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Plantar Fasciitis

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

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Plantar Fasciitis

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  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

  3. 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

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

  5. 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

  6. 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

  7. 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

  8. 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

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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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)

  15. 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.

  16. 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).

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

  18. THANKS

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