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

1. Make accurate patho-anatomical diagnosis

2. Control inflammation

5. Rehab exercise

4. Correct predispositions

3. Control abuse/promote healing

Sportsparticipation

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 injection5 ml 1% lidocaine AND40 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

• 1-2x/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 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

• 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 P3 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?