Plantar Fasciitis: Nonsurgical & Surgical Options for Chronic Heel Pain. Mathew M. John, DPM, FACFAS Atlanta, GA

Transcription

1 Plantar Fasciitis: Nonsurgical & Surgical Options for Chronic Heel Pain Mathew M. John, DPM, FACFAS Atlanta, GA

2 Heel Pain:Plantar fasciitis Over 2 million Americans suffer from heel pain Most common cause of plantar heel pain

3 Anatomy Plantar fascia Dense fibrous ligament Collagen/elastin fibers 3 distinct bands Central Lateral Medial

4 Anatomy Plantar fascia Origin Medial calcaneal tuberosity Insertion Flexor tendons / base proximal phalanx

5 Anatomy Muscle origins at the calcaneus Abductor hallucis Flexor digitorum brevis Abductor digiti quinti

6 Anatomy Origins near calcaneal tuberosity Quadratus plantae Long plantar calcaneocuboid ligament

7 Anatomy Subcalcaneal bursa Between the calcaneal tuberosity and fat pad

8 Anatomy Tibial nerve Medial Calcaneal nerve Lateral plantar nerve 1 st branch

9 Anatomy 1 st branch of the lateral plantar nerve Course deep to the plantar fascia and abductor hallucis muscle

10 Basic Biomechanics % of body weight with each heel strike Windlass mechanism

11 Basic Biomechanics Windlass Mechanism Dorsiflexion of the hallux Elevation of the longitudinal arch Midfoot locked

12 Symptoms Pain with prolonged standing or walking or exercise No specific trauma Deep ache Occasional burning/throbbing Relief with rest

13 Symptoms Post static dyskinesia Pain with initial weightbearing after rest Initially improves but returns later in the day

14 Symptoms Chronic pain Typically >6 mo Plantar fasciosis Pain constant with weightbearing Antalgic gait

15 Chronic vs. Acute Pain Plantar Fasciosis Decreased edema Noninflammatory Localized fibrosis Collagen necrosis Fibroblastic hyperplasia Plantar fasciitis Localized edema Inflammation Microtearing of fascia Insertional thickening of fascia

16 Associated symptoms Achilles tendonitis Posterior tibial tendonitis Lateral column pain Lower leg muscle pain Knee / back pain

17 Associated Conditions Pes planus Pes cavus Equinus Limb length difference

18 Aggravating Factors Obesity Running / aerobic exercise Prolonged standing on hard surfaces Poor shoewear

19 Biomechanics Normal Gait (walk) Stance Phase (60%) Heel strike Midstance Pronation Supination Push off Swing Phase (40%)

20 Biomechanics Equinus Decreased ankle joint dorsiflexion <10 degrees Compensatory pronation Increased strain on plantar fascia ligament

21 Biomechanics Over-Pronation Not flat feet eversion / dorsiflexion Weak posterior tibial tendon Increased subtalar joint motion

22 Biomechanics Pes planus Increased plantar fascia strain Pes cavus Tight plantar fascia

23 Physical Exam Palpation Engage Windlass mechanism Proximal plantar medial heel Medial heel Baxter s s nerve Proximal medial heel Medial calcaneal nerve Proximal plantar lateral heel

24 Physical Exam Palpation Central plantar fascia Side to side compression calcaneus Central calcaneus Bursa Posterior tibial tendon insertion Navicular Palpate/percussion Tarsal tunnel

25 Physical Exam Range of Motion Subtalar inversion / plantarflexion eversion / dorsiflexion Midtarsal Ankle dorsiflexion

26 Physical Exam Ankle dorsiflexion Evaluate for equinus Supinate foot and dorsiflex With knee straight and flexed Gastroc equinus Gastrocsoleus equinus

27 Physical Exam Gait Exam antalgic Early heel lift Equinus Overpronation Compensatory gait Equinovarus Shoulder drop Limb length difference

28 Radiographic Signs Plantar calcaneal spur NOT source of symptoms Formed due to tension from Fascia Muscles

29 Radiographic Signs Plantar calcaneal spur Present in over 50% of patients who suffer from PF Also present in asymptomatic patients

