Plantar “Fasciitis” or “Fasciosis” Edward P. Mulligan, MS, PT, SCS, ATC

Definition Repetitive microtrauma resulting in collagen degeneration at the origin of the plantar fascia on the medial calcaneal tubercle † Histological evaluation of 50 surgical cases support the contention that this is a degenerative, not an inflammatory condition †

National Director of Clinical Education - Grapevine, TX Faculty Instructor University of Texas Southwestern School of Allied Health Department of Physical Therapy Dallas, TX

Lemont H, et al. 2003, J Am Podiatr Med Assoc

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Prevalence - Incidence

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Plantar Fascia Anatomy

Most common foot condition treated by healthcare providers according to a survey of APTA Orthopedic Sections Foot-Ankle SIG group members

PF

10% incidence over course of lifetime Estimated to affect 2 million Americans so prevalence is around 1%

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ADM

FDB AH

FP

dense multilayered fibrous connective tissue; bands 2-4 mm thick Originates at the medial calcaneal tuberosity and inserts into the plantar plates of the MTP joints and bases of the proximal phalanges Medial band is twice as thick as the lateral and central bands and most commonly involved in plantar fasciitis www.continuing-ed.cc

Proximate Neurological Structures

Proximate Neurological Structures

Medial Calcaneal Nerve

Medial and Lateral Plantar Nerves

arises from the posterior tibial nerve at level of the malleolus and supplies sensation to the plantar medial aspect of the foot

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located between the FDB and QP and provides sensation to the medial and lateral plantar aspect the foot Compression can be a cause of the heel pain complaint

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Plantar Fascia Function

Windlass Mechanism The windlass mechanism, secondary to toe extension during propulsion, puts tension on the plantar fascia and passively raises the arch

passive truss support of the longitudinal arch absorbs forces in early stance stabilizes the foot during propulsion

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Truss Support Function When a superior load is applied on the arch – the plantar fascia (truss) prevents migration of the two ends away from one another, thus supporting the imposed load

Heel Spur

Body Weight

GRF

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plantar fascia truss

GRF

Interpretation Tensile strain is increased as a patient’s body weight increases

The heel spur isn’t the problem - it’s the reaction to the problem 50% of patients with plantar fasciitis have heel spurs 50% of patients with bilateral heel spurs only had unilateral symptoms 15-20% of patients without plantar fasciitis have heel spurs Tauz, et al, 1963, Clin Orthop Lapidus, et al, 1965, Clin Orthop Young ,et al, 2001, Am Fam Phys Cornwall, et al, 2003, J Orthop Sports Phys Ther

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Etiological Considerations

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Etiological Considerations Primary cause is

“time wounds all heels”

obesity and/or prolonged standing cause and/or promote the problem in the non-athletic population

Groucho Marx

65-70% of adults patients with plantar fasciitis are overweight

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Foot Type Predisposing Factor

Obesity Risk Factor Patients with higher BMI at higher risk † Recommended < 25 Rano JA, 2001, J Foot Ankle Surg † 5-6 times higher risk than those Riddle DL, et al, 2003, J Bone Joint Surg

Pes Planus

Pes Cavus

increased tensile tension on the plantar fascia

inherently tight, shortened fascia increases bowstring like load

under BMI of 25

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Musculoskeletal Risk Factor

Musculoskeletal Risk Factor

GastrocGastroc-Soleus Tightness

1st MTP Hypomobility

78% had at least 5º limitations in df ROM Amis J, et al, Foot Ankle, 1988

23 times higher risk if >0º df ROM Riddle DL, et al J Bone Joint Surg, 2003

hold the calcaneus in varus and limits pronation causes compensatory substitution at the MTJ to increase sagittal plane dorsiflexion

patients with plantar fasciitis often present with a loss of passive and active 1st MTP extension ROM this finding could adversely affect the windlass mechanism function Unclear if this is a cause or result of plantar fasciitis Creighton, et al, 1987, J Orthop Sports Phys Ther

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Musculoskeletal Risk Factor Additional findings positively correlated to plantar fasciitis

Decreased plantar flexion strength

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Extrinsic Risk Factor Training/Activity errors magnified by presence of previous risk factors †

BW, foot type, MS deficits

Kibler WB, et al, 1991, Amer J Sports Med

Violate Rule of “2s”

Decreased plantarflexion ROM

†

too much … too long … too often ….

