Heel pain: Plantar Fasciitis

1. Heel pain: Plantar Fasciitis Dr Isstelle Joubert May 2011

2. Presenting History: • Mr A, 39yo man • bilateral painful feet • one year history • gradual onset • no history of trauma or recent surgery lower limbs • job: salesman • Previous history: • Surgical: both ankles, knee and right arm fracture • Medical: gout, chronic sinusitis • Social: OH stop July 2010, non-smoker, 4L coke DAILY! • Family history: dad died age 48 - myocardial infarction

3. Clinical examination: • BP - 130/90 • BMI - 39.8 (W=138kg, H=184cm) • Examination of feet: • localized tenderness plantar aspects, • especially medial calcaneal tuberosities • Current chronic medication: • Puricos 300 i od (raised u/a) • Glucophage 500mg i od (raised insulin) • Lorien20mg i od (depressive mood)

4. Special investigations: • X-ray of both feet - “heel spurs” seen on X-ray Heel spur

5. Management: • Local infiltration of steroid (both heels) • Insoles in shoes • Weight loss advised • Follow-up: • one foot - totally pain free • other one - some discomfort

6. Three stage assessment: • Biological • change his current health status drastically - • diet, weight, level of exercise • Personal/Psychological impact • fear of loss of income if pain persists • stays at home when pain is unbearable • gets frustrated - conflict with clients • Social/contextual impact • expectations colleagues (not staying at home), • family (activity, diet - better quality of life)

7. Problem list: • Active - bilateral painful feet • Passive • obesity • hyperinsulinaemia • family history - MI • increased blood levels of uric acid • unhealthy diet • no exercise

8. Differential diagnosis: • Plantar fasciitis • Tibialis posterior syndrome • Referred pain as a result of a S1-radiculopathy • Stress fracture - calcaneal or navicular • Fat pad injury • Peripheral neurogenic pain: tibial nerve related • Trigger point pain

9. Plantar Fasciitis...

10. Synonyms: • painful heel syndrome • heel spur syndrome • runner’s heel • subcalcaneal bursitis • periostitis • policeman’s heel (most of day-time on their feet)1

11. Definition: • musculoskeletal disorder • affecting the plantar aponeurosis or fascia (inflammation) • mostly infero-medial aspect

12. Prevalence: • young and old • athletes and non-athletes • not gender specific2 • United States3,4 • 600 000 outpatient visits annually • athletes, 5 - 14%5 of running injuries

13. Anatomy of the foot and plantar fascia: • arises: medial process of calcaneal tuberosity • attachment: distally to plantar aspect of the forefoot, medial and lateral intermuscularsepta • mechanoreceptors respond to mechanical loading • noci-ceptorstransmit info on pain and inflammation6

14. Pathophysiology: • not well understood • mechanical overload and excessive strain • microscopic tears in the fascia • triggering the inflammatory repair processes • entesal fibrocartilage - prone to degenerative change • increase cartilage cell clustering • formation of fissures within the fibrocartilage • ossification = spurs

15. Differential diagnosis4,8,9:

16. Symptoms and signs: • pain inferior on heel • worse on weight bearing • worse: first few steps in the morning • persisting from months to years • character: throbbing or piercing • improves after resting - worsens again with continued activity throughout the day • limiting daily activities - walking barefoot, on toes or climbing stairs

17. tenderness localised to medial aspect of the calcaneal tuberosity

18. assessing gait: excessive supination or pronation

19. plantar fascia tight - stretching reproduce pain

20. Possible causes7:

21. Possible causes7... • Anatomical • Pesplanus (flat feet): strain - fascia try maintain stable arch • during the propulsive phase of gait • Pescavus (high arch): strain - decreased eversion - absorb shock • Activities • running / dancing: max plantarflexionankle + dorsiflexion MTP joints • Elderlypersons - non-supportive / inappropriate footwear10 • Obesity/increased work-related weight bearing • study found NO association for BMI11

22. Special investigations: • aim • confirm the diagnosis • modalities available • ultrasound • plain x-rays of feet • bone-scan • MRI • nerve conduction studies • blood tests

23. Special investigations: • Ultrasound • useful • non-invasive technique • increased thickness +hypo-echoic fascia

24. Special investigations: • Plain x-rays of feet • generally unhelpful • rule out stress fractures of calcaneus • calcifications noticed + osteophytes (heel spurs) • study: osteophytes visible • 50% withplantar fasciitis, • 19% withoutplantar fasciitis12

25. Special investigations: • Bone-scan • increased uptake at the calcaneus • not very specific technique • very sensitive • potential malignant bony lesions

26. Special investigations: • Magnetic Resonance Imaging (MRI) • thickening of the plantar fascia • detecting tears or rupture of the fascia

27. Special investigations: • Nerve conducting studies • no improvement in three months’ of conservative Rx • ? other causes: nerve entrapment / tarsal tunnel syndrome