30 Other Diagnostic Tests Bone scan MRI Ultrasound

31 Bone Scan 4 phase Technetium Increased uptake: Calcaneal fractures Infection Bone tumors

32 MRI Soft tissue tumors Bone tumors Marrow edema Localized soft tissue edema Plantar fascia thickening

33 Magnetic Resonance Imaging -MRI

34 Diagnostic Ultrasound Thickening of plantar fascia insertion Soft tissue masses

35 Diagnostic Ultrasound

36 Diagnostic Ultrasound

37 Diagnostic Tests Help to identify differential diagnoses Diagnosis of plantar fasciitis mainly clinical Does not dictate treatment management of plantar fasciitis

38 Differential Diagnoses Calcaneal apophysitis Calcaneal bursitis Tarsal tunnel syndrome Calcaneal stress fracture Inflammatory arthritis Soft tissue or bone neoplasm Infection Lower lumbar radiculopathy Neuritis

39 Calcaneal Apophysitis Severs disease Inflammatory condition of the calcaneal epiphysis Age Pain aggravated with activity Relief with rest, NSAIDs

40 Calcaneal Bursitis Inflammation of plantar bursa Pain more central to calcaneal tuberosity Associated fat pad atrophy

41 Tarsal Tunnel Syndrome Compression of neurovascular structures in tarsal tunnel Pain at the tarsal tunnel Radiating to medial heel and arch Pain constant

42 Calcaneal Stress Fracture Pain with side to side compression of the calcaneus Axial calcaneal radiograph Bone scan

43 Inflammatory Arthritis Rheumatoid arthritis Psoriatic arthritis Gout Acute pain/swelling Reiter's syndrome Conjunctivitis/urethritis/arthritis Ankylosing spondylitis Systemic lupus erythematosus(sle)

44 Bone Neoplasms Aneurysmal bone cyst Unicameral bone cyst Osteoid osteoma Night pain Chondroblastoma

45 Soft tissue neoplasm Plantar fibroma Neurilemoma Angiolipoma Fibrolipoma Fibrosarcoma

46 Infection Abscess Osteomyelitis Symptoms Constant pain Mild to severe Erythema Localized edema

47 Lower Lumbar Radiculopathy Compression of lower lumbar nerves L4-5, S1-2 Sciatica pain NCV/EMG required

48 Medial Calcaneal Neuritis Medial heel pain Increased pain the longer they walk Pain at night Orthotics may increase pain Neurosensory test to confirm diagnosis

49 Baxter s s Neuritis Przylucki 1981 Baxter 1992 Entrapment of the 1 st branch of the lateral plantar nerve Also referred to as the inferior calcaneal nerve Compressed between the proximal plantar fascia and abductor hallucis muscle

50 Baxter s s Neuritis Up to 20% of heel pain Typically pain more medial than plantar Can be present with plantar fasciitis/ fasciosis Seen in recalcitrant heel pain

51 Treatment 85-90% success with conservative treatment ACFAS Heel Pain Guide phase treatment protocol No one universal treatment successful Combination of treatment options Conservative treatment for at least 6 months prior to surgical options

52 Treatment Phase 1 NSAIDs Stretching cryotherapy Appropriate shoewear Athletic running shoe OTC arch support Padding/strapping Corticosteroid injection Activity limitation

53 Treatment Phase 1 Nonsteroidal Anti- inflammatory Drugs Celebrex ibuprofen diclofenac Provides reduction of symptoms only

54 NSAIDs Donley et al. (2007) 29 patients Mild improvement in overall treatment vs. no use of NSAID

55 Treatment Phase 1 Stretching Focused on gastrocsoleus / Achilles tendon Plantar fascia ligament Hamstrings Reduce forefoot loading

56 Plantar Fascia Stretch DiGiovanni et al. (2003) Prospective study showed plantar fascia stretching to be more be more beneficial than weightbearing Achilles stretch

57 Treatment Phase 1 Cryotherapy Various methods Therapist s wonder drug Intermittent 10 min on/off/on

58 Treatment Phase 1 Appropriate shoewear Replace old shoewear Avoid going barefoot

59 Treatment Phase 1 OTC arch support Soft Semi-flexible Low dye strapping With or without metatarsal pad Plantar fascia support

60 Low Dye Strapping Landorf et al. (2005) 65 low dye strapping 40 patients with no strapping 3-55 days Results Significant improvement in pain levels

61 Low Dye Strapping

62 Treatment Phase 1 Corticosteroid injection Mixture of anesthetic/short acting steroid/ long acting steroid Limited to no more than 3 injections to one area/6 mo-1yr Tissue atrophy Plantar fascia rupture

