PLANTAR FASCIITIS. Key Contents. Learning Objectives. Indep Rev Oct-Dec 2013;15(10-12) IR-276. Dr. Farhad Alam

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1 Indep Rev Oct-Dec 2013;15(10-12) IR-276 PLANTAR FASCIITIS Dr. Farhad Alam Key Contents Pathophysiology Causes and risk factor Diagnostic feature Treatment Options Prognosis and prevention Learning Objectives To understand pathology of plantar fasciitis To describe its causes and risk factors To describe its clinical feature To explain need for investigations To discuss the treatment options and prognosis Key words: Plantar fasciitis, foot orthotics, coblation surgery,night splints. Article Citation: Alam F, Planter Fasciitis. Indep Rev Oct-Dec 2013;15(10-12): Correspondence Address: Dr.Farhad Alam, FCPS(ORTHO) Assistant Professor Department of Orthopedics Independent Medical College / Hospital 476

2 PF is a painful inflammatory process of the plantar fascia, the connective tissue or ligament on the sole (bottom surface) of the foot. It is often caused by overuse of the plantar fascia, increases in activities, weight or age.plantar fasciitis is a very common kind of tendinitis especially in runners, and is seen in both men and women. However, it most often affects active men ages It is one of the most common orthopedic complaints relating to the 1 foot. Pathophysiology The plantar fascia is a thick fibrous band of connective tissue, similar to a ligament or tendon, originating on the bottom surface of the calcanium and extending along the sole of foot 2 towards the toes, spanning the arch of the foot. Plantar fasciitis is an inflammation or thickening or degeneration of the plantar fascia. The itis suffix means inflammation but it is quite misleading. Longstanding cases demonstrate more degenerative changes than inflammatory changes, in which case they are termed plantar fasciosis. The suffix "osis" implies a pathology of chronic degeneration without inflammation. Since tendons and ligaments do not contain blood vessels, they do not actually become inflamed. Instead, injury to the tendon is usually the result of an accumulation over time of microscopic tears at the cellular level. Technically, plantar fasciitis is better compared to tendinopathy or tendonosis, because the tissue is often not actually inflamed it shows signs of collagen degeneration. In 2003, Lemont et al looked at 50 cases and found so little inflammation that they declared that plantar fasciitis is a degenerative fasciosis without 1 inflammation, not a fasciitis. Foot Arch-ery The arch of the foot functions like a bow (as in a bow and arrow), and the plantar fascia is like the string of the bow. The tension in the bow string holds the shape of the arch. But every time you step, the bow string stretches and when stretched too hard and too often, it gets irritated, and then it's like a bow shooting you in the foot.plantar fasciitis is basically caused by chronic irritation of the arch of the foot due to excessive strain. Causes and Risk factors Foot arch problems (both flat feet and high arches) 1. Long-distance running, especially running downhill or on uneven surfaces. 2. Sudden weight gain or obesity. 3. Tight Achilles tendon. 4. Shoes with poor arch support or soft soles. Heel Bone with Heel Spur 2 477

3 3 Plantar fasciitis is commonly thought of as being caused by a heel spur, but research has found that this is not the case. On x-ray, heel spurs are seen in people with and without plantar fasciitis. Diagnosis History The most common complaint is pain and stiffness in the bottom of the heel. The heel pain may be dull or sharp. The bottom of the foot may also ache or burn. The pain is usually worse: In the morning when you take your first steps After standing or sitting for a while When climbing stairs After intense activity The pain may develop slowly over time, or suddenly after intense activity. Exams and Tests Tenderness on the bottom of your foot. Flat feet or high arches. Mild foot swelling or redness Stiffness or tightness of the arch in the bottom of your foot. Decreased dorsiflexion of the ankle. (2) Investigation The diagnosis of plantar fasciitis is usually made by clinical examination alone. X-rays may be taken to rule out other problems. 3 Diagnostic radiology and MRI Treatment Treatment options for plantar fasciitis include rest, massage therapy, stretching, night splints, physical therapy, cold therapy, heat therapy, orthotics, anti-inflammatory medications, injection of corticosteroids and surgery in refractory cases. Also, in some cases, massaging of the inflamed location serves as a 4 temporary relief. Physical Treatment Recommendations for immediate relief and reduction of inflammation include heel and foot stretching exercises as can be tolerated, rest as much as possible for at least one week, and wearing shoes with good support and cushions. Other steps to relieve pain include: applying ice or ice-heat-ice, and using night splints to stretch the injured fascia. Customized functional foot orthotics can offer a decrease in the pain associated with plantar fasciitis and may provide an additional benefit in terms of increased functional ability in patients with the condition. According to a clinical practice guideline, "there is no evidence" to support the use of foot or thotics for long-term (1 year) pain management or function improvement. Stretching of the calf and plantar fascia may provide up to 2 4 months of benefit. Pain with the first steps of the day can be markedly reduced by stretching the plantar fascia and Achilles tendon before getting out of bed.(5) Night Splint Can be used to keep the foot in a dorsi-flexed position during sleep to improve calf muscle flexibility and decrease pain on waking. These have many different designs. 478

