Plantar Fasciitis Objectives Review the pathophysiology of PF

Plantar Fasciitis

Objectives • • • Review the patho-physiology of PF Review the underlying causes Review the numerous treatment methods Describe a rehabilitation program Recommend a return-to-play program

Magnitude of the problem • Affects 10% of runners • Affects numerous other athletes – soldiers – soccer, basketball, tennis, gymnastics, others • 2 million Americans treated per year • Significant interference in athletics

Patho-physiology • Micro-tears of fascia from repetitive trauma • Degeneration of collagen • More similar to tendonosis than -itis

Clinical features • Severe plantar foot pain aggravated by weight bearing with first steps of the AM • May improve after a few minutes of running, then worsen • Deep ache over anteromedial calcaneus • TTP over plantar medial calcaneal tubercle • Tight heel cord a common finding

Predisposing factors • Extrinsic factors – Training errors – Improper footwear (300 mile rule) – Unyielding running surfaces • Intrinsic factors – Pes planus w/ hyperpronation – Pes cavus w/ supination – Tight heel cords – Weak intrinsic foot muscles

History • • • Training regimen (any changes prior? ) Exacerbating activities Duration Past treatments Other medical problems Miles on running shoes

Examination • • • Establish point of maximal tenderness Evaluate for other tenderness Ankle ROM (tight Achilles? ) Evaluate longitudinal arches Look at running shoes/boots

Ankle ROM

Radiology? • Rarely useful; not needed in most cases • What about heel spurs? – Probably negligible • 13% prevalence • only 5% of those c/o heel pain

Differential Diagnosis • • Calcaneal stress fracture FHL tendonitis Tarsal tunnel syndrome Fat pad insufficiency Paget’s disease of bone Midfoot DJD Reiter’s syndrome (inflammatory arthritis)

Overuse Injury Management Pyramid Sports participation 5. Rehab exercise 4. Correct predispositions 3. Control abuse/promote healing 2. Control inflammation 1. Make accurate patho-anatomical diagnosis

1. Control inflammation • • Ice massage NSAID Iontopheresis Steroid injection

Control inflammation (cont): Ice Massage • 15 minutes rolling on frozen juice can • Ice baths • After activity, several times a day

Control inflammation (cont): NSAID • Short course, 2 weeks • Largely analgesic properties • Useful, but MINOR role in treatment

Control inflammation (cont): Iontopheresis • Ultrasound using corticosteroid cream • Six treatments over 2 weeks • One study: Ionto vs sham – more rapid sx relief and improvement at 2 wks – no better than sham at 1 month • Gudeman et al, Am J Sports Med 1997 • Marginal benefit • Consider cost and compliance

Control inflammation (cont): Steroid Injection • Quicker pain relief at 1 mo but no long-term advantage – Crawford et al, Rheum 1999. • Predisposes to PF rupture, which causes chronic pain – Acevedo JI et al, 1998: 765 pts tx’d for PF • Those tx’d w/ injection: 44 ruptures (10%) • Others: 7 ruptures (1%)

Plantar fascia injection 5 ml 1% lidocaine AND 40 mg triamcinolone/Prednisolone OR 6 mg Betameth/Dexameth

2. Protect from ongoing abuse • Only do activity that is NON-painful – cross training useful, e. g. bike, deep pool running – if running, less distance/hills/speed • Increase 10% a week, if improving • Expect 8 -12 weeks to resume full activity for athletes

3. Promote healing • Tension night splint

Studies on tension night splints • Batt et al, 1996 – 32 pts, randomized to 2 months tx • NSAID/heel cup/stretching: 35% “cured” – failures crossed-ever to TNS: 73% “cured” • Above + TNS: 100 /heel cup: 100% “cured” • Probe et al, 1999 – 116 pts randomized to 3 months tx • NSAID/stretching/shoe changes: 68% improved • Above + TNS: 68%

Studies on tension night splints (cont) • Barry et al, 2002 – 160 pts in retrospective study • Achilles stretching • TNS – TNS group had stat-sig • shorter recovery time • fewer f/u visits • fewer other interventions required

Studies on tension night splints (cont) • Martin JE at al, 2001 – 255 pts randomized to 3 months tx • Custom orthoses • OTC arch pads • TNS – NO stat-sig differences

Night splint conclusions • Mixed results in studies • May try if initial response poor

4. Correct predisposing factors • • Work on Achilles inflexibility Change running surface? New shoes? OTC arch pads – consider custom orthotics if no response • Educate on training principles (10% rule)

Which type of orthotic is best? • Pfeffer et al, Foot Ankle Int 1999. – 236 patients, tx’d w/ Achilles and PF stretching – Randomly assigned to 5 groups: • stretching alone: 72% improved • custom 3/4 length polypro orthoses: 68% • OTC arch pads (full length, felt): 81% • rubber heel cups: 88% • silicone heel inserts: 95% – Study problem: custom orthoses only 3/4 length • no motion control

Which type of orthotic is best? (cont) • Martin JE at al, 2001 – 255 pts randomized to 3 months tx • Custom orthoses • OTC arch pads • TNS – NO stat-sig differences

Which type of orthotic is best? (cont) • Lynch et al, J Am Pot Med Assoc 1998 – 103 patients randomized to 3 months tx • silicone heel cup plus APAP: 58% improved • steroid injection plus NSAID: 77% • Arch pads f/b custom orthosis: 96% – Good to fair improvement seen in 70% of orthosis group vs 30% other groups

Which type of orthosis is best? Conclusions: • Use low-cost orthoses first – OTC arch pads, OR – Heel cups, OR – Silicone heel pads • Consider custom arch pads if good response

5. Rehabilitative exercise: Principles • Overall flexibility puts less strain on PF – Achilles, longitudinal arch • Intrinsic foot muscles support the PF • Ankle stability reduces stress on PF • Improved running form protects the PF – lower leg strength and flexibility

Rehabilitative exercises • 1 -2 x/day Achilles stretching • Daily eccentric (stair edge) heel ex’s – 2 sets of 15 to fatigue • Barefoot heel/toe/backward walking while carrying weights • Towel toe-grabbing (intrinsic foot muscles) • Ankle tubing strength ex’s (inv/ev/DF)

Typical treatment protocol New patient • • • Profile to control abuse 2 wks piroxicam Ice massage 4 x/day OTC arch pads or gel heel cup Handout for exercises, esp heel stretching f/u 2 wks; reinforce need for rehab ex’s; modify profile

Poor response after 1 month • Add tension night splint (brace shop) • Refer for custom orthotics • Refer to Physical Therapy for more instruction on rehab • Consider steroid injection for those who require rapid pain relief/return to duty

Poor response after 2 months • Make sure patient is doing what you Rx’d • Discuss option of steroid injection x 1

PF Surgery • Indications – Failure of 12 months of conservative tx using multiple methods – 9 months of continuous profiles • Effectiveness 90% • Recovery several months • Evans Podiatry practice – write P 3 profile and refer for MMRB – rare surgery

In the research pipeline • Lithotripsy – Europe – Possible alternative to surgery for chronic PF

Summary • Time is required for recovery (pt ed) • Rehab exercise is critical in healing • Look for predisposing factors and correct them • Use multiple treatments • <10% need surgery

Questions?