Plantar Fasciitis:

What to Do With Refractory Patients Craig Young, MD Medical College of Wisconsin

Goals !  Basic science background - brief !  Diagnosis - really brief !  Treatment !  Brief summary of treatment options !  Discuss my approach to patients

Etiology ! Acute (rare) - may occur from trauma ! Chronic !  Repetitive overloading of the plantar fascia (Kogler 95,96,99) !  Tendonopathic & chronic enthesitic changes !  !  !  ! 

Collagen degeneration Fiber disorientation Increased ground substance Absence of inflammatory cells

(Maffulli 03 & Yuan 03)

Key findings on history & exam !  Worse pain with 1st AM steps

!  Pain after prolonged non-weight bearing

!  Pain with barefoot walking !  No symptoms & signs of neurologic involvement !  Pain & tenderness over plantar fascia origin !  Windlass test !  Sensitivity 13.6%; Specificity 100% !  Weight-bearing windlass !  Sensitivity 31.8%; Specificity 100% (DeGarceau 2003 Foot & Ankle Intl)

Treatment options “Traditional”

“Newer”

!  Stretching & strengthening

!  Deep tissue techniques

!  Modalities !  NSAIDs !  Cortisone !  Night splints & walking boots !  Foot wear, orthotics, heel cups & arch supports !  Surgery

!  Extracorporeal & intracorporeal shock wave !  Prolotherapy, PRP, botox autologous blood injection !  Nitroglycerin patches !  Nerve ablasion ‒ cryo & RF

My approach ! Relative rest ! Stretching

!  Consider night splint !  Physical therapy !  Strengthening?

! Arch support

!  Check shoes !  Arch taping !  OTC !  Orthotic

! Patience

! Adjunctive !  Acetaminophen !  NSAIDs

My approach, continued !  More patience !  For chronic or those who like intervention !  Injection !  Autologous blood vs. vs. PRP vs. cortisone !  ECSW !  Surgery

Panel comments

Any questions?

http://pier.acponline.org/ physicians/diseases/ d065/d065.html

[email protected]

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!  Dogramaci Y. Kalaci A. Emir A. Yanat AN. Gokce A. Intracorporeal pneumatic shock application for the treatment of chronic plantar fasciitis: a randomized, double blind prospective clinical trial. Arch Orthop Trauma Surg 2010. 130(4):541-6. UI: 19669773 !  Donley BG, Moore T, Sferra J, Gozdanovic J, Smith R. The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: a randomized, prospective, placebo-controlled study. Foot Ankle Int. 2007;28:20-3. (PMID:17257533) !  Fadale PD, Wiggins ME. Corticosteroid Injections: Their Use and Abuse. J Am Acad Orthop Surg. 1994;2:133-140. (PMID:10709001) !  Frater C, Vu D, Van der Wall H, Perera C, Halasz P, Emmett L, Fogelman I. Bone scintigraphy predicts outcome of steroid injection for plantar fasciitis. J Nucl Med. 2006;47:1577-80. (PMID:17015890)

!  Gerdesmeyer L, Frey C, Vester J, Maier M, Weil L Jr, Weil L Sr, et al. Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis: results of a confirmatory randomized placebo-controlled multicenter study. Am J Sports Med. 2008;36:2100-9. (PMID:18832341) !  Gray RG. Gottlieb NL. Intra-articular corticosteroids. An updated assessment. Clin Orthop Rel Res. 1983. (177): 235-63.UI: 6345042 !  Haake M, Buch M, Schoellner C, Goebel F, Vogel M, Mueller I, et al. Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial. BMJ. 2003;327:75. (PMID:12855524) !  Hammer DS, Adam F, Kreutz A, Kohn D, Seil R. Extracorporeal shock wave therapy (ESWT) in patients with chronic proximal plantar fasciitis: a 2-year follow-up. Foot Ankle Int. 2003;24:823-8. (PMID:14655885)