28. Special investigations: • Blood tests • CRP - ? infection • HLA B27-genes - ? HLA-B27-spondyloarthropaties (psoriatic arthritis or ankylosing spondylitis) • uric acid - gout • raised ALP, normal PO4 + Ca2+ - ? Paget’s disease

29. Management: • Avoidance of aggravating activities • Cryotherapy • NSAID • Stretching • Taping • Foot orthoses • Night splinting • Soft tissue therapy • Corticosteroid injection • Iontophoresis16 • Extracorporeal shock wave therapy17,18 • Surgery

30. Management: • Avoidance of aggravating activities • Cryotherapy8↓ pain by • ↓ motor, sensory nerve conduction velocity • ↓ swelling, cellular metabolism • methods • reusable cold packs / crushed ice bags • ice massage / endothermalcold packs • (towel between bag and skin - avoid nerve damage/ frostbite) • on area of pain - 5 - 30 minutes • NSAID: orally / topically / injection (1st month of Rx) • ↓ local inflammation

31. Management: • Stretching7: • Focus on calf and Achilles tendon or plantar fascia itself • Key-component in Rx • Short term benefits • pain relief • increased calf flexibility • Long-term benefits • decrease in pain and functional limitations • high rate of satisfaction • effective • inexpensive • easy to implement-tool

32. Management: • Taping: • designed to provide inversion of the calcaneus • improving the biomechanical position and stability • limits the range of motion • increase proprioception • increase reduction of intensity of pain • Biomechanical correction with foot orthoses: • ↓ pain associated with plantar fasciitis14 • prefabricated foot orthoses+ stretching = ↓ pain • silicone heel pads / well supported arches and midsoles

33. Management: • Night splints or Strasbourg sock: • maintains ankle dorsiflexion and toe extension • constant mild stretch of fascia • allows heal at a functional length • indicated – no improvement after 6 months • wearing - 3 months

34. Management: • Soft tissue therapy: • manual therapeutic techniques • aim - restore normal muscle length + joints movement • Corticosteroid injection15 • advantages ↓ inflammatory process • outpatient basis • fast recovery • pain ↓ • risk of rupture of the plantar • mixture: • 4ml of local anaesthetic • 1ml of corticosteroid

35. Iontophoresis16 • topically applied steroid • Dexamethasone 0.4% or acetic acid 5% delivered topically • propelled into the injured tissue with a small electric charge • short term pain relief (2 - 4 weeks) Management:

36. Management: • Extracorporeal shock wave therapy17,18 • what: • stimulation healing of the soft tissue • reduction of calcification • inhibition of pain receptors or denervation • to achieve pain relief • proposed responses due to • release of enzymes • hyperstimulationof axons • release of nitrous oxide and growth factors • Three devices • OssaTron • Epos Ultra • Sonorex

37. ... Extracorporeal shock wave therapy17,18 • How? • conversion of electrical energy to mechanical energy

38. Management: • ... Extracorporeal shock wave therapy17,18 • four main goals • 50% improvement in pain from baseline • ↓ pain on rising, walking in morning of at least 50% • ↑ activity level + self-assessed ability to move pain free for time + distance • discontinuation of pain meds • Successful when: • all criteria are met in 3 - 12 months after treatment

39. Management: • Surgery: • Options isolated, partial or complete release • with or without the resection of the calcaneal spur • excision of abnormal tissue or nerve decompression • Open or via endoscopic approach • Who? moderate to severe symptoms • persistent • resistant in spite of conservative management • at least six months • Endoscopic procedures • more rapid recovery • return to pre-surgery activities

40. What is new / controversial in plantar fasciitis? • Shock waves • Elastography20 • Botulinum toxin A21 • Bipolar radiofrequency22 • Acupunture23 • Platelet rich plasma therapy24,25

41. What is new / controversial in plantar fasciitis? • Shock waves: • sound waves create vibrations • cause controlled injury to tissue • ↑ healing ability • ↑ repair process • Intracorporealpneumatic shock19 therapy vs extracorporeal shock wave therapy • energy generated inside / outside the body • when extracorporeal shock devices are not available • cheap, readily available, effective, safe

42. What is new / controversial in plantar fasciitis? • Elastography20 • new modality • measures tissue elasticity of plantar fascia • detect early stages of plantar fasciitis • ultrasonography (U/S): • U/S: 65.8% sensitivity, 75% specificity • elastography: 95% sensitivity, 100% specificity • sono-elastography ↑ accuracy of dx from 68% to 96% • staging of disease

43. What is new / controversial in plantar fasciitis? • Botulinum toxin A21: • improve pain relief and overall foot function • ease severe muscle contractions • decrease inflammatory reactions • diminish wrinkles + tension headaches • Dr Brodsky, president of American Orthopaedic Foot and Ankle Society • pain relief lasted at least one year • larger study under way • cost-effectiveness - $$ • refractory patients

