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“What Do We Know (or not know) about Plantar Fasciitis? Scott T. Doberstein, MS, ATC, LAT Head Athletic Trainer/Senior Lecturer University of Wisconsin.

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Presentation on theme: "“What Do We Know (or not know) about Plantar Fasciitis? Scott T. Doberstein, MS, ATC, LAT Head Athletic Trainer/Senior Lecturer University of Wisconsin."— Presentation transcript:

1 “What Do We Know (or not know) about Plantar Fasciitis? Scott T. Doberstein, MS, ATC, LAT Head Athletic Trainer/Senior Lecturer University of Wisconsin – La Crosse Wisconsin Athletic Trainers’ Association Annual Meeting & Symposium Wisconsin Dells, WI April 12, 2013

2 THE FOLLOWING PRESENTATION HAS BEEN APPROVED FOR [PROFESSIONAL AUDIENCES] By the Wisconsin Athletic Trainers’ Association THIS PRESENTATION HAS NOT YET BEEN RATED THE FOLLOWING PRESENTATION HAS BEEN APPROVED FOR [PROFESSIONAL AUDIENCES] By the Wisconsin Athletic Trainers’ Association THIS PRESENTATION HAS NOT YET BEEN RATED Graphic

3 © Scott T. Doberstein, MS, ATC, LAT Overview… where are we headed?  Background  Anatomy/Pathophysiology  Etiology  Differential Diagnosis  Classic Presentation  Treatment Interventions  Prognosis

4 © Scott T. Doberstein, MS, ATC, LAT Background (What it is!)  PF most common cause of heel pain 2 million pts seek Tx annually in US (Riddle, 2003)2 million pts seek Tx annually in US (Riddle, 2003) PF accounts for 11-15% of all foot S/S seeking professional care (Buchbinder, 2004)PF accounts for 11-15% of all foot S/S seeking professional care (Buchbinder, 2004) 10% of running related injuries ( Buchbinder, 2004)10% of running related injuries ( Buchbinder, 2004)  PF most common condition Tx by podiatric foot/ankle specialists (APMA, 2001)

5 © Scott T. Doberstein, MS, ATC, LAT Background (What it is!)  1/3 of pts have bilateral PF (Neufeld, 2008)  10% probability of getting PF in lifetime (Crawford, 2003)  Peak age of incidence is y, especially women (Riddle, 2003)

6 © Scott T. Doberstein, MS, ATC, LAT Background (What it isn’t!)  1812 – Wood first to describe PF as infection secondary to TB (Neufeld, 2008)  Fascial layer – not a tendon but…  Interesting tissue to treat!!

7 © Scott T. Doberstein, MS, ATC, LAT What is Plantar Fasciitis? RECALCITRANT* HEEL PAIN!! *(difficult to treat; resistant to commonly used treatments, Taber’s 2013)

8 © Scott T. Doberstein, MS, ATC, LAT Other names for Recalcitrant heel pain (What it is?)  Painful heel syndrome  Runner’s heel  Jogger’s heel  Tennis heel  Subcalcaneal pain  Calcaneodynia  Plantar faschiopathy  PLANTAR FASCIOSIS (new school)*

9 © Scott T. Doberstein, MS, ATC, LAT Other names for Recalcitrant heel pain (What it isn’t?)  Heel spur syndrome  Calcaneal periostitis  PLANTAR FASCIITIS (old school)*

10 © Scott T. Doberstein, MS, ATC, LAT Anatomy/Pathophysiology  PF function = provide support to med long arch, dynamic shock absorber  Windlass Effect = tensile force at proximal attachment with MTP extension  PF is INFLEXIBLE – max elongation of 4% (Lee,2007)  ~ Age 40 – calcaneal fat pad breaks down = less shock absorption  more force on PF attachment (Lee, 2007)

11 © Scott T. Doberstein, MS, ATC, LAT Anatomy/Pathophysiology  Actually continuous with the Achilles tendon  Is it inflammation? Only acutely??  Most of what we deal with is actually chronic!  Lemont, 2003 = chronic degeneration Resection of PF shows histological evidence of PLANTAR FASCIOSIS not fasciitis!Resection of PF shows histological evidence of PLANTAR FASCIOSIS not fasciitis!