63 Corticosteroid Injection Reduces inflammatory response to injury Inhibits leukocyte & macrophage proliferation Inhibits vasoactive kinin release Inhibits destructive enzyme release Decreases prostaglandin formation

64 Corticosteroid Injection Crawford et al. (1999) 160 patients Steroid + lidocaine Tibial nerve block, steroid + lidocaine Lidocaine only Tibial nerve block, lidocaine only Significant pain relief at 1 mo f/u But no difference at 3, 6 month f/u

65 Corticosteroid Injections Varied combinations and approaches Medial Plantar Post injection flare Elevated glucose in DM patients

66 Treatment Phase 1 Activity limitation Cut workouts in half Stop all high impact workouts No running No aerobics

67 Activity Limitation Riddle et al. (2003) Working in a standing position all day increases risk for plantar fasciitis to develop Increase in BMI = increase incidence of plantar fasciitis

68 Treatment Phase 1 Physical Therapy Ultrasound Iontophoresis Phonophoresis Interferential current Anodyne Stretching Deep massage

69 Iontophoresis Gudeman et al. (1997) 36 patients 0.4% dexamethasone vs. placebo 6 treatments over 2 weeks Significant decrease in symptoms for treated group No difference 1 mo after end of treatment

70 Treatment Phase 1 Symptoms should resolve within 6 weeks If improvement is noted treatment should be continued until symptoms are resolved If symptoms plateau Phase 2 treatment should be initiated

71 Treatment Phase 2 Continuation of Phase 1 treatment Custom molded orthotics Nightsplint Cast boot walker

72 Treatment Phase 2 Custom molded orthotics(orthoses) Neutral cast Proper rearfoot / forefoot posting Type of orthotic patient/activity dependant

73 Orthoses Pfeffer et al (1999) 200 patients Silicone heel pad Felt arch pad Tullis rubber heel cup Custom molded polypropylene orthotic Prefabricated inserts provided better pain relief than custom orthoses

74 Orthoses Rome et al. (2004) Compared functional orthoses vs. accommodative inserts Prefabricated orthoses Functional orthoses provided significant improvement in pain relief compared with accommodative inserts

75 Orthoses Collins et al. (2007) insufficient evidence to support or refute the use of foot orthoses, custom or prefabricated, in the treatment of lower limb overuse injuries.

76 Treatment Phase 2 Night splint Static dorsiflexion Dynamic Prolonged low load stretch of tendo Achilles

77 Orthoses / Night splint Roos et al. showed significant improvement in symptoms: Custom orthotic Custom orthotic + night splint Night splint alone Long term pain relief noted with continued use of orthotics

78 Night Splint Batt et al. (1996) 34 patients All 17 patients wearing dorsiflexion night splint showed improvement in symptoms Powell et al. (1998) 37 patients After 1 mo treatment group showed significant improvement

79 Night Splint Probe et al. (1999) 116 patients NSAIDs, Achilles stretch, shoe wear Above treatment + night splint x 3 mo Did not find any significant difference with use of night splint

80 Treatment Phase 2 Cast immobilization Removable pneumatic boot FWB Rockerbottom Eliminates windlass mechanism

81 Treatment Phase 2 Symptoms typically resolve in 2-32 months (4-6 6 mo from initial treatment) If improvement noted continue treatment from both Phase 1 and Phase 2 until symptoms resolve If symptoms plateau or do not improve then proceed to Phase 3

82 Treatment Phase 3 Nonweightbearing cast immobilization Surgical plantar fasciotomy Endoscopic plantar fasciotomy (EPF) Extracorporeal shockwave therapy (ESWT) Coblation-based based fasciotomy

83 Treatment Phase 3 Nonweightbearing cast immobilization Removable Fiberglass Limitation on stretching

84 Treatment Phase 3 Plantar fasciotomy Traditional Duvries 1957 Medial approach Removal of spur Transect medial and central bands

85 Treatment Phase 3 Instep fasciotomy Direct visualization Reduced risk of nerve entrapment Allows immediate PWB to FWB Incision parallel to relaxed skin tension lines

86 Instep Plantar Fasciotomy

87 Instep Plantar Fasciotomy Postoperative Course 2-33 weeks in sterile bandages PWB to FWB in CAM walker Physical Therapy initiated once incision healed No high impact activity x 6 weeks Full recovery may take 12 weeks

88 Instep Plantar Fasciotomy Complications / risks Lateral column pain Alteration of biomechanics Nerve entrapment Painful hypertrophic scar

