Transcript (or not know) About Plantar Fasciitis

“What Do We Know (or not
know) about Plantar
Fasciitis?
Scott T. Doberstein, MS, ATC, LAT
Head Athletic Trainer/Senior Lecturer
University of Wisconsin – La Crosse
Wisconsin Athletic Trainers’ Association
Annual Meeting & Symposium
Wisconsin Dells, WI
April 12, 2013
Graphic
THE FOLLOWING PRESENTATION HAS BEEN APPROVED FOR
[PROFESSIONAL AUDIENCES]
By the Wisconsin Athletic Trainers’ Association
THIS PRESENTATION HAS NOT YET BEEN RATED
Overview… where are we headed?
Background
Anatomy/Pathophysiology
Etiology
Differential Diagnosis
Classic Presentation
Treatment Interventions
Prognosis
© Scott T. Doberstein, MS, ATC, LAT
Background (What it is!)
PF most common cause of heel pain
• 2 million pts seek Tx annually in US (Riddle,
2003)
• PF accounts for 11-15% of all foot S/S
seeking professional care (Buchbinder, 2004)
• 10% of running related injuries (Buchbinder, 2004)
PF most common condition Tx by podiatric
foot/ankle specialists (APMA, 2001)
© Scott T. Doberstein, MS, ATC, LAT
Background (What it is!)
1/3 of pts have bilateral PF (Neufeld, 2008)
10% probability of getting PF in lifetime
(Crawford, 2003)
Peak age of incidence is 40-60 y,
especially women (Riddle, 2003)
© Scott T. Doberstein, MS, ATC, LAT
Background (What it isn’t!)
1812 – Wood first to describe PF as
infection secondary to TB (Neufeld, 2008)
Fascial layer – not a tendon but…
Interesting tissue to treat!!
© Scott T. Doberstein, MS, ATC, LAT
What is Plantar Fasciitis?
RECALCITRANT*
HEEL PAIN!!
*(difficult to treat; resistant to commonly used treatments, Taber’s 2013)
© Scott T. Doberstein, MS, ATC, LAT
Other names for Recalcitrant
heel pain (What it is?)
Painful heel syndrome
Runner’s heel
Jogger’s heel
Tennis heel
Subcalcaneal pain
Calcaneodynia
Plantar faschiopathy
PLANTAR FASCIOSIS (new school)*
© Scott T. Doberstein, MS, ATC, LAT
Other names for Recalcitrant
heel pain (What it isn’t?)
Heel spur syndrome
Calcaneal periostitis
PLANTAR FASCIITIS (old school)*
© Scott T. Doberstein, MS, ATC, LAT
Anatomy/Pathophysiology
PF function = provide support to med long
arch, dynamic shock absorber
Windlass Effect = tensile force at proximal
attachment with MTP extension
PF is INFLEXIBLE – max elongation of 4%
(Lee,2007)
~ Age 40 – calcaneal fat pad breaks
down = less shock absorption  more
force on PF attachment (Lee, 2007)
© Scott T. Doberstein, MS, ATC, LAT
Anatomy/Pathophysiology
Actually continuous with the Achilles
tendon
Is it inflammation? Only acutely??
Most of what we deal with is actually
chronic!
Lemont, 2003 = chronic degeneration
• Resection of PF shows histological evidence
of PLANTAR FASCIOSIS not fasciitis!
© Scott T. Doberstein, MS, ATC, LAT
Anatomy/Pathophysiology
Lemont, 2003 reported:
•
•
•
•
•
Collagen necrosis and loss of collagen continuity
Increased ground substance
Increased vascularity
Increased fibroblasts
No inflammation markers or cells (similar to
tendinosis)
Caused by repetitive microtears of PF that
overtake the body’s ability to repair itself
© Scott T. Doberstein, MS, ATC, LAT
Etiology = MULTIFACTORIAL
RISK FACTORS REPORTED:
Decreased ankle DF ROM
Obesity
Prolonged standing
Pes planus (excessive pronation)
Seronegative arthritis
© Scott T. Doberstein, MS, ATC, LAT
Etiology = MULTIFACTORIAL
Running is a risk factor:
•
•
•
•
•
Increased distance/intensity
Poor footwear
Unyielding surface
Pes cavus
Shortened Achilles tendon
© Scott T. Doberstein, MS, ATC, LAT
Etiology – What it isn’t!
