PLANTAR FASCIITIS. Plantar Fasciitis. Plantar Fasciitis. Heel Pain - common causes. Plantar Fasciitis 1/16/2012. Robert A Erdin III, MD

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1 PLANTAR FASCIITIS Robert A Erdin III, MD Special thanks to the AOFAS and David Richardson MD for slide reproductions Most common symptom related to the foot leading a patient to seek professional care May occur at any age Race and ethnicity yplay no role Middle-aged women appear to have the highest incidence in particular However, over all age ranges, heel pain, and specifically plantar fasciitis, appears equally in men and women Definition repetitive tensile overload of plantar fascia origin leads to degeneration and attenuation Pathomechanics windlass mechanism Equinus contraction recurrent microtrauma microtears in plantar fascia microavulsions from origin Risk Factors: Limited ankle dorsiflexion due to tightness of the Achilles tendon Obesity Prolonged weight bearing Heel Pain - common causes Plantar fasciitis Calcaneal stress fracture Central heel pain (fat pad atrophy or contusion) Entrapment of the 1 st branch of the lateral plantar nerve 1

2 Other Entities in the Differential Calcaneal apophysitis (Sever disease) Plantar fascia rupture Tumor (e.g. osteoid osteoma, intraosseous ganglion) g Tarsal tunnel syndrome Gout Inflammatory arthropathies (e.g. Psoriatic arthritis) SYMPTOMS Pain at its worst first steps in the morning first steps after prolonged sitting patients t can typically point to area of maximal tenderness point specific, not diffuse Pain that worsens with prolonged activity History Often reports start-up inferior heel pain May walk on their toes for the first few steps Pain usually lessens with ambulation and increases with activity, especially on hard surfaces Anatomy Aponeurosis Origin: os calcis Insertion: sesamoids of the great toe and the proximal phalanges of the lesser toes PHYSICAL EXAMINATION Tenderness medial tubercle of calcaneus (origin of PF) point specific and reproducible not diffuse central heel or mid arch tenderness Physical Exam: Plantar fasciitis Point of maximal tenderness May have Equinus contracture Compare plantar fascia of both feet place plantar fascia on stretch maximal toe and ankle dorsiflexion recreates windless mechanism 2

3 INVESTIGATIONS Diagnosis: based on characteristic history and exam Plain radiographs not needed first visit only if fail to improve (occult calcaneus stress fracture?) INVESTIGATIONS: X-Rays Role of heel spur spur at origin flexor digitorum brevis importance unknown 50% patients with PF have spur 50% patients with bilateral spurs only have pain on 1 side INVESTIGATIONS Technetium bone scan Limited Indications only if diagnosis in doubt and (ex. suspected stress fracture) MRI only if diagnosis in doubt rule out tumor suspect stress fracture Ultrasound MANAGEMENT Nonoperative mainstay of management high success rate 90% will resolve / burn out but resolution of symptoms can be slow 6 to 9 months of symptoms typical Recurrence is common NON-OPERATIVE TREATMENT Primary modalities stretching exercises Calf stretching t with knee straight plantar fascia specific stretch Non-weight bearing plantar fascia-specific stretching More effenctive than the traditional Achilles tendon-stretching exercises J Bone Joint Surg Am Jul;85-A(7): Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. DiGiovanni BF, Nawoczenski DA, Lintal ME, Moore EA, Murray JC, Wilding GE, Baumhauer JF. 3

4 : Plantar fasciitis Non-operative Night splints NSAID s orthotics ti decreased activity NON-OPERATIVE TREATMENT Secondary modalities night splints walking cast or fracture boot steroid injection use rarely risk of plantar fascia rupture risk of causing fat pad atrophy extracorporeal shock wave (ESW) treatment encouraging early results Extracorporeal shockwave therapy (ESWT) High energy vs Low energy High energy- electrohydraulic Ossatron Low energy- elecromagnetic Epos, Sonicur Chronic plantar heel pain Lasting longer than 6 months Failed other treatment options Efficacy remains controversial OPERATIVE TREATMENT Rarely indicated 90% resolve within 9 months time Indications at least 6 months to 1 year of symptoms exhausted appropriate non-operative treatment regimens presence of associated nerve compression first branch of lateral plantar nerve (to abductor digiti quinti) J Bone Joint Surg Am Nov 3;92(15): Plantar fascia-specific stretching versus radial shock-wave therapy as initial treatment of plantar fasciopathy. Rompe JD, Cacchio A, Weil L Jr, Furia JP, Haist J, Reiners V, Schmitz C, Maffulli N. Operative Through a medial incision the medial third of the plantar fascia is incised May be done open or endoscopically with similar reported success rates recovery time may be less with endoscopic treatment If plantar fasciitis and compression neuropathy open procedure must be performed distal tarsal tunnel release and partial PF release OPERATIVE TREATMENT Open versus endoscopic release? most not in favor of endoscopic release iatrogenic nerve injury Open partial versus complete plantar fascia release? try to avoid complete release but little data to guide method and amount of partial release Gastrocnemius Recession 4