Warren, 1984, Med Sci Sports Exer

3½ times more likely to have plantar fasciitis if the majority of the workday is spent on feet

Decreased toe flexor strength †

But not 1st MTP hypomobility

Allen, et al, 2003, J Orthop Sports Phys Ther

Riddle, et al, 2003, J Bone Joint Surg www.continuing-ed.cc

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Training Activity Modifications

COMMON SUBJECTIVE HISTORY

Reduce volume of prolonged weight-bearing Avoid sprinting and uphill running †

Clinical Presentation X “worst steps are first steps” Y gradual, insidious onset Z sharp localized pain at plantar fascial origin

Increases TCJ dorisflexion and MTP extension ROM requirements

[ pain worse in AM, eases with gentle activity, increases again as day progresses

Avoid hard training surfaces

\ aggravated by stairs, hills, running, jumping, or “barefoot” activities www.continuing-ed.cc

Common Objective Findings STRUCTURE

Look for varus deformities or malalignment

PALPATION

Assess tenderness at medial calcaneal tuberosity and/or medial arch tenderness with palpable nodules

MOBILITY

Screen for decreased gastroc/soleus flexibility; limited 1st MTP ROM

FUNCTION

Often has pain or difficulty in performing unilateral heel raise

GAIT

May have supinated gait to avoid stress on plantar fascia

PROVOCATION

Simultaneous 1st MTP and ankle dorsiflexion with subtalar joint eversion

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Windlass Provocation Test Forceful great-toe extension in a standing position causing pain at the medial calcaneal tubercle

100% specificity 31% sensitivity † just

13% sensitivity if performed in NWB

DeGarceau D, et al. Foot-Ankle Int, 2003

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Heel Pain Differential Diagnosis Neurologic

Soft Tissue

Skeletal

Systemic

Medial Calcaneal Nerve Entrapment

Subcalcaneal Bursitis

Calcaneal Stress Fracture

Reiter’s Syndrome

Plantar Nerve Entrapment

Achilles Tendinopathy

Calcaneal Apophysitis

Ankylosing Spondylitits

S1 Radiculopathy

Fat Pad Atrophy

Haglund Deformity

Rheumatoid Arthritis

Bone Bruise

Psoriasis

Tarsal Tunnel Syndrome

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Differential Diagnosis Tarsal Tunnel Syndrome posterior tibial nerve entrapment burning or throbbing pain paraesthias on the plantar foot, toes, or lower leg tenderness distal and posterior to medial malleolus + Tinel’s weakness of IP flexors sensory deficits to medial arch and toes 1-3 www.continuing-ed.cc

General Treatment Approaches 1. 2. 3. 4.

Conservative (non-operative) Interventions ESWT Injections and Medications Surgical Interventions

Available Evidence There is limited evidence at this time on which to base clinical practice Common treatments used to reduce heel pain offer marginal gains over no treatment or control groups Crawford F, et al, 2007, Cochrane Review

I’m going to limit presentation to information within my scope of care

Consequently, we’ll review the quality of the evidence to support or refute individual interventions www.continuing-ed.cc

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Quality of Evidence

Recovery Expectations

Level of Evidence

80-90% of patients respond to conservative treatment

Description Evidence supported by high quality randomized controlled trials Evidenced supported by lower quality randomized controlled trials or prospective comparative studies Evidence supported by retrospective comparative or case-controlled designed studies Evidence obtained from case studies Consensus - Agreement by an expert panel, in the absence of scientific evidence in the literature, based on experience and/or assumptions in the literature www.continuing-ed.cc