Heel Spur – significant evidence that bony
exostosis does not cause PF
• However, quite common to have an exostosis
simultaneously with PF but…the spur is NOT
the cause of PF
© Scott T. Doberstein, MS, ATC, LAT
Differential Diagnosis
(What it isn’t!)
Neurologic (tarsal tunnel syndrome, lateral plantar n.
entrapment, medial calcaneal n. entrapment, peripheral neuropathy,
S1 radiculopathy)
Soft tissue (PF rupture, enthesopathies, fat pad atrophy,
Achilles tendinitis, flexor hallucis longus tendinitis, posterior tibialis
tendinitis, plantar fibromatosis)
Skeletal (calcaneal stress fracture, bone contusion, infection
(osteomyelitis, etc), subtalar arthritis, inflammatory arthropathies)
Miscellaneous (neoplasm, vascular insufficiency,
osteomalacia, Paget’s disease, sickle cell disease)
© Scott T. Doberstein, MS, ATC, LAT
Classic Presentation
(What it is!)
Inferior heel pain (self limiting!)
Increased pain w/ first steps in morning =
Post Static Dyskinesia (McNally, 2010)
Increased pain upon standing after
prolonged sitting
Increased pain during prolonged standing
Increased pain with barefoot walking
Pain worsens near end of the day
© Scott T. Doberstein, MS, ATC, LAT
Classic Non-Presentation
(What it isn’t!)
Inferior heel pain with multi-joint pain or
other ligament/tendon pain
Nocturnal pain
Foot pain anywhere besides medial
tubercle or medial longitudinal arch
Radiating or neurological S/S
© Scott T. Doberstein, MS, ATC, LAT
Treatment Options Reported
Rest/modification of activity
Ice
Heat
Ultrasound
E-stim
Iontophoresis
Strengthening
© Scott T. Doberstein, MS, ATC, LAT
Treatment Options Reported
Massage
NSAID’s
Stretching (both calf and PF specific)
Night splints
Heel cups/pads
Taping
Casts
© Scott T. Doberstein, MS, ATC, LAT
Treatment Options Reported
Orthoses (custom and off the shelf)
Injections (corticosteroids, PRP, botulinum
toxin)
Accupuncture
Shockwave therapy
Magnets
Nutritional Considerations
Surgery
© Scott T. Doberstein, MS, ATC, LAT
Evidence - Based Outcomes
20-30 interventions out there being used
Difficult to research with RCT’s
• Many management strategies are used
simultaneously = too many variables
© Scott T. Doberstein, MS, ATC, LAT
Evidence - Based Medicine
Grades of Evidence (McPoil, 2008)
A = strong evidence
B = moderate evidence
C = weak evidence
D = conflicting evidence
E = theoretical/foundational evidence
F = expert opinion
© Scott T. Doberstein, MS, ATC, LAT
Evidence - Based Outcomes
(McPoil, 2008)
Most significant risk factors are limited DF
ROM and obesity  B
S/S including pain in plantar medial heel,
post static dyskinesia, prolonged standing,
pain w/ initial steps following inactivity  B
Evaluation findings including decreased DF
ROM, palpable pain at proximal PF
attachment, + Windlass test  B
© Scott T. Doberstein, MS, ATC, LAT
Evidence - Based Outcomes
(McPoil, 2008)
Iontophoresis (dexamethasone or acetic
acid)  B
• Only short term relief of 2-4 weeks
Manual Therapy (specific ankle/foot/MTP joint
mobilizations)  E
Taping (calcaneal and low dye)  C
• Only short term relief of 7-10 days
© Scott T. Doberstein, MS, ATC, LAT
Evidence - Based Outcomes
(McPoil, 2008)
Stretching (both calf/Achilles and PF
specific)  B
• ST relief for 2-4 months
• Remember Achilles and PF have continuous
fibers!