12 © Scott T. Doberstein, MS, ATC, LAT Anatomy/Pathophysiology  Lemont, 2003 reported: Collagen necrosis and loss of collagen continuityCollagen necrosis and loss of collagen continuity Increased ground substanceIncreased ground substance Increased vascularityIncreased vascularity Increased fibroblastsIncreased fibroblasts No inflammation markers or cells (similar to tendinosis)No inflammation markers or cells (similar to tendinosis)  Caused by repetitive microtears of PF that overtake the body’s ability to repair itself

13 © Scott T. Doberstein, MS, ATC, LAT Etiology = MULTIFACTORIAL RISK FACTORS REPORTED:  Decreased ankle DF ROM  Obesity  Prolonged standing  Pes planus (excessive pronation)  Seronegative arthritis

14 © Scott T. Doberstein, MS, ATC, LAT Etiology = MULTIFACTORIAL  Running is a risk factor: Increased distance/intensityIncreased distance/intensity Poor footwearPoor footwear Unyielding surfaceUnyielding surface Pes cavusPes cavus Shortened Achilles tendonShortened Achilles tendon

15 © Scott T. Doberstein, MS, ATC, LAT Etiology – What it isn’t!  Heel Spur – significant evidence that bony exostosis does not cause PF However, quite common to have an exostosis simultaneously with PF but…the spur is NOT the cause of PFHowever, quite common to have an exostosis simultaneously with PF but…the spur is NOT the cause of PF

16 © Scott T. Doberstein, MS, ATC, LAT Differential Diagnosis (What it isn’t!)  Neurologic (tarsal tunnel syndrome, lateral plantar n. entrapment, medial calcaneal n. entrapment, peripheral neuropathy, S1 radiculopathy)  Soft tissue (PF rupture, enthesopathies, fat pad atrophy, Achilles tendinitis, flexor hallucis longus tendinitis, posterior tibialis tendinitis, plantar fibromatosis)  Skeletal (calcaneal stress fracture, bone contusion, infection (osteomyelitis, etc), subtalar arthritis, inflammatory arthropathies)  Miscellaneous (neoplasm, vascular insufficiency, osteomalacia, Paget’s disease, sickle cell disease)

17 © Scott T. Doberstein, MS, ATC, LAT Classic Presentation (What it is!)  Inferior heel pain (self limiting!)  Increased pain w/ first steps in morning = Post Static Dyskinesia (McNally, 2010)  Increased pain upon standing after prolonged sitting  Increased pain during prolonged standing  Increased pain with barefoot walking  Pain worsens near end of the day

18 © Scott T. Doberstein, MS, ATC, LAT Classic Non-Presentation (What it isn’t!)  Inferior heel pain with multi-joint pain or other ligament/tendon pain  Nocturnal pain  Foot pain anywhere besides medial tubercle or medial longitudinal arch  Radiating or neurological S/S

19 © Scott T. Doberstein, MS, ATC, LAT Treatment Options Reported  Rest/modification of activity  Ice  Heat  Ultrasound  E-stim  Iontophoresis  Strengthening

20 © Scott T. Doberstein, MS, ATC, LAT Treatment Options Reported  Massage  NSAID’s  Stretching (both calf and PF specific)  Night splints  Heel cups/pads  Taping  Casts

21 © Scott T. Doberstein, MS, ATC, LAT Treatment Options Reported  Orthoses (custom and off the shelf)  Injections (corticosteroids, PRP, botulinum toxin)  Accupuncture  Shockwave therapy  Magnets  Nutritional Considerations  Surgery

22 © Scott T. Doberstein, MS, ATC, LAT Evidence - Based Outcomes  interventions out there being used  Difficult to research with RCT’s Many management strategies are used simultaneously = too many variablesMany management strategies are used simultaneously = too many variables

23 Evidence - Based Medicine   Grades of Evidence (McPoil, 2008) A = strong evidence B = moderate evidence C = weak evidence D = conflicting evidence E = theoretical/foundational evidence F = expert opinion © Scott T. Doberstein, MS, ATC, LAT

24 Evidence - Based Outcomes (McPoil, 2008)   Most significant risk factors are limited DF ROM and obesity  B   S/S including pain in plantar medial heel, post static dyskinesia, prolonged standing, pain w/ initial steps following inactivity  B   Evaluation findings including decreased DF ROM, palpable pain at proximal PF attachment, + Windlass test  B © Scott T. Doberstein, MS, ATC, LAT