!  Huang YC, Wei SH, Wang HK, Lieu FK. Ultrasonographic guided botulinum toxin type A treatment for plantar fasciitis: an outcome-based investigation for treating pain and gait changes. J Rehabil Med. 2010;42:136-40. (PMID:20140409) !  Höfling I, Joukainen A, Venesmaa P, Kröger H. Preliminary experience of a single session of low-energy extracorporeal shock wave treatment for chronic plantar fasciitis. Foot Ankle Int. 2008;29:150-4. (PMID:18315969) !  Hogan KA, Webb D, Shereff M. Endoscopic plantar fascia release. Foot Ankle Int. 2004;25:875-81. (PMID:15680100) !  Ibrahim MI, Donatelli RA, Schmitz C, Hellman MA, Buxbaum F. Chronic plantar fasciitis treated with two sessions of radial extracorporeal shock wave therapy. Foot Ankle Int. 2010;31:391-7. (PMID:20460065) !  Kiter E, Celikbas E, Akkaya S, Demirkan F, Kiliç BA. Comparison of injection modalities in the treatment of plantar heel pain: a randomized controlled trial. J Am Podiatr Med Assoc. 2006;96:293-6. (PMID:16868321)

!  Kudo P, Dainty K, Clarfield M, Coughlin L, Lavoie P, Lebrun C. Randomized, placebo-controlled, double-blind clinical trial evaluating the treatment of plantar fasciitis with an extracoporeal shockwave therapy (ESWT) device: a North American confirmatory study. J Orthop Res. 2006;24:115-23. (PMID:16435344) !  Kogler GF, Solomonidis SE, Paul JP. In vitro method for quantifying the effectiveness of the longitudinal arch support mechanism of a foot orthosis. Clin Biomech (Bristol, Avon). 1995;10:245-252. (PMID:11415561) !  Kogler GF, Veer FB, Solomonidis SE, Paul JP. The influence of medial and lateral placement of orthotic wedges on loading of the plantar aponeurosis. J Bone Joint Surg Am. 1999;81:1403-13. (PMID:10535590) !  Kogler GF, Solomonidis SE, Paul JP. Biomechanics of longitudinal arch support mechanisms in foot orthoses and their effect on plantar aponeurosis strain. Clin Biomech. 1996;11:243-252. (PMID:11415628)

!  Liden B, Simmons M, Landsman AS. A retrospective analysis of 22 patients treated with percutaneous radiofrequency nerve ablation for prolonged moderate to severe heel pain associated with plantar fasciitis. J Foot Ankle Surg. 2009;48:642-7. (PMID:19857819) !  Maffulli N, Wong J, Almekinders LC. Types and epidemiology of tendinopathy. Clin Sports Med. 2003;22:675-92. (PMID:14560540) !  Malay DS, Pressman MM, Assili A, Kline JT, York S, Buren B, et al. Extracorporeal shockwave therapy versus placebo for the treatment of chronic proximal plantar fasciitis: results of a randomized, placebo-controlled, double-blinded, multicenter intervention trial. J Foot Ankle Surg. 2006;45:196-210. (PMID:16818146) !  Martin RP. Autologous Blood Injection for Plantar Fasciitis: A Retrospective Study [abstract]. Clin J Sport Med. 2005; 15:387-8.

!  McCallum SD. Paoloni JA. Murrell GA. Five-year prospective comparison study of topical glyceryl trinitrate treatment of chronic lateral epicondylosis at the elbow. Br J Sports Med 2011. 45(5):416-20. UI: 19553221 !  Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int. 2004;25:303-10. (PMID:15134610) !  Ogden JA, Alvarez RG, Levitt RL, Johnson JE, Marlow ME. Electrohydraulic high-energy shock-wave treatment for chronic plantar fasciitis. J Bone Joint Surg Am. 2004;86-A: 2216-28. (PMID:15466731) !  Paoloni JA. Murrell GA.Three-year followup study of topical glyceryl trinitrate treatment of chronic noninsertional Achilles tendinopathy. Foot & Ankle International 2007. 28(10):1064-8, UI: 17923056

!  Roos E, Engstrom M, Soderberg B. Foot orthoses for the treatment of plantar fasciitis. Foot Ankle Int. 2006;27:606-11. (PMID:16919213) !  Rompe JD, Decking J, Schoellner C, Nafe B. Shock wave application for chronic plantar fasciitis in running athletes. A prospective, randomized, placebo-controlled trial. Am J Sports Med. 2003;31:268-75. (PMID:12642264) !  Rompe JD, Furia J, Weil L, Maffulli N. Shock wave therapy for chronic plantar fasciopathy. Br Med Bull. 2007;81-82:183-208. (PMID:17456546) !  Ryan MB. Wong AD. Gillies JH. Wong J. Taunton JE. Sonographically guided intratendinous injections of hyperosmolar dextrose/lidocaine: a pilot study for the treatment of chronic plantar fasciitis. Br J Sports Med 2009. 43(4):303-6. UI: 19019908 !  Saxena A. Uniportal endoscopic plantar fasciotomy: a prospective study on athletic patients. Foot Ankle Int. 2004;25:882-9. (PMID:15680101)

