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The Foot xxx (2014) xxxxxx

Contents lists available at ScienceDirect

The Foot
journal homepage: www.elsevier.com/locate/foot

Case Report

Complete remission of plantar fasciitis with a gluten-free diet:

Relationship or just coincidence?
Marco Paoloni a, , Emanuela Tavernese b , Francesco Ioppolo c , Massimo Fini d ,
Valter Santilli a,c
a
Board of Physical Medicine and Rehabilitation, Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza University, Rome, Italy
b
Pediatric Neuro-Rehabilitation Division, Bambino Ges Childrens Hospital, IRCCS, Rome, Italy
c
Physical Medicine and Rehabilitation Unit, Azienda Policlinico Umberto I, Rome, Italy
d
IRCCS San Raffaele Pisana, Rome, Italy

a r t i c l e i n f o a b s t r a c t

Article history: We report the case of a 46-year-old woman with no known history for gluten sensitivity who pre-
Received 22 May 2014 sented severe heel pain, and was successfully managed with a gluten-free diet. Previously she had been
Accepted 18 June 2014 unsuccessfully treated with several conservative remedies. The presence of musculoskeletal problems in
patients with gluten sensitivity is not rare. To the best of our knowledge, however, this is the rst case
Keywords: report mentioning the successful management of plantar fasciitis with a gluten-free diet. The case report
Plantar fasciitis
highlights the importance of considering gluten sensitivity among other possible differential diagnosis
Gluten-free diet
for musculoskeletal pain insensitive to traditional therapies.
Heel pain
Gluten sensitivity 2014 Elsevier Ltd. All rights reserved.

1. Introduction in about 12% of cases among those CD patients with ultrasound

Plantar fasciitis (PF) is a chronic and disabling cause of foot pain
in the adult population and has no known etiology [1]. PF typi-
cally presents itself with an insidious onset of a sharp, stabbing
pain localized in the plantarmedial aspect of the heel, occurring
upon standing up as the movement starts (start-up pain). It
responds well to several conservative therapies, including oral
anti-inammatory drugs, stretching exercises, taping, orthoses and
extracorporeal shock wave therapy (ESWT) [1], while surgical treat-
ment is considered in only a small subset of patients with persistent,
severe symptoms insensitive to nonsurgical intervention for at least
612 months [2].
Recently, it has been demonstrated that patients affected by
coeliac disease (CD), a chronic inammatory disorder of the small
bowel induced in genetically susceptible people by the irritant
gluten [3], display a high percentage of asymptomatic enthe-
sopathies, as detected by ultrasound examination [4], that partially
relapse with gluten-free diet [5]. Notably, plantar fascia is involved
Corresponding author at: Board of Physical Medicine and Rehabilitation,
Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza
University, piazzale Aldo Moro 5, 00185 Rome, Italy. Tel.: +39 6 49975924;
fax: +39 6 49914192.
E-mail address: marco.paoloni@uniroma1.it (M. Paoloni).
signs of enthesopathy [4]. This fact together with its association
with rheumatic diseases and spondyloarthropathies [6] suggests
that PF may not be entirely a degenerative and/or biomechanical
determined disorder, but rather that, in some cases, an autoim-
mune substrate might contribute to its genesis.
We report the recent case of a patient with severe and unman-
ageable PF who was successfully treated with a gluten free diet,
despite no known history of CD.
2. Case report
A 46-year-old Caucasian female (height: 163 cm; weight:
79.4 kg; body mass index: 29.5) referred to us for pain in both heels
had appeared 2 years prior without any clear cause for the sore-
ness. The pain was described as burning and continuous, mainly
localized at the medial aspect of both heels and was more severe
at the onset of movements. The pain gradually worsened, mainly
on the right foot, making walking and standing difcult. Previ-
ously unsuccessful treatments consisted in the local application of
cold therapy, stretching of the plantar fascia, and use of oral non-
steroidal anti-inammatory drugs. Despite the treatments, the pain
in the right heel became so severe at times that she was unable
to walk and was forced to stop recreational activities such as t-
ness training and dancing. Moreover, wearing shoes without heels