5 Success rates: 60-90% Potential complications Damage to lateral plantar nerve Complete fascia rupture PRP loss of the medial longitudinal arch Stress reaction of the dorsolateral midfoot Topaz Guidelines from the APTA Heel pain - plantar fasciitis: clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Modalities Dexamethasone 0.4% or acetic acid 5% delivered via iontophoresis can be used to provide short-term (2 to 4 weeks) pain relief and improved function. (Grade of Recommendation: B) Manual Therapy There is minimal evidence to support the use of manual therapy and nerve mobilization procedures to provide short-term (1 to 3 months) pain relief and improved function. Suggested manual therapy procedures include talocrural joint posterior glide, subtalar joint lateral glide, anterior and posterior glides of the first tarsometatarsal joint, subtalar joint distraction manipulation, soft tissue mobilization near potential nerve entrapment sites, and passive neural mobilization procedures. (Grade of Recommendation: E) Stretching Taping Calf muscle and/or plantar fascia specific stretching can be used to provide short-term (2 to 4 months) pain relief and improvement in calf muscle flexibility. The dosage for calf stretching can be either 3 times a day or 2 times a day utilizing either a sustained (3 minutes) or intermittent (20 seconds) stretching time, as neither dosage produced a better effect. (Grade of Recommendation: B) Calcaneal or low-dye taping can be used to provide short-term (7 to 10 days) pain relief. Studies indicate that taping does cause improvements in function. (Grade of Recommendation: C) Orthotic Devices Prefabricated or custom foot orthoses can be used to provide short-term (3 months) reduction in pain and improvement in function. There appear to be no differences in the amount of pain reduction or improved function created by custom foot orthoses in comparison to prefabricated orthoses. There is currently no evidence to support the use of prefabricated or custom foot orthoses for long-term (1 year) pain management or function improvement. (Grade of Recommendation: A) Night Splints Night splints should be considered as an intervention for patients with symptoms greater than 6 months in duration. The desired length of time for wearing the night splint is 1 to 3 months. The type of night splint used (i.e., posterior, anterior, sock-type) does not appear to affect the outcome. (Grade of Recommendation: B) Other Causes Entrapment 1st branch of the lateral plantar nerve Baxter s nerve entrapped between: deep fascia of abductor hallucis muscle inferomedial margin of quadratus plantae muscle. More common in athletes who are on their toes a significant amount of time (e.g. sprinters, ballet dancers) Anatomy First branch of the lateral plantar nerve mixed (sensory and motor) nerve Passes deep to the plantar fascia immediately distal to the medial process of the calcaneal tuberosity Innervates Abductor digiti quinti muscle Flexor digitorum brevis (partial) Quadratus plantae (partial) Plantar fascia (partial) Periosteum of the calcaneus (partial) History Pain radiating distally and proximally from the medial aspect of the heel Numbness, burning, tingling or other form of paresthesia. Pain may radiate proximally into the calf 5

6 Physical Exam May have a positive Tinel s signs Percussion irritated nerve causes tingling or numbness radiating in the nerve s distribution Additional studies? Electromyography and nerve conduction studies are not consistent in diagnosing this condition. Sensory more effective than motor potentials Dorsiflexion and eversion of the ankle may exacerbate symptoms Motor weakness or atrophy of AbDQ Difficult to detect Non-operative treatment Rest, activity modification, anti-inflammatory medication, stretching, ice perhaps steroid injection Shock-absorbing inserts with a medial longitudinal arch support Most cured with conservative treatment try at least 6 months Operative treatment Decompression should be performed open not through an endoscope Medial third of the plantar fascia is incised if one suspects a simultaneous proximal plantar fasciitis Release of the deep fascia of the abductor hallucis muscle and neurolysis of the 1 st nerve Calcaneal stress fx Repetitive and submaximal loading Calcaneus absorbs: 110% body weight during walking 200% body weight during running Calcaneal Stress Fx Risk factors Menstrual disturbances Decreased caloric intake Decreased bone density Leg length discrepancy Muscle weakness Females appear more prone Not associated with abnormal alignment of the ankle 6

7 Insidious onset of pain History Recent increase in amount or intensity of activity Pain improves with rest and intensifies with activity Female athlete triad disordered eating amenorrhea osteoporosis Compression of posterior calcaneal tuberosity Physical Exam Imaging Initial radiographs usually normal Band of increased density 2-4 wks after onset on symptoms Posterior aspect of the calcaneus Extending from the superior cortex into the body Bone scan or MRI useful if radiographs nml If no pain with normal walking Restriction of painful activity 4-6 wks Placement of a cushioned insert If Pain with normal walking Short leg non-weight bearing cast 6-8 weeks Gradually return to activity if the pain has resolved and radiographs confirm resolution May need a referral to endocrinologist if metabolic abnormalities are suspected Does not require operative treatment unless displacement occurs Central heel pain Usually due to fat pad atrophy or contusion Fat pad atrophy and decreased elasticity with: Increasing age Steroid injections Inflammatory arthritis Trauma to heel pad Axial load Osteophyte on central portion of the heel 7

8 History Pain More central and diffuse than with plantar fasciitis Increased on hard surfaces Not improved with initial ambulation as observed with plantar fasciitis Center of heel Physical exam Usually localized Non-operative treatment Heel cups and soft inserts Orthosis corrective posting may alter weight-bearing forces Well-relief (accommodative cut-out) under painful osteophyte Operative treatment No role for operative treatment in isolated heel fat pad atrophy If pain caused by an osteophyte, a lateral longitudinal incision may be used for removal of the prominence Pearls: Heel pain Most common symptom related to the foot leading a patient to seek professional care Many potential causes History and physical High index of suspicion Labs and imaging studies are often of limited value Basic radiographs should be obtained STRETCH! Pearls Steroid injections should be limited plantar fascia rupture ft fat pad atrophy Conservative tx attempted at least 6 mo. Exceptions: tumor etc Avoid complete release of the plantar fascia Thank you 8