!  Sharma NK. Loudon JK. Static progressive stretch brace as a treatment of pain and functional limitations associated with plantar fasciitis: a pilot study. Foot & Ankle Specialist. 2010. 3(3):117-24. UI: 20508011 !  Speed CA, Nichols D, Wies J, Humphreys H, Richards C, Burnet S, et al. Extracorporeal shock wave therapy for plantar fasciitis. A double blind randomised controlled trial. J Orthop Res. 2003;21:937-40. (PMID:12919884) !  Taunton JE, Ryan MB, Clement DB, McKenzie DC, LloydSmith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002;36:95-101. (PMID:11916889) !  Theodore GH, Buch M, Amendola A, Bachmann C, Fleming LL, Zingas C. Extracorporeal shock wave therapy for the treatment of plantar fasciitis. Foot Ankle Int. 2004;25:290-7. (PMID:15134608)

!  Tornese D, Mattei E, Lucchesi G, Bandi M, Ricci G, Melegati G. Comparison of two extracorporeal shock wave therapy techniques for the treatment of painful subcalcaneal spur. A randomized controlled study. Clin Rehabil. 2008;22:780-7. (PMID:18728131) !  Tong KB. Furia J. Economic burden of plantar fasciitis treatment in the United States. Am J Orthop 2010. 39(5): 227-31. !  Tweed JL. Barnes MR. Allen MJ. An evaluation of the longterm effects of total plantar fasciotomy--a preliminary study. Foot 2009. 19(2):75-9. UI: 20307454 !  Wang CJ, Wang FS, Yang KD, Weng LH, Ko JY. Long-term results of extracorporeal shockwave treatment for plantar fasciitis. Am J Sports Med. 2006;34:592-6. (PMID:16556754)

!  Young CC, Rutherford DS, Niedfeldt MW. Treatment of Plantar Fasciitis. Am Fam Physician 63(3): 467-474, 2001. !  Young CC. Plantar fasciitis. American College of Physicians Physicians' Information and Education Resource (PIER) Project [serial online: http://pier.acponline.org/physicians/ diseases/d065/d065-pdf.html]. 2007 Jan !  Young CC. Plantar fasciitis. eMedicine Journal [serial online: http://emedicine/sports]. Rev Jan 2012 !  Young CC. In the clinic: Plantar fasciitis. Ann Int Med. 2012. 156(1):ITC1-1-16. !  Yuan J, Wang MX, Murrell GA. Cell death and tendinopathy. Clin Sports Med. 2003;22:693-701. (PMID: 14560541)

Epidemiology !  2 million person/yr in US !  1 million patient visits/yr !  3rd most common injury in runners !  Cost of treatment to third-party payers ranged from $192-376 million in 2007 in USA

(Riddle 2004, Tauton 2002, Tong 2010)

Radiologic studies ! Plain x-rays - only useful to r/o other conditions ! Heel spurs 2x more likely in pt with PF

! MRI or Dx UTZ ! Both show increases in fascia thickness in PF of 1.5 -1.9 mm

Differential diagnosis !  Plantar fascia rupture !  Calcaneal fracture !  Calcaneal apophysitis !  Heel fat pad syndrome !  Longitudinal arch strain !  Nerve entrapment !  Tumor

Modalities !  Studies including ultrasound, laser, magnetic fields !  Overall - no significant improvement !  When to use !  Resistant cases !  Speed is of essence

NSAIDs ! A randomized, PC study of 29 patients !  17 on placebo and 12 on NSAIDs

! Both groups improved at the 1, 2 & 6 month follow-up !  Trend toward improved pain control & disability in the NSAID group

! Significant improvements overall in both groups.

