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Plantar Fasciitis
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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
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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
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Patho-physiology
• Micro-tears of fascia from repetitive trauma
• Degeneration of collagen
• More similar to tendonosis than -itis
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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
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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
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History
• Training regimen (any changes prior?)
• Exacerbating activities
• Duration
• Past treatments
• Other medical problems
• Miles on running shoes
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Examination
• Establish point of maximal tenderness
• Evaluate for other tenderness
• Ankle ROM (tight Achilles?)
• Evaluate longitudinal arches
• Look at running shoes/boots
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Ankle ROM
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Radiology?
• Rarely useful; not needed in most cases
• What about heel spurs?– Probably negligible
• 13% prevalence
• only 5% of those c/o heel pain
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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)
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Overuse Injury Management Pyramid
1. Make accurate patho-anatomical diagnosis
2. Control inflammation
5. Rehab exercise
4. Correct predispositions
3. Control abuse/promote healing
Sportsparticipation
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1. Control inflammation
• Ice massage
• NSAID
• Iontopheresis
• Steroid injection
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Control inflammation (cont):
Ice Massage• 15 minutes rolling on frozen juice can
• Ice baths
• After activity, several times a day
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Control inflammation (cont):
NSAID• Short course, 2 weeks
• Largely analgesic properties
• Useful, but MINOR role in treatment
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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
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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%)
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Plantar fascia injection5 ml 1% lidocaine AND40 mg triamcinolone/Prednisolone OR
6 mg Betameth/Dexameth
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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
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3. Promote healing• Tension night splint
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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%
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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
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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
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Night splint conclusions
• Mixed results in studies
• May try if initial response poor
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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)
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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
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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
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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
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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
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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
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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)
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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
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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
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Poor response after 2 months
• Make sure patient is doing what you Rx’d
• Discuss option of steroid injection x 1
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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
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In the research pipeline
• Lithotripsy– Europe– Possible alternative to surgery for chronic PF
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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
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Questions?