89 Plantar Fasciotomy Lane & London (2004) Retrospective study 29 patients 96% success rate Ave 21 months postop VAS reduced from 8.4 to 1.2

90 Plantar Fasciotomy Fishco et al. (2000) Retrospective study 83 patients Heel pain ave 14 months prior to surgery 21 months postop 93.6% success

91 Treatment Phase 3 Endoscopic Plantar Fasciotomy (EPF) Release of fascia ligament through uni or two portal endoscope

92 Endoscopic Plantar Fasciotomy Postoperative Course days incision healing FWB in CAM walker Physical Therapy initiated weeks No exercise activity x 6 weeks Full recovery up to 12 weeks

93 Endoscopic Plantar Fasciotomy Advantages Minimally invasive Quicker recovery Disadvantages Risk of nerve entrapment Learning curve Risk of reoccurrence of heel pain

94 Treatment Phase 3 Extracorporeal Shockwave Therapy (ESWT) Propagation of shockwave transmitted through to injured tissue

95 Extracorporeal Shockwave Therapy Neovascularization Local hyperemia tissue growth factors Inhibition of pain receptors

96 Extracorporeal Shockwave Therapy Developed from lithotripsy Early 1990s Orthopedic use (orthotripsy) FDA approved for chronic plantar fasciitis (fasciosis)

97 Extracorporeal Shockwave Therapy 3 types Electrohydraulic OssaTron Electromagnetic Dornier Epos Piezoelectric Piezoson

98 Extracorporeal Shockwave Therapy Electrohydraulic spark plug principle High voltage applied to water filled ellipsoid reflective housing Shockwave generated between tips of electrode

99 Extracorporeal Shockwave Therapy Electromagnetic Electric current passed through coil generating a magnetic field Shockwave generated from water immersed conductive membrane

100 Extracorporeal Shockwave Therapy Piezoelectric Piezoelectric crystals charged with high voltage Crystals expand/contract generating shockwave

101 Extracorporeal Shockwave Therapy High Energy Outpatient IV MAC sedation Local block One treatment Low Energy Office setting No anesthesia Multiple treatments

102 ESWT Postop Course Immediate weightbearing in athletic shoe w/ orthoses No NSAIDs Continue nightsplint, stretching 1-22 weeks of continued heel pain Full recovery up to 12 weeks

103 Extracorporeal Shockwave Therapy Complications Localized swelling Localized bruising Reoccurrence of heel pain

104 Extracorporeal Shockwave Therapy Advantages Noninvasive Quick recovery Minimal to no complications Disadvantages High cost Insurance coverage No universally accepted protocol

105 Extracorporeal Shockwave Therapy Buchbinder et al. (2002) Double-blind blind prospective study 160 patients diagnosed with plantar fasciitis for at least 6 weeks Low energy device Weekly treatment x 3 weeks No significant difference in symptoms

106 Extracorporeal Shockwave Therapy Ogden et al. (2004) Prospective study 293 patients High energy ESWT 47% success at 3 months

107 Extracorporeal Shockwave Therapy Malay et al. (2006) Prospective double-blind blind study 172 patients (115:57) Electrohydraulic device (high energy) No anesthesia Overall reduction of pain on VAS 43% ESWT group vs. 19.6% placebo

108 Extracorporeal Shockwave Therapy Efficacy still controversial No standardized treatment protocol High energy vs. low energy Retrospective studies reveal 60% success rate Prospective studies vary in success rates dependant on type of ESWT

109 Treatment Phase 3 Coblation-based based fasciotomy / microtenotomy Use of bipolar radiofrequency Evolved from cardiology research

110 Coblation fasciotomy Stimulates inflammatory response Angiogenesis Antinociceptive effect Rapid pain reduction

111 Coblation fasciotomy Indications Plantar fasciosis >6 months heel pain Techniques Open Percutaneous Postop course PWB-FWB in CAM walker weeks

112 Coblation fasciotomy Advantages Rapid recovery Less invasive Risks percutaneous Plantar fascia rupture Nerve entrapment

113 Coblation fasciotomy Tendon coblation has shown over 90% improvement in VAS pain scale Initial studies show significant improvement in pain levels as early as 2 weeks Pain continued to improve up to 6 months Larger, prospective studies needed to assess effect on plantar fascia ligament

114 Summary Diagnosis of heel pain etiology essential for proper treatment A combination of conservative treatment required Treatment can extend for months, no quick fixes Surgery: last option

115 Thank you