“what do we know (or not know) about plantar fasciitis? scott t. doberstein, ms, atc, lat head...

““What Do We Know (or not What Do We Know (or not know) about Plantar know) about Plantar

Fasciitis?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

THE FOLLOWING PRESENTATION HAS BEEN APPROVED FORTHE FOLLOWING PRESENTATION HAS BEEN APPROVED FOR

[PROFESSIONAL AUDIENCES][PROFESSIONAL AUDIENCES]By the Wisconsin Athletic Trainers’ AssociationBy the Wisconsin Athletic Trainers’ Association

THIS PRESENTATION HAS NOT YET BEEN RATED THIS PRESENTATION HAS NOT YET BEEN RATED

THE FOLLOWING PRESENTATION HAS BEEN APPROVED FORTHE FOLLOWING PRESENTATION HAS BEEN APPROVED FOR

[PROFESSIONAL AUDIENCES][PROFESSIONAL AUDIENCES]By the Wisconsin Athletic Trainers’ AssociationBy the Wisconsin Athletic Trainers’ Association

THIS PRESENTATION HAS NOT YET BEEN RATED THIS PRESENTATION HAS NOT YET BEEN RATED

Graphic

© Scott T. Doberstein, MS, ATC, LAT

Overview… Overview… where are we headed?where are we headed?

Background Background Anatomy/Pathophysiology Anatomy/Pathophysiology EtiologyEtiologyDifferential DiagnosisDifferential DiagnosisClassic Presentation Classic Presentation Treatment Interventions Treatment Interventions PrognosisPrognosis


Background (What it is!)

PF most common cause of heel painPF most common cause of heel pain• 2 million pts seek Tx annually in US 2 million pts seek Tx annually in US (Riddle, (Riddle,

2003)2003)

• PF accounts for 11-15% of all foot S/S PF accounts for 11-15% of all foot S/S seeking professional care seeking professional care (Buchbinder, 2004)(Buchbinder, 2004)

• 10% of running related injuries 10% of running related injuries ((Buchbinder, 2004)Buchbinder, 2004)

PF most common condition Tx by podiatric PF most common condition Tx by podiatric foot/ankle specialists foot/ankle specialists (APMA, 2001)(APMA, 2001)


Background (What it is!)

1/3 of pts have bilateral PF 1/3 of pts have bilateral PF (Neufeld, 2008)(Neufeld, 2008)

10% probability of getting PF in lifetime 10% probability of getting PF in lifetime (Crawford, 2003)(Crawford, 2003)

Peak age of incidence is 40-60 y, Peak age of incidence is 40-60 y, especially women especially women (Riddle, 2003)(Riddle, 2003)


Background (What it isn’t!)

1812 – Wood first to describe PF as 1812 – Wood first to describe PF as infection secondary to TB infection secondary to TB (Neufeld, 2008)(Neufeld, 2008)

Fascial layer – not a tendon but…Fascial layer – not a tendon but…

Interesting tissue to treat!!Interesting tissue to treat!!


What is Plantar Fasciitis?

RECALCITRANT*RECALCITRANT*

HEEL PAIN!!HEEL PAIN!!

*(difficult to treat; resistant to commonly used treatments, Taber’s 2013)*(difficult to treat; resistant to commonly used treatments, Taber’s 2013)


Other names for Recalcitrant heel pain (What it is?)

Painful heel syndromePainful heel syndromeRunner’s heelRunner’s heelJogger’s heelJogger’s heelTennis heelTennis heelSubcalcaneal painSubcalcaneal painCalcaneodyniaCalcaneodyniaPlantar faschiopathyPlantar faschiopathyPLANTAR FASCIOSIS (new school)*PLANTAR FASCIOSIS (new school)*


Other names for Recalcitrant heel pain (What it isn’t?)

