2 Plantar FasciaThick broad connective tissue that spans the arch of the footOriginates on the medial tubercle of the calcaneus and inserts onto the proximal phalanges and flexor tendon sheathsForms longitudinal arch of the foot and functions as a shock absorberSupports the arch as weight is transferred over the foot from heel strike to toe off
4 Fasciitis???A degenerative condition that may or may not be associated with inflammatory changes in the tissuesPain may be caused by repetitive micro trauma to the fascia
5 FrequencyOccurs in 10 % of runners and may be associated with training errorsAccounts for 11-15% of all foot symptoms requiring medial care
6 SymptomsClassic presentation: heel pain in the morning when first rising from bedMay improve through the day but tends to hurt again by afternoon and evening.Reoccurs upon standing after prolonged sittingWorse with walking barefoot and walking up stairs
7 Physical ExamTenderness to palpation on the anteromedial aspect of the heelAnkle dorsiflexion limited by calf tightnessPain increased by toe extension or by standing on toes
8 Risk Factors Obesity Occupation requiring prolonged standing Pes planus or cavusCalf tightnessToe runners, running up hills or in sandRapid change in activity level: intensity or durationLack of warm up or cold weather
9 Differential Diagnosis Tarsal tunnelBone bruise or heel contusionSever diseaseCalcaneal stress fractureFat pad atrophy / central heel painInflammatory arthropathiesNeuropathic painRetrocalcaneal bursitisAchilles insertional pain
10 Prognosis80% are better in 12 monthsSurgical intervention is rare
12 Treatment PlanTake away source of irritation: boot / crutches, if neededStretching arch and calf and forefootIceSoft tissue massage: gentle to start, advance to aggressive as toleratedOpen chain strengthening: manual, bands to both ankle and forefoot
13 Treatment PlanAdvance to closed chain strengthening and balance work as symptoms allowBrisk walking, cross training, pain freeAdd light impactPhase return to run program, watch running formGradual progressions : 10 % ruleSports specific return to activities
14 Mike Shaffer’s Concept of Dosing of Rehab in Evidence Based Medicine: “The Black Box” JOSPT – April 2008 : Clinical Guidelines related to Heel Pain-Plantar Fasciitis. Clinical practice guidelines linked to international classification of function, disability , and health from ortho section of APTAPanel of experts did a scientific review of the literature prior to may 2007, up for review again in 2012.Grade level of evidence I-V, grade of evidence A-F
15 Recommendations for Interventions: Strength of Evidence Summary Modalities: iontophoresis (dexamethasone 0.4% or acetic acid 5%) can provide short term (2-4 weeks) pain relief and improved functionStretching: calf and PF stretching can be used in short term (2-4 mo) for pain relief and improved calf flexibility. Dose of calf stretching is 2-3 x day, either sustained 3 min hold or 20 sec intermittent stretching hold time. . Both hold times produced a beneficial effect.Taping: provided short term pain relief ( 7-10 days)
16 Continued summary of recommendations Orthotics: Prefab or custom orthotics used to provide short term (3 mo ) pain reduction and improvement in function. No difference in pain reduction or function between the two types of orthotics. No evidence to support long term use greater than one year for pain management or functional improvement.
17 Continued summary of recommendations. Night splints: consider for patients with symptoms > 6 mo. The desired length of wearing time is 1-3 months. The type of night splint did not matter. ( ant, post or sock type).No super strong evidence for manual therapy (joint mobilization).
18 Conclusion:When does a presentation or research article “change how you practice” and when does it “guide how you practice”?????????????????????????????????A potential future topic