25 Evidence - Based Outcomes (McPoil, 2008)   Iontophoresis (dexamethasone or acetic acid)  B Only short term relief of 2-4 weeks   Manual Therapy (specific ankle/foot/MTP joint mobilizations)  E   Taping (calcaneal and low dye)  C Only short term relief of 7-10 days © Scott T. Doberstein, MS, ATC, LAT

26 Evidence - Based Outcomes (McPoil, 2008)   Stretching (both calf/Achilles and PF specific)  B ST relief for 2-4 months Remember Achilles and PF have continuous fibers!   Orthoses (both custom and prefabricated) ST relief for ~ 3 months  A LT relief at 1year  F © Scott T. Doberstein, MS, ATC, LAT

27 Evidence - Based Outcomes (McPoil, 2008)   Night Splints (posterior, anterior, sock type) Only use after 6 months of S/S and use only for 1-3 months  B   NSAID’s – no RCT studies at all  E, F   Injections (corticosteroids only)  C Only ST relief up to 2 weeks Significant risk of PF rupture (better with US guided technique) © Scott T. Doberstein, MS, ATC, LAT

28 Other Interventions   Extracorporeal Shock Wave Therapy  C   Autologous Platelet Rich Plasma  C   It’s the SHOES (ADL’s vs. activity)  E,F   Nutritional Considerations (Roxas, 2005)  E, F Vitamin C Zinc CT repair/regen Glucosamine Bromelain (pineapple enzyme) Fish oilanti-inlam © Scott T. Doberstein, MS, ATC, LAT

29 What does all this mean for us as clinicians treating patients with plantar fasciosis/fasciopathy? © Scott T. Doberstein, MS, ATC, LAT

30 What it isn’t! Where science meets art….??? OR

31 © Scott T. Doberstein, MS, ATC, LAT What is it? Where art meets science…….?? “No evidence strongly supports the effectiveness of any treatment of PF, and most patients improve without specific therapy or by using conservative measures.” (Cole, 2005)

32 Intervention Algorithms? x4   Young, Correct training errors, relative rest, ice post activity, inspect footwear 2. Correct biomechanical factors with stretching and strengthening 3. Night splints and orthotics 4. All other Tx options considered  NSAID’s used throughout Tx but… pt educated that meds are used for pain control and not curative! © Scott T. Doberstein, MS, ATC, LAT

33 Intervention Algorithms?   Cole, Shoe inserts, stretching, NSAID’s, ice (because it works for other musculoskeletal conditions making it reasonable to do) 2. Corticosteroid injection or dexamethasone iontophoresis 3. Night splints, ESWT (but only for runners w/ S/S > 1 year) 4. Possible surgery © Scott T. Doberstein, MS, ATC, LAT

34 Intervention Algorithms?   Neufeld, ADL’s as tolerated, NSAID’s, heel pads, prefabricated orthotics, calf & PF stretching, night splint, pt assured surgery uncommon, dispel myths about heel spur not causing PF, 4-6 weeks 2. Corticosteroid injection followed by cast or cam walker 3. Custom orthoses w/ deep heel cup, Rx strength NSAID’s, lateral x-ray to r/o other pathology cont. © Scott T. Doberstein, MS, ATC, LAT

35 Intervention Algorithms?   Neufeld, Continue above if improvement is progressing  d/c 5. If no improvement, MRI to confirm PF, ESWT or other alternative Tx 6. Surgery if S/S > 1 year © Scott T. Doberstein, MS, ATC, LAT

36 Intervention Algorithms?   Rompe, R/O neuro and osseous pathologies 2. PF specific stretching for 6-12 weeks 3. continue stretching, modify activity, soft heel pads for another 6-12 weeks 4. continue above, night splints, ionto 6-12 wks 5. continue above, ESWT, corticosteroid injection 6. botulinum toxin 7. Surgery after 6-12 months of unsuccessful mgmt © Scott T. Doberstein, MS, ATC, LAT

37 Prognosis  Hastened recovery if Tx initiated w/in 6 wks of onset (Young, 2001)  Non-surgical mgmt success rate = 90% (Neufeld, 2008)  80% of pts have favorable results w/in 12 months (Rompe, 2009)

38 Further Research  We need more research on many interventions to get a better handle on this significant problem!!!  On the horizon…..?? Injections of botulinum toxin Injections of autologous platelet rich plasma Anything else you can think of?????? © Scott T. Doberstein, MS, ATC, LAT

39 Thank You Enjoy the rest of the Symposium!


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