Plantar Fasciitis Dick Evans PT,OCS

Plantar Fascia Thick broad connective tissue that spans the arch of the foot Originates on the medial tubercle of the calcaneus and inserts onto the proximal phalanges and flexor tendon sheaths Forms longitudinal arch of the foot and functions as a shock absorber Supports the arch as weight is transferred over the foot from heel strike to toe off

Fasciitis??? A degenerative condition that may or may not be associated with inflammatory changes in the tissues Pain may be caused by repetitive micro trauma to the fascia

Frequency Occurs in 10 % of runners and may be associated with training errors Accounts for 11-15% of all foot symptoms requiring medial care

Symptoms Classic presentation: heel pain in the morning when first rising from bed May improve through the day but tends to hurt again by afternoon and evening. Reoccurs upon standing after prolonged sitting Worse with walking barefoot and walking up stairs

Physical Exam Tenderness to palpation on the anteromedial aspect of the heel Ankle dorsiflexion limited by calf tightness Pain increased by toe extension or by standing on toes

Risk Factors Obesity Occupation requiring prolonged standing Pes planus or cavus Calf tightness Toe runners, running up hills or in sand Rapid change in activity level: intensity or duration Lack of warm up or cold weather

Differential Diagnosis Tarsal tunnel Bone bruise or heel contusion Sever disease Calcaneal stress fracture Fat pad atrophy / central heel pain Inflammatory arthropathies Neuropathic pain Retrocalcaneal bursitis Achilles insertional pain

Prognosis 80% are better in 12 months Surgical intervention is rare

Treatment Activity modification Shoe inserts / orthotics / taping / supportive shoes Night splints Stretching program: arch, calf, soft tissue massage, ice Modalities : iontophoresis, ultrasound NSAIDS Corticosteroid injections Shock wave therapy

Treatment Plan Take away source of irritation: boot / crutches, if needed Stretching arch and calf and forefoot Ice Soft tissue massage: gentle to start, advance to aggressive as tolerated Open chain strengthening: manual, bands to both ankle and forefoot

Treatment Plan Advance to closed chain strengthening and balance work as symptoms allow Brisk walking, cross training, pain free Add light impact Phase return to run program, watch running form Gradual progressions : 10 % rule Sports specific return to activities

Mike Shaffer’s Concept of Dosing of Rehab in Evidence Based Medicine: “The Black Box” JOSPT – April 2008 : Clinical Guidelines related to Heel Pain-Plantar Fasciitis. Clinical practice guidelines linked to international classification of function, disability , and health from ortho section of APTA Panel of experts did a scientific review of the literature prior to may 2007, up for review again in 2012. Grade level of evidence I-V, grade of evidence A-F

Recommendations for Interventions: Strength of Evidence Summary Modalities: iontophoresis (dexamethasone 0.4% or acetic acid 5%) can provide short term (2-4 weeks) pain relief and improved function Stretching: calf and PF stretching can be used in short term (2-4 mo) for pain relief and improved calf flexibility. Dose of calf stretching is 2-3 x day, either sustained 3 min hold or 20 sec intermittent stretching hold time. . Both hold times produced a beneficial effect. Taping: provided short term pain relief ( 7-10 days)

Continued summary of recommendations Orthotics: Prefab or custom orthotics used to provide short term (3 mo ) pain reduction and improvement in function. No difference in pain reduction or function between the two types of orthotics. No evidence to support long term use greater than one year for pain management or functional improvement.

Continued summary of recommendations. Night splints: consider for patients with symptoms > 6 mo. The desired length of wearing time is 1-3 months. The type of night splint did not matter. ( ant, post or sock type). No super strong evidence for manual therapy (joint mobilization).

Conclusion: When does a presentation or research article “change how you practice” and when does it “guide how you practice” ????????????????????????????????? A potential future topic

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