4 4 needle is inserted into the plantar fascia and moved back and forwards to disrupt the fibrous 7 tissue. Medication To relieve pain and inflammation, nonsteroidal antiinflammatory drugs (NSAIDs) such as aspirin and ibuprofen are often used but are of limited benefit. Local Injection of Corticosteriods Often gives temporary or permanent relief, but may be painful, especially if not combined with a local anesthetic and injected slowly with a smalldiameter needle. Recurrence rates may be lower if injection is performed under ultrasound guidance. Repeated steroid injections may result 6 in rupture of the plantar fascia. Surgery Surgical procedures, such as plantar fascia release are a last resort, and often lead to further complications such as a lowering of the arch and pain in the supero-lateral side of the foot due to compression of the cuboid bone. This will allow decompression of the nearby FDB muscle belly that is inflamed.this allows more space for the inflamed muscle belly, thus, relieving pain/pressure. An ultrasound-guided needle fasciotomy can be used as a minimally invasive surgical intervention for plantar fasciitis. A Coblation Surgery Aka Topaz procedure has been used successfully in the treatment of recalcitrant plantar fasciitis.this procedure utilizes radiofrequency ablation and is a minimally 8 invasive procedure. Extracorporeal Shockwave Therapy There is contradictory evidence and recommendations for the efficacy of extracorporeal shockwave therapy (ESWT), or the use of acoustic shock waves, as treatment for plantar fasciitis. One review found that the preponderance of evidence supports the use of ESWT, but only after several months of treatment with more accepted and proven therapies have failed, as a possible alternative to surgical intervention. but due to lack of consistent results it is not 9 commonly performe. Prognosis Nonsurgical treatments almost always improve the pain. Treatment can last from several months to 2 years before symptoms get better. Most patients feel better in 9 months. Some people need surgery to relieve the pain. Prevention Making sure your ankle, Achilles tendon, and calf muscles are flexible can help prevent plantar fasciitis. 479

5 5 References 1. Lemont, H.; Ammirati, K. M.; Usen, N. (2003). "Plantar fasciitis: A degenerative process (fasciosis) without inflammation". Journal of the American Podiatric Medical Association 93 (3): Riddle, D. L.; Pulisic, M.; Pidcoe, P.; Johnson, R. E. (2003). "Risk factors for Plantar fasciitis: A matched case-control study". The Journal of bone and joint surgery. American volume 85 A (5): Cole, C.; Seto, C.; Gazewood, J. (2005). "Plantar fasciitis: Evidence-based review of diagnosis and therapy". American family physician 72 (11): Carlson, R. E.; Fleming, L. L.; Hutton, W. C. (2000). "The biomechanical relationship between the tendo-achilles, plantar fascia and metatar-sophalangeal joint dorsiflexion angle". Foot & ankle international / American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society 21 (1): Uden, H; E. Boesch, S. Kumar (2011). Plantar fasiitis- to jab or to support?a systematic review of the current best evidence. The Journal of Multi-discipinary Healthcare 4: Genc, Hakan; Meryem Saracoglu, Bans Nacir, Hatice Rana Erdem and Mahmut Kacar (2005). "Long-term ultrasonographic follow-up of plantar fasciitis patients treated with steroid injection". Joint Bone spine 72 (1): Treatment of recalcitrant plantar fasciitis by s o n o g r a p h i c a l l y - g u a i d e d n e e d l e fasciotomy. Am College of Foot and Ankle Surgeons. 8. Sorensen, M. D.; Hyer, C. F.; Philbin, T. M. ( ). " P e r c u t a n e o u s B i p o l a r Radiofrequency Microdebridement for Recalcitrant Proximal Plantar Fasciosis". The Journal of Foot and Ankle Surgery 50 (2): Ogden, JA; Alvarez, RG; Marlow, M (2002 Apr). "Shockwave therapy for chronic proximal plantar fasciitis: a meta-analysis.". Foot & ankle international / American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society 23 (4):