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Plantar Fasciitis

Plantar Fasciitis. Kevin deWeber, MD Primare Care Sports Medicine. 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.

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Plantar Fasciitis

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  1. Plantar Fasciitis Kevin deWeber, MD Primare Care Sports Medicine

  2. 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

  3. 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

  4. Patho-physiology • Micro-tears of fascia from repetitive trauma • Degeneration of collagen • More similar to tendonosis than -itis

  5. 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

  6. 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

  7. History • Training regimen (any changes prior?) • Exacerbating activities • Duration • Past treatments • Other medical problems • Miles on running shoes

  8. Examination • Establish point of maximal tenderness • Evaluate for other tenderness • Ankle ROM (tight Achilles?) • Evaluate longitudinal arches • Look at running shoes/boots

  9. Ankle ROM

  10. Radiology? • Rarely useful; not needed in most cases • What about heel spurs? • Probably negligible • 13% prevalence • only 5% of those c/o heel pain

  11. 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)

  12. Overuse Injury Management Pyramid Sports participation 5. Rehab exercise 4. Correct predispositions 3. Control abuse/promote healing 2. Control inflammation 1. Make accurate patho-anatomical diagnosis

  13. 1. Control inflammation • Ice massage • NSAID • Iontopheresis • Steroid injection

  14. Control inflammation (cont):Ice Massage • 15 minutes rolling on frozen juice can • Ice baths • After activity, several times a day

  15. Control inflammation (cont):NSAID • Short course, 2 weeks • Largely analgesic properties • Useful, but MINOR role in treatment

  16. 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

  17. 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%)

  18. Plantar fascia injection 5 ml 1% lidocaine AND 40 mg triamcinolone/Prednisolone OR 6 mg Betameth/Dexameth

  19. 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

  20. 3. Promote healing • Tension night splint

  21. 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%

  22. 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

  23. 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

  24. Night splint conclusions • Mixed results in studies • May try if initial response poor

  25. 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)

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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)

  32. 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

  33. 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

  34. Poor response after 2 months • Make sure patient is doing what you Rx’d • Discuss option of steroid injection x 1

  35. 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

  36. In the research pipeline • Lithotripsy • Europe • Possible alternative to surgery for chronic PF

  37. 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

  38. Questions?

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