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Plantar Fasciitis. Kevin deWeber, MD Primare Care Sports Medicine. 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.

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plantar fasciitis

Plantar Fasciitis

Kevin deWeber, MD

Primare Care Sports Medicine

objectives
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
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
Patho-physiology
  • Micro-tears of fascia from repetitive trauma
  • Degeneration of collagen
  • More similar to tendonosis than -itis
clinical features
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
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
History
  • Training regimen (any changes prior?)
  • Exacerbating activities
  • Duration
  • Past treatments
  • Other medical problems
  • Miles on running shoes
examination
Examination
  • Establish point of maximal tenderness
  • Evaluate for other tenderness
  • Ankle ROM (tight Achilles?)
  • Evaluate longitudinal arches
  • Look at running shoes/boots
radiology
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
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
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
1. Control inflammation
  • Ice massage
  • NSAID
  • Iontopheresis
  • Steroid injection
control inflammation cont ice massage
Control inflammation (cont):Ice Massage
  • 15 minutes rolling on frozen juice can
  • Ice baths
  • After activity, several times a day
control inflammation cont nsaid
Control inflammation (cont):NSAID
  • Short course, 2 weeks
  • Largely analgesic properties
  • Useful, but MINOR role in treatment
control inflammation cont iontopheresis
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
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
Plantar fascia injection

5 ml 1% lidocaine AND

40 mg triamcinolone/Prednisolone OR 6 mg Betameth/Dexameth

2 protect from ongoing abuse
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
3. Promote healing
  • Tension night splint
studies on tension night splints
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
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 cont26
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
Night splint conclusions
  • Mixed results in studies
  • May try if initial response poor
4 correct predisposing factors
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
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
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 cont31
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
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
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
Rehabilitative exercises
  • 1-2x/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
Typical treatment protocolNew patient
  • Profile to control abuse
  • 2 wks piroxicam
  • Ice massage 4x/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
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
Poor response after 2 months
  • Make sure patient is doing what you Rx’d
  • Discuss option of steroid injection x 1
pf surgery
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 P3 profile and refer for MMRB
    • rare surgery
in the research pipeline
In the research pipeline
  • Lithotripsy
    • Europe
    • Possible alternative to surgery for chronic PF
summary
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