Orthoses (both custom and prefabricated)
• ST relief for ~ 3 months  A
• LT relief at 1year  F
© Scott T. Doberstein, MS, ATC, LAT
Evidence - Based Outcomes
(McPoil, 2008)
Night Splints (posterior, anterior, sock type)
• Only use after 6 months of S/S and use only for
1-3 months  B
NSAID’s – no RCT studies at all  E, F
Injections (corticosteroids only)  C
• Only ST relief up to 2 weeks
• Significant risk of PF rupture (better with US
guided technique)
© Scott T. Doberstein, MS, ATC, LAT
Other Interventions
Extracorporeal Shock Wave Therapy  C
Autologous Platelet Rich Plasma  C
It’s the SHOES (ADL’s vs. activity)  E,F
Nutritional Considerations (Roxas, 2005)  E, F
•
•
•
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Vitamin C
Zinc
CT repair/regen
Glucosamine
Bromelain (pineapple enzyme)
Fish oil
anti-inlam
© Scott T. Doberstein, MS, ATC, LAT
What does all this mean for us as
clinicians treating patients with
plantar fasciosis/fasciopathy?
© Scott T. Doberstein, MS, ATC, LAT
What it isn’t!
Where science meets art….???
OR
© Scott T. Doberstein, MS, ATC, LAT
What is it?
Where art meets science…….??
“No evidence strongly supports the
effectiveness of any treatment of PF,
and most patients improve without
specific therapy or by using
conservative measures.” (Cole, 2005)
© Scott T. Doberstein, MS, ATC, LAT
Intervention Algorithms?
x4
Young, 2001
1. Correct training errors, relative rest, ice post
activity, inspect footwear
2. Correct biomechanical factors with stretching
and strengthening
3. Night splints and orthotics
4. All other Tx options considered
 NSAID’s used throughout Tx but… pt
educated that meds are used for pain control
and not curative!
© Scott T. Doberstein, MS, ATC, LAT
Intervention Algorithms?
Cole, 2005
1. Shoe inserts, stretching, NSAID’s, ice
(because it works for other musculoskeletal
conditions making it reasonable to do)
2. Corticosteroid injection or dexamethasone
iontophoresis
3. Night splints, ESWT (but only for runners w/ S/S
> 1 year)
4. Possible surgery
© Scott T. Doberstein, MS, ATC, LAT
Intervention Algorithms?
Neufeld, 2008
1. ADL’s as tolerated, NSAID’s , heel pads,
prefabricated orthotics, calf & PF stretching,
night splint, pt assured surgery uncommon,
dispel myths about heel spur not causing PF,
4-6 weeks
2. Corticosteroid injection followed by cast or
cam walker
3. Custom orthoses w/ deep heel cup, Rx
strength NSAID’s, lateral x-ray to r/o other
pathology
cont.
© Scott T. Doberstein, MS, ATC, LAT
Intervention Algorithms?
Neufeld, 2008
4. Continue above if improvement is
progressing  d/c
5. If no improvement, MRI to confirm PF, ESWT
or other alternative Tx
6. Surgery if S/S > 1 year
© Scott T. Doberstein, MS, ATC, LAT
Intervention Algorithms?
Rompe, 2009
1. R/O neuro and osseous pathologies
2. PF specific stretching for 6-12 weeks
3. continue stretching, modify activity, soft heel pads for
another 6-12 weeks
4. continue above, night splints, ionto 6-12 wks
5. continue above, ESWT, corticosteroid injection
6. botulinum toxin
7. Surgery after 6-12 months of unsuccessful mgmt
© Scott T. Doberstein, MS, ATC, LAT
Prognosis
Hastened recovery if Tx initiated w/in 6
wks of onset (Young, 2001)
Non-surgical mgmt success rate = 90%
(Neufeld, 2008)
80% of pts have favorable results w/in 12
months (Rompe, 2009)
© Scott T. Doberstein, MS, ATC, LAT
Further Research
We need more research on many
interventions to get a better handle on this
significant problem!!!
On the horizon…..??
• Injections of botulinum toxin
• Injections of autologous platelet rich plasma
• Anything else you can think of??????
© Scott T. Doberstein, MS, ATC, LAT
Thank You
Enjoy the rest of the
Symposium!
© Scott T. Doberstein, MS, ATC, LAT