1. Plantar Fasciitis
Dick Evans PT,OCS

2. 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

4. 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

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

6. 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

7. 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

8. 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

9. 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

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

11. 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

12. 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

13. 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

14. 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

15. 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)

16. 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.

17. 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).

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

19. THANKS