http://dx.doi.org/10.1016/j.foot.2014.06.004
0958-2592/ 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Paoloni M, et al. Complete remission of plantar fasciitis with a gluten-free diet: Relationship or just
coincidence? Foot (2014), http://dx.doi.org/10.1016/j.foot.2014.06.004
G Model
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2 M. Paoloni et al. / The Foot xxx (2014) xxxxxx
Fig. 1. Lateral X-ray of the right foot of our patient, showing a small heel spur (white
circle).
became almost impossible. The patients medical history was oth-
erwise unremarkable. Her family history revealed a rst-degree
relative (her mother) with a conrmed diagnosis of CD. Clinical
examination of the patient was normal, with the exception of a
marked tenderness at the proximal plantar fascia insertion of right
foot. The patient scored pain was 80 mm on a 100-mm visual ana-
log scale (VAS). To better clarify diagnosis, an X-ray scan of the right
foot was performed, revealing a heel spur, thereby ruling out other
possible sources of pain such as fracture or osteochondritis (Fig. 1).
A magnetic resonance imaging (MRI) scan revealed strong edema
in the insertion of both plantar fasciae and in the fat tissue below.
The plantar aponeurosis was also visibly thickened and on the right
side edema in the trabecular bone of calcaneus was evident (Fig. 2).
Hemato-chemical parameter investigation was normal, with the
exception of a slight eosinophilia (8.1%). Furthermore, no clinical or
instrumental signs of arthritis could be detected at this stage. On the
basis of clinical and radiographic features, diagnosis of PF was made
and a session of three ESWT applications was scheduled. Severe
symptomatic worsening at the second application, however, lead
the patient to give up therapy. At this time the pain was unbearable
and the patient was extremely discouraged about her clinical sta-
tus. As all proposed interventions failed and as the patient refused
surgical treatment we decided, as an ex adiuvantibus criterion, to
remove gluten from her diet for two weeks to understand if it could
Fig. 2. The sagittal T1-weighted MRI reveals a thickened plantar aponeurosis
(arrow) at and anterior to the calcaneal attachment. A small plantar calcaneal osteo-
phyte (arrowhead) is also evident.
Please cite this article in press as: Paoloni M, et al. Complete remission of plantar fasciitis with a gluten-free diet: Relationship or just
coincidence? Foot (2014), http://dx.doi.org/10.1016/j.foot.2014.06.004
mitigate the pain. A clinical control was than performed after this
period and the patient referred a marked reduction of pain (VAS
15/100 mm). We therefore reintroduced the gluten in to her diet in
order to collect her immune-serology. A panel of CD antibodies was
prescribed, including immunoglobulin (Ig)G and IgA antiendomy-
sium (EMA), antitransglutaminase (hTTG) and antigliadin (AGA),
all of which resulted negative. The heel pain, meanwhile, reap-
peared up to a moderate/severe level (VAS 60/100). The patient
was referred to a Gastroenterology service to perform biopsy of
the small intestine, but she refused to perform the test. Gluten was,
therefore, newly removed from her diet.
Moreover, due to the presence of eosinophilia at the previous
hemato-chemical examination, a stool microscopic and parasito-
logical investigation was prescribed, which showed the presence of
Candida colonies and of some Giardia Lamblia cysts. For this reason
an appropriate therapy was prescribed (paromomycin sulfate). The
patient was clinically re-evaluated 1 month after the gluten-free
diet started. On this occasion she referred a complete disappear-
ance of foot pain (VAS 0 mm). She also reported that walking was
no longer painful, nor was dancing for that matter and that she
could comfortably wear any kind of shoes. The patient remained
in our care and no longer suffered pain or symptoms for 9 months
after the diet had started.
3. Discussion
The most important nding in our case report is that the patient
had severe PF lasting 2 years, resistant to all the conservative treat-
ments prescribed that suddenly improved after a gluten-free diet,
despite negative CD serology. The most useful marker for diagno-
sis of CD is the study of IgA EMA, although the absence of positive
serological markers does not completely exclude it [7]. Moreover, it
should be considered that serum EMA and hTTG antibodies behav-
ior is not a permanent, life-long feature whereby the repetition of
EMA or hTTG antibodies assays must be recommended in the same
patient. Though serological testing is often a good means for diag-
nosing CD, the use of endoscopy and biopsy are the gold standard.
The diagnosis of CD disease is based on the presence of characteris-
tic lesions in small-intestinal biopsy samples, and four endoscopic
