compression? J Foot Ankle Res 2008;1:7.
10Kullar JS, Randhawa GK, Kullar KK. A study of calcaneal enthesophytes (spurs) in Indian population. Int J Appl Basic Med Res 2014;4 Suppl 1:S13-6.
11AI Fischer Associates; 2002 Podiatric Practice Survey. Statistical results. J Am Podiatr Med Assoc 2003;Jan-Feb; 93(1): p 67-86. https://www.ncbi.nlm.nih.gov/pubmed/12533562. [Last accessed on 2015 Mar 24].
12Gindha GS, Kaushal S, Kaur H, Singh M. A study of incidence of calcaneal spurs in North Indian population: A dry bone study. Hum Biol Rev 2015;4:264-74.
13Klein SE, Dale AM, Hayes MH, Johnson JE, McCormick JJ, Racette BA. Clinical presentation and self-reported patterns of pain and function in patients with plantar heel pain. Foot Ankle Int 2012;33:693-8.
14Thomas JL, Christensen JC, Kravitz SR, Mendicino RW, Schuberth JM, Vanore JV, et al. The diagnosis and treatment of heel pain: A clinical practice guideline-revision 2010. J Foot Ankle Surg 2010;49 3 Suppl: S1-19.
15Pai PN. Thiosinaminum in the treatment of plantar fasciitis with calcaneal spurs, uncontrolled study. Br Homoeopath J 1992;81:173-5.
16Clark J, Percivall A. A preliminary investigation into the effectiveness of the homeopathic remedy, Ruta graveolens in the treatment of pain in plantar fasciitis. Br J Podiatry2000;3:81-5. Available from: http://www.homeopathyeurope.org. [Last accessed on 2015 Mar 24].
17WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004;363:157-63.
18Kent JT. Repertory of the Homoeopathic Materia Medica. 6th edition. New Delhi: B. Jain Publishers Pvt. Ltd.; 2008. p. 1080-1.
19Boericke W. Boericke's New Manual of Homoeopathic Materia Medica with Repertory. 3rd Revised and Augmented Edition Based on 9th ed. New Delhi: B. Jain Publishers (P) Ltd.; 2010.
20Allen HC. Keynotes and Characteristics With Comparisons of Some of the Leading Remedies of the Materia Medica. Rep. ed. New Delhi: Indian Books and Periodicals Publishers; 2003.
21Hahnemann S. Organon of Medicine. Trans Dudgeon RE, Boericke W. Combined 5th and 6th Edition. New Delhi: B. Jain Publishers (P) Ltd.; 1921.
22Kent JT. Lectures on Homoeopathic Philosophy. New Delhi: B. Jain Publishers (P) Ltd.; 2011. p. 231-41.