Heel spur syndromeHeel spur syndromeCalcaneal periostitisCalcaneal periostitisPLANTAR FASCIITIS (old school)*PLANTAR FASCIITIS (old school)*


Anatomy/Pathophysiology

PF function = provide support to med long PF function = provide support to med long arch, dynamic shock absorberarch, dynamic shock absorber

Windlass Effect = tensile force at proximal Windlass Effect = tensile force at proximal attachment with MTP extension attachment with MTP extension

PF is INFLEXIBLE – max elongation of 4% PF is INFLEXIBLE – max elongation of 4% (Lee,2007)(Lee,2007)

~ Age 40 – calcaneal fat pad breaks ~ Age 40 – calcaneal fat pad breaks

down = less shock absorption down = less shock absorption more more force on PF attachment force on PF attachment (Lee, 2007)(Lee, 2007)


Anatomy/PathophysiologyActually continuous with the Achilles Actually continuous with the Achilles

tendontendon Is it inflammation? Only acutely??Is it inflammation? Only acutely??Most of what we deal with is actually Most of what we deal with is actually

chronic!chronic!Lemont, 2003 = chronic degeneration Lemont, 2003 = chronic degeneration

• Resection of PF shows histological evidence Resection of PF shows histological evidence of PLANTAR FASCIOSIS not fasciitis!of PLANTAR FASCIOSIS not fasciitis!


Anatomy/PathophysiologyLemont, 2003 reported:Lemont, 2003 reported:

• Collagen necrosis and loss of collagen continuityCollagen necrosis and loss of collagen continuity• Increased ground substanceIncreased ground substance• Increased vascularityIncreased vascularity• Increased fibroblastsIncreased fibroblasts• No inflammation markers or cells (similar to No inflammation markers or cells (similar to

tendinosis) tendinosis)

Caused by repetitive microtears of PF that Caused by repetitive microtears of PF that overtake the body’s ability to repair itselfovertake the body’s ability to repair itself


Etiology = MULTIFACTORIAL

RISK FACTORS REPORTED:RISK FACTORS REPORTED:Decreased ankle DF ROMDecreased ankle DF ROMObesityObesityProlonged standingProlonged standingPes planus (excessive pronation)Pes planus (excessive pronation)Seronegative arthritisSeronegative arthritis


Etiology = MULTIFACTORIAL

Running is a risk factor:Running is a risk factor:• Increased distance/intensityIncreased distance/intensity• Poor footwearPoor footwear• Unyielding surfaceUnyielding surface• Pes cavusPes cavus• Shortened Achilles tendonShortened Achilles tendon


Etiology – What it isn’t!

Heel Spur – significant evidence that bony Heel Spur – significant evidence that bony exostosis does not cause PFexostosis does not cause PF• However, quite common to have an exostosis However, quite common to have an exostosis

simultaneously with PF but…the spur is NOT simultaneously with PF but…the spur is NOT the cause of PFthe cause of PF


Differential Diagnosis (What it isn’t!)

NeurologicNeurologic (tarsal tunnel syndrome, lateral plantar n. (tarsal tunnel syndrome, lateral plantar n. entrapment, medial calcaneal n. entrapment, peripheral neuropathy, entrapment, medial calcaneal n. entrapment, peripheral neuropathy, S1 radiculopathy)S1 radiculopathy)

Soft tissueSoft tissue (PF rupture, enthesopathies, fat pad atrophy, (PF rupture, enthesopathies, fat pad atrophy, Achilles tendinitis, flexor hallucis longus tendinitis, posterior tibialis Achilles tendinitis, flexor hallucis longus tendinitis, posterior tibialis tendinitis, plantar fibromatosis)tendinitis, plantar fibromatosis)

SkeletalSkeletal (calcaneal stress fracture, bone contusion, infection (calcaneal stress fracture, bone contusion, infection (osteomyelitis, etc), subtalar arthritis, inflammatory arthropathies)(osteomyelitis, etc), subtalar arthritis, inflammatory arthropathies)

MiscellaneousMiscellaneous (neoplasm, vascular insufficiency, (neoplasm, vascular insufficiency, osteomalacia, Paget’s disease, sickle cell disease)osteomalacia, Paget’s disease, sickle cell disease)


Classic Presentation Classic Presentation (What it is!)(What it is!)

Inferior heel pain (self limiting!)Inferior heel pain (self limiting!) Increased pain w/ first steps in morning =Increased pain w/ first steps in morning =

Post Static DyskinesiaPost Static Dyskinesia (McNally, 2010)(McNally, 2010)

Increased pain upon standing after Increased pain upon standing after prolonged sittingprolonged sitting

Increased pain during prolonged standingIncreased pain during prolonged standing Increased pain with barefoot walkingIncreased pain with barefoot walkingPain worsens near end of the dayPain worsens near end of the day


Classic Non-Presentation Classic Non-Presentation (What it isn’t!)(What it isn’t!)