Treatment Considerations

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Baxter, et al, 1984, Foot-Ankle Int † 90% recovered with conservative care in average of 11 months Wolgin, Cook, Mauldin, 1994, Foot Ankle Int † good results (resolution of symptoms) took an average of 6 months † stretching, cushioned inserts, and NSAIDs most helpful according to patients † poor results were in patients who were overweight, had bilateral symptoms, or longer duration of symptoms prior to medical management www.continuing-ed.cc

Basic Intervention Goals

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Initial Treatment

Initial Treatment EDUCATION

REST avoidance of any activity that aggravates symptoms by decreasing its IDF As an example change the manner of the activity walk instead of run swim instead of walk † bicycle in lower gear † reduce plyometric movements † †

Quality of Internet-Derived Information † 152 web sites evaluated and assigned a 0-10 rating based on the information it provided Definition, causes, risk factors, symptoms, diagnostic tests, conservative and surgical treatment options, and complications † Mean score was 3.8 36% of sites had obvious conflict of interest or financial bias and these sites had significantly lower ratings Sites authored by orthopedic surgeons had the highest mean ratings (7.1) – followed by DPMs (5.2) and PTs (4.8) Moshirfar A, et al. 2004, Clin Orthop Relat Res

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Symptomatic Care •

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Iontophoresis

ice massage for its anesthetic value

dexamethasone iontophoresis provided more immediate reduction in acute symptoms, but does not alter the long outcome Gudeman, et al, 1997, Am J Sports Med

acetic acid iontophoresis provided a complete or substantial relief of heel pain over 6 treatments in 3 weeks Japour, et al, 1999, J Am Pod Med Assoc

Acetic acid/taping superior to dexamethasone/taping Osborne, et al. 2006, Br J Sports Med

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No evidence for the effectiveness of:

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Magnetic Therapy RCT showed that magnetic-embedded insoles NO more effective than placebo insoles in alleviating pain

Therapeutic ultrasound Crawford F, et al, 1996, Ann Rheum Dis

Low-intensity laser therapy

Winemiller MH, et al, 2003, JAMA

Basford JR, et al, 1998, Arch Phys Med Rehabil

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Symptomatic Care

Therapeutic Exercise –

STRETCHING EMPHASIS

Anecdotally Critical †

Rolling pin, Coke bottle, ball, or frozen juice can at bedside for arch roll stretching prior to weight bearing

† Commercial

CAVUS Foot

Gastroc-Soleus Stretching †

83% of successful patients said this was the most important treatment

†

Both sustained and intermittent stretching are effective in the management for painful heel syndrome

†

No statistically significant short term improvements in “ first-step” pain or foot function as compared to a control group

Wolgin, Mauldin, et al Foot Ankle J, 1994

products

Porter D, et al, 2002, J Rheumatol

“That Foot Thing” Foot Rubz

Radford JA, et al, 2007 BMC Musculoskeletal

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Therapeutic Exercise –

CAVUS Foot

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Intrinsic Plantar Fascia Stretch Greater improvement of pain and function, as well as greater patient satisfaction than traditional standing Achilles stretch

1st MTP stretching/mobilization Sesamoid mobilization Shamus J, et al, 2004 J Orthop Sports Phys Ther

Most effective when performed before initial few steps in AM

Soft Tissue Mobilization and Cross Fiber Massage to fascial tolerance

10 x 10 sec/TID and after prolonged NWB prescription

Intrinsic Plantar Fascia Stretch!!

DiGiovanni, et al. 2003, JBJS DiGiovanni, et al. 2006, JBJS

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Therapeutic Exercise – PLANUS

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Foot

STRENGTHENING EMPHASIS strengthen the muscles that control and reverse pronation posterior tibialis anterior tibialis peroneals www.continuing-ed.cc

Posterior Tib Training

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Therapeutic Exercise – PLANUS Foot

STRENGTHENING EMPHASIS Intrinsic strengthening † sweeps,

curls, and pick ups

Most helpful treatment by patient report (35% of subjects) as compared with night splints, orthotics, heel cups, NSAIDs, and corticosteroid injections