44. What is new / controversial in plantar fasciitis? • Bipolar radiofrequency22: • minimally invasive technique • viable surgical treatment option • not improve on conservative measures • Acupunture23: • enhances inhibitory processes • by stimulation of trigger points • muscles and peripheral nerves • increase the concentration of endorphins in the CNS • decreasing local inflammation

45. What is new / controversial in plantar fasciitis? • Platelet rich plasma therapy24,25 (autologous growth factors) • new therapy • mid 1990’s for the discipline of maxillofacialsurgery • pain relief • long lasting healing of musculoskeletal conditions • sample of patient’s blood - centrifuge • separates platelets from other components • concentrated platelet rich plasma injected into site of injury • initiates an increased healing response • lasting results

46. Plantar Fasciitis • In conclusion... • think on your feet... • Be aware of many reasons for painful feet • Be aware of many management options

47. References: Akhtar A, Abbasie SH, Shami A et al. A comparative study of conventional versus interventional treatment in patients of plantar fasciitis. Ann Pak Inst Med Sci 2009; 5(2): 81-83 DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissue specific plantar fascia stretching exercise enhances outcomes in patients with chronic heel pain. The Journal of Bone and Joint Surgery 2003;85A:1270-77 Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int 2004; 25:303-10 Cole C, Seto C, Gazewood J. Plantar Fasciitis: evidence-based review of diagnosis and therapy. Am Fam Physician 2005;72:2237-42 Noakes T. Lore of Running. Human Kinetics 2001 Wearing SC, Smeathers JE, Urry SR et al. The pathomechanics of plantar fasciitis. Sports Med 2006;36 (7):585-611 Leaque AC. Current concepts Review: Plantar Fasciitis. Foot and Ankle international. 2008;29 (3) 358-366

48. References: Brukner P, Khan K. Clinical Sports Medicine 3rd edition. McGraw Hill 2002. Murphy C. Plantar Fasiitis. Sportex.net Riddle DL, Pulisic M, Pidcoe P, et al. Risk factors for plantar fasciitis: a matched case-control study. J Bone Joint Surg Br. 2003;85B (5): 872-7 Irving DB, Cook JL, Menz HB. Factors associated with chronic plantar heel pain: a systematic review. Journal of Science and Medicine in Sport 2006;9:11-22 DiMarcangelo MT, Yu TC. Diagnostic imaging of heel pain and plantar fasciitis. ClinPodiatr Med Surg 1997;14:281-301. Potter AJ. Investigating plantar Fasciitis. Foot and Ankle online Journal. Nov 2009 2(11):4. Hume P, Hopkins W, Rome K et al. Effectiveness of Foot orthoses for treatment and prevention of lower limb injuries. Sports Med 2008; 38 (9): 759-779

49. References: Wen-Chung T, Chih-Chin Hsu, Carl PC et al. Plantar fasciitis treated with local steroid injection: comparison between sonographic and palpation guidance. Journal of Clinical U/S Jan 2006 ; 34 (1) 12-16 Foye PM, Lorenzo CT. Physical medicine and rehabilitation for plantar fasciitis treatment and management. Sep 2010. Kaltenborn JM. The Efficacy of Extracorporeal shock-wave treatment: a new perspective. Human Kinetics. 2005;6:50-51 Moretti B, Garofalo R, Patella V et al. Extracorporeal shock wave therapy in runners with a symptomatic heel spur. Knee Surg Sports TraumatolArthrose 2006; 14:1029-1032 Dogramaci Y, Kalaci A, Emir A, Yanat AN, Gökce A. Intracorporeal pneumatic shock application for the treatment of chronic plantar fasciitis: a randomized, double blind prospective clinical trial. Arch Orthop Trauma Surg. 2010 Apr; 130 (4): 541-6. Epub 2009 Aug 11 Kapoor A, Sandhu HS, Sandhu PS et al. Realtimeelastography in plantar fasciitis: comparison with ultrasonography and MRI. Current orthopaedic practice. Nov/Dec 2010; 21(6): 600-608

50. References: Zablocki E. Botulinum toxin injection decreases plantar fascia pain. Medscape medical news. Nov 2005. Weil L Jnr, Glover JP, Weil LS Sr. A new minimally invasive technique for treating plantar fasciosis using bipolar radiofrequency: a prospective analysis. Foot Ankle Spec Feb 2008; 1 (1): 13-18 Perez-Millan R, Foster L. Low frequency electro-acupuncture in the management of refractory plantar fasciitis: a case series. Medical Acupuncture: a Journal for physicians by physicians. 2001(13) nr 1. Creaney L, Hamilton B. Growth factor delivery methods in management of sports injuries: the state of play. Br. J. Sports Med. Nov 2007. Barrett SL, Erredge SE . Growth Factors for Chronic Plantar Fasciitis? Podiatry Today. Nov 2004.