Inferior heel pain with multi-joint pain or Inferior heel pain with multi-joint pain or other ligament/tendon painother ligament/tendon pain

Nocturnal painNocturnal painFoot pain anywhere besides medial Foot pain anywhere besides medial

tubercle or medial longitudinal archtubercle or medial longitudinal archRadiating or neurological S/SRadiating or neurological S/S


Treatment Options ReportedTreatment Options Reported

Rest/modification of activityRest/modification of activity IceIceHeatHeatUltrasoundUltrasoundE-stimE-stim IontophoresisIontophoresisStrengthening Strengthening



MassageMassageNSAID’sNSAID’sStretching (both calf and PF specific)Stretching (both calf and PF specific)Night splintsNight splintsHeel cups/padsHeel cups/padsTapingTapingCastsCasts



Orthoses (custom and off the shelf)Orthoses (custom and off the shelf) Injections (corticosteroids, PRP, botulinum Injections (corticosteroids, PRP, botulinum

toxin)toxin)AccupunctureAccupunctureShockwave therapyShockwave therapyMagnetsMagnetsNutritional ConsiderationsNutritional ConsiderationsSurgerySurgery


Evidence - Based OutcomesEvidence - Based Outcomes

20-30 interventions out there being used20-30 interventions out there being usedDifficult to research with RCT’sDifficult to research with RCT’s

• Many management strategies are used Many management strategies are used simultaneously = too many variablessimultaneously = too many variables

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


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



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



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



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, FInjections (corticosteroids only) C

• Only ST relief up to 2 weeks• Significant risk of PF rupture (better with US

guided technique)


Other Interventions

Extracorporeal Shock Wave Therapy CAutologous Platelet Rich Plasma CIt’s the SHOES (ADL’s vs. activity) E,FNutritional Considerations (Roxas, 2005) E, F

• Vitamin C• Zinc CT repair/regen• Glucosamine• Bromelain (pineapple enzyme) • Fish oil anti-inlam


What does all this mean for us as clinicians treating patients with plantar fasciosis/fasciopathy?



What it isn’t!

Where science meets art….???Where science meets art….???

OROR


What is it?

Where art meets science…….??Where art meets science…….??

““No evidence strongly supports the No evidence strongly supports the effectiveness of any treatment of PF, effectiveness of any treatment of PF, and most patients improve without and most patients improve without specific therapy or by using specific therapy or by using conservative measures.” conservative measures.” (Cole, 2005)(Cole, 2005)

Intervention Algorithms?x4

Young, 20011. Correct training errors, relative rest, ice post

activity, inspect footwear 2. Correct biomechanical factors with stretching

and strengthening3. Night splints and orthotics4. All other Tx options considered NSAID’s used throughout Tx but… pt

educated that meds are used for pain control and not curative!


Intervention Algorithms?

Cole, 20051. 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



Neufeld, 20081. 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.



Neufeld, 20084. 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



Rompe, 20091. 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



Prognosis

Hastened recovery if Tx initiated w/in 6 Hastened recovery if Tx initiated w/in 6 wks of onset wks of onset (Young, 2001)(Young, 2001)

Non-surgical mgmt success rate = 90% Non-surgical mgmt success rate = 90% (Neufeld, 2008)(Neufeld, 2008)

80% of pts have favorable results w/in 12 80% of pts have favorable results w/in 12 months months (Rompe, 2009)(Rompe, 2009)

Further Research

We need more research on many We need more research on many interventions to get a better handle on this interventions to get a better handle on this significant problem!!!significant problem!!!

On the horizon…..??On the horizon…..??• Injections of botulinum toxin• Injections of autologous platelet rich plasma• Anything else you can think of??????



Thank You

Enjoy the rest of the

Symposium!

“what do we know (or not know) about plantar fasciitis? scott t. doberstein, ms, atc, lat head...

Documents

lat background

pf accounts

graphic slide

lat overview

recalcitrant heel pain

pf attachment lee

bilateral pf neufeld

mtp extension pf