(Donley 2007 Foot Ankl Intl)

Corticosteroid injection ! Short term benefits ! Risks/side effects !  Pain !  Post-injection flare (2-5%)

!  Infection !  0.072% with aseptic technique !  0.0001% with sterile technique

!  Bleeding !  HPA suppression Gray 1983

AAOS orthopaedic surgeons survey re: cortisone ! 90% use cortisone !  73% injected plantar fascia in past yr

! 89% observed complication !  Subcutaneous fat atrophy (64%) !  Skin atrophy & pigment changes (54%) !  Tendon rupture (39%) !  Cartilage damage (20%) !  Infection (18%) Fadale & Wiggins 1994 J Am Acad Ortho Surg

Is a 3-phase bone scan a cortisone success prognosticator? ! 14/20 feet responding to injection had focal hyperemia on the blood-pool images ! None with diffuse uptake on the blood-pool images responded. (Frater 2006 J Nuclear Med)

Injecting cortisone !  Dose ~ 40 mg of methylprednisolone ~ 1 cc of most corticosteroid preparations + 2 cc anesthetic 25 gauge 1.5” needles

Plantar fascia injection technique #1 !  Advantage !  Easy to hit target

!  Disadvantages !  Increased risk of heel fat pad atrophy !  Increased risk of plantar fascia rupture?

Plantar fascia injection technique #2 ! Advantages

!  Decreased risk of heel fat pad rupture !  Decreased risk of plantar fascia rupture?

! Disadvantages !  Greater chance of missing target !  Less effective?

! Ultrasound guidance?

Night splints !  Multiple trials including crossover and RCT show significant improvement !  4 positive; 1 no effect

Walking boot? !  Pilot study 16 subjects in randomized single blinded study !  Stretching vs. “SAS brace” !  No difference

! Sharma NK. 2010

Arch support !  Both taping & orthotics show increases in function &/or decreases VAS in most studies !  5 positive; 1 no effect

Orthotics vs. night splints ! RCT of 43 patients to foot orthosis, foot orthosis and night splint, or night splint alone. ! All patients had significant improvement on their Foot and Ankle Outcome Scores at 12 week and 1 year follow-up visits. ! The foot orthosis had significantly !  better pain reduction !  better compliance !  fewer side effects.

(Roos 2006 Foot Ankle Intl)

Treatment !  Do nothing !  Most/many patients in control group of RCT eventually heal

!  Key is proper framing !  Rest, ice, stretching, cross-friction massage

Shoe exam !  Beware of midshoe breakdown !  If shoe bends easily midsole instead of at MTP joint !  Cause overstretch of the plantar fascia with each footstep

Surgical !  Risks !  Infection, bleeding, pain !  Scarring, nerve damage !  Loss of arch

Surgical release ! Retrospective review of 22 consecutive patients with chronic plantar fasciitis & endoscopic plantar fascia release after at least 6 months postoperatively !  Satisfaction rate of 97.7% !  All patients reporting at least a 50% improvement in pain. !  Modified Mayo Foot and Ankle Score, 15 of 22 (68%) had good or excellent results (Hogan 2004 Foot & Ankle Intl).

Surgical release ! 32 patients endoscopic plantar fasciotomy. !  16 athletic patients all had results were excellent or good. !  Good or excellent results in the non-athletic group were obtained only in patients who walked for exercise !  All five patients with poor results having a BMI of more than 27 (Saxena 2004 Foot & Ankl Intl)

Long term effects !  Change in center of pressure in gait analysis compared to non-operated foot (Tweed JL 2009)

“Newer” treatments

Deep tissue techniques !  A.R.T., ASTYM & Graston !  Theory !  Mechanical breakdown of scar tissue !  Stimulate healing cascade

Extracorporeal shock wave therapy (ECSW) ! High energy shock waves generated ! Mechanical pressure & tension force plus trailing cavitation bubbles which collapse into “micro-jets” !  Both induce microtrauma

!  Induces blood vessel formation !  Increased delivery of nutrients !  Increased dissolution of calcific deposits

ECSW ! Low-energy shock wave

!  Series of three or more treatments. !  Minimal to mildly painful

! High-energy shock wave

!  Single session. !  Quite painful - require anesthesia (regional block or general)

! Theory is to induce neovascularization & healing via creating localized inflammatory process

ECSW study results Favorable Rompe 2003 Ogden 2004 Kudo 2006 Wang 2006 Malay 2006 Gerdesmeyer 2008 Ibrahim 2010

Neutral Speed 2003 Haake 2003 Hammer 2003 Theodore 2004 Greve 2009

Intracorporeal pneumatic shock application

!  50 patients in RCDB study !  6 month follow-up

!  Excellent & Good outcomes (92%) vs. control group (24%) (P