biopsies are necessary for absolute diagnostic certainty [8]. In our
case report we did not perform a biopsy to conrm diagnosis and
since the pain suddenly improved and completely disappeared, we
never scheduled a post-treatment biopsy. For this reason, and due
to the negative serology, we actually do not have a conrmed diag-
nosis of CD, despite the efcacy of gluten-free diet treatment lead
us to strongly suspect a relationship between gluten intake and
heel pain.
The spectrum of gluten-related disorders, in fact, comprises,
besides CD and wheat allergy, a relatively new entity, repre-
sented by non-celiac gluten sensitivity (NCGS) [9]. This disorder,
whose prevalence, as well as pathophysiology are still uncertain,
is generally characterized by both intestinal and extra-intestinal
symptoms, that show a rapid appearance after gluten ingestion
and a rapid relief after gluten withdrawal [10]. It has been recently
proposed that subjects with negative celiac serologies on a regular
diet are unlikely to have CD, and that those with negative serology
who also lack clinical evidence of malabsorption and CD risk factors
are highly likely to have NCGS and may not require further testing
[11]. Remarkably our patient never complained gastrointestinal nor
malabsorption symptoms.
In our case study, we also found and treated an intestinal gia-
rdiasis, a parasitological infection frequently associated with CD
[12]. One hypothesis may be that pain disappearance was due to
the pharmacological treatment for intestinal giardiasis rather than
to the gluten-free diet. Regression of intestinal damage, i.e., has
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M. Paoloni et al. / The Foot xxx (2014) xxxxxx
been reported in a young child with CD only as a consequence of
his intestinal giardiasis treatment [13]. Pharmacological treatment
for giardiasis, however, began in our patient only after the gluten-
free diet started and symptoms disappeared. We might therefore
exclude that pain control was obtained through the paromomycin
sulfate use. As our patient never referred any gastrointestinal symp-
toms nor musculoskeletal pain, something happened to cause the
pain. We may speculate that giardiasis has led to an altered intesti-
nal permeability that would have caused a temporary increased
susceptibility to dietary antigen loads in a vulnerable subject. The
increased intestinal permeability, in fact, lead to a greater exposure
to bacterial and dietary antigens. Normally, the antigenic expo-
sure to the complex microora composed of aerobic and anaerobic
bacteria harboring in the human gut results in tolerance rather
than immunity. However, when this local tolerance is harmed, as
happens in inamed intestinal tissue, an increased susceptibility
to an antigenic load occurs. The increased intestinal permeability
commonly observed in course of CD, in fact, may determine other
associated symptoms, including musculoskeletal and rheumatic
complaints [14].
As a matter of fact, a growing interest can be found in the
scientic literature for the interaction between gluten and mus-
culoskeletal complaints, as demonstrated by recent evidences of
symptoms remission in patients with bromyalgia [15].
From this point of view, as recently pointed out in other research
[14], careful attention should be given to those musculoskeletal
pain which are resistant to conventional therapies.
In these cases, the diagnostic process should take in to account
the possibility of differential diagnosis with pathologies that may
be apparently different from musculoskeletal ones.
On the basis of this experience, clinical trials should be sched-
uled for the future to determine if an association exists between
some kinds of PF and gluten-sensitivity.
Obviously, the possibility that PF in our patient spontaneously
remitted could also be taken into account, although this is highly
unlikely considering the temporal sequence of events.
Ethical approval
Written informed consent was obtained from the patient for
publication of this case report and any accompanying images.
Please cite this article in press as: Paoloni M, et al. Complete remission of plantar fasciitis with a gluten-free diet: Relationship or just
coincidence?
The Foot (2014),
author has requested http://dx.doi.org/10.1016/j.foot.2014.06.004
enhancement of the downloaded file. All in-text references underlined in blue are linked to publications on ResearchGate.
3
Conicts of interest
None of the authors has any conicts of interest to declare.
Authors contribution
Each author has made substantial contributions to case report
descriptions, has been involved in drafting the manuscript and has
given nal approval to the version to be published.
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