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 Sports participation

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 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 5 ml 1% lidocaine AND 40 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 –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 protocol New 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?