Manual Therapy Intervention Evaluate and treat all arthokinematic impairments and restrictions at TCJ, STJ, MTJ, TMTJ, and 1st MTPJ Case series – Young B, et al, 2004, J Orthop Sports Phys Ther

Martin RL, et al, 1998. Foot Ankle Int

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Shoe Recommendations

External Support

to Control Symptoms

Shoes Tape Orthotics

stiff, firm heel counter with straight last well molded Achilles collar beveled and flared heel for stability midsole cushioning elevated heel good midfoot/forefoot flexibility 14% of patients with chronic heel pain found a change in shoes the most effective treatment Wolgin M, et al. 1994 , Foot Ankl Int

“Tape it up real tight, Floyd … and the other ankle, too.”

Low-Dye Taping

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Calcaneal Taping

Significant short-term reduction in pain Landorff et al. 2005, J Am Podatr Med Assoc

Calcaneal taping was shown to be be more effective than stretching sham taping, or no treatment Hyland, et al, 2006, J Orthop Sports Phys Ther

temporary or trial technique to reduce pronation and stabilize 1st ray www.continuing-ed.cc

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Taping and Orthotic Mechanical Support Randomized, prospective study to compare mechanical support (taping for first month and custom orthotic for next two months) with accommodative heel cups or corticosteroid injections † Significantly better outcomes in mechanical group (70% satisfaction) as compared to 30-33% with antiinflammatory or accommodative modalities. Lynch DM, et al, 1998, J Am Podiatr Med Assoc

Orthotic Intervention Pain and function improved with the use of foot orthotics Roos E, et al, 2006, Foot Ankle Int

Soft Accommodative Orthotic provides total contact to the medial longitudinal arch customized heel pad/soft orthotic offered significant pain relief in a small sample of elderly patients Siligman DA, et al, 2003, Arch Phys Med Rehabil

Biomechanical Orthotic provide semi-rigid support to hyperpronation 66% decrease in pain and 75% reduction in disability Gross MT, et al, 2002, J Ortho Sports Phys Ther

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No-Need for Long Term Use or Customization? Pre-fabricated orthotic insert more likely to provide symptom improvement that customized rigid device Pfeffer G, et al, 1999, Foot Ankle Int

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Night Splints Maintains position of ankle and toe in dorsiflexion during the night †

Did not account for foot types in randomization Both customized and pre-fabricated orthoses provided short-term improvements (3 months) in pain and function as compared to a sham group but no difference at 12 months

allows the plantar fascia to heal at a functional length and prevent physiological creep

Most effective in chronic conditions †

symptoms present for > 6 months

Landorf KB, et al, 2006; Arch Intern Med

Could it be that condition has largely resolved by this point in time? Simple off-the-shelf orthoses have significant effect on fascitiis symptoms Tinley P, et al. Biomechanics, 2007

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Night Splint Research ☺ Relief provided in 83% of patients with recalcitrant plantar fasciitis - Wapner, et al Foot-Ankle, 1991

☺ Ankle DynaSplint beneficial in patients with recalcitrant plantar fasciitis – Berlet GC, et al; Orthopedics, 2002

☺ Dorsiflexion splints provide symptomatic relief of recalcitrant plantar fasciitis in the majority of patients – Powell, M, et al, 1998, Foot Ankle Int

☺ Tension night splint improved the efficiency of a standard treatment protocol

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Outcome Assessment Lower Extremity Functional Scale (LEFS) Foot Health Status Questionnaire (FHSQ) Foot and Ankle Ability Measure (FAAM) Foot Function Index (FFI) Martin RL, 2007, J Ortho Sports Phys Ther

– Batt ME, et al; Clin J Sports Med, 1996

No added benefit with addition of night splint to a standard treatment protocol – Probe RA, et al; Clin Orthoped Relat Res, 1999

Inconclusive on best type of splint to affect outcome, however, Strassburg sock shown to speed recovery. - Barry LD, et al; J Foot Ankle Surg 2002 www.continuing-ed.cc

All have been shown to reliable, valid (content and construct), and responsive www.continuing-ed.cc

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