““What Do We Know (or not What Do We Know (or not know) about Plantar know) about Plantar
Fasciitis?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
THE FOLLOWING PRESENTATION HAS BEEN APPROVED FORTHE FOLLOWING PRESENTATION HAS BEEN APPROVED FOR
[PROFESSIONAL AUDIENCES][PROFESSIONAL AUDIENCES]By the Wisconsin Athletic Trainers’ AssociationBy the Wisconsin Athletic Trainers’ Association
THIS PRESENTATION HAS NOT YET BEEN RATED THIS PRESENTATION HAS NOT YET BEEN RATED
THE FOLLOWING PRESENTATION HAS BEEN APPROVED FORTHE FOLLOWING PRESENTATION HAS BEEN APPROVED FOR
[PROFESSIONAL AUDIENCES][PROFESSIONAL AUDIENCES]By the Wisconsin Athletic Trainers’ AssociationBy the Wisconsin Athletic Trainers’ Association
THIS PRESENTATION HAS NOT YET BEEN RATED THIS PRESENTATION HAS NOT YET BEEN RATED
Graphic
© Scott T. Doberstein, MS, ATC, LAT
Overview… Overview… where are we headed?where are we headed?
Background Background Anatomy/Pathophysiology Anatomy/Pathophysiology EtiologyEtiologyDifferential DiagnosisDifferential DiagnosisClassic Presentation Classic Presentation Treatment Interventions Treatment Interventions PrognosisPrognosis
© Scott T. Doberstein, MS, ATC, LAT
Background (What it is!)
PF most common cause of heel painPF most common cause of heel pain• 2 million pts seek Tx annually in US 2 million pts seek Tx annually in US (Riddle, (Riddle,
2003)2003)
• PF accounts for 11-15% of all foot S/S PF accounts for 11-15% of all foot S/S seeking professional care seeking professional care (Buchbinder, 2004)(Buchbinder, 2004)
• 10% of running related injuries 10% of running related injuries ((Buchbinder, 2004)Buchbinder, 2004)
PF most common condition Tx by podiatric PF most common condition Tx by podiatric foot/ankle specialists foot/ankle specialists (APMA, 2001)(APMA, 2001)
© Scott T. Doberstein, MS, ATC, LAT
Background (What it is!)
1/3 of pts have bilateral PF 1/3 of pts have bilateral PF (Neufeld, 2008)(Neufeld, 2008)
10% probability of getting PF in lifetime 10% probability of getting PF in lifetime (Crawford, 2003)(Crawford, 2003)
Peak age of incidence is 40-60 y, Peak age of incidence is 40-60 y, especially women especially women (Riddle, 2003)(Riddle, 2003)
© Scott T. Doberstein, MS, ATC, LAT
Background (What it isn’t!)
1812 – Wood first to describe PF as 1812 – Wood first to describe PF as infection secondary to TB infection secondary to TB (Neufeld, 2008)(Neufeld, 2008)
Fascial layer – not a tendon but…Fascial layer – not a tendon but…
Interesting tissue to treat!!Interesting tissue to treat!!
© Scott T. Doberstein, MS, ATC, LAT
What is Plantar Fasciitis?
RECALCITRANT*RECALCITRANT*
HEEL PAIN!!HEEL PAIN!!
*(difficult to treat; resistant to commonly used treatments, Taber’s 2013)*(difficult to treat; resistant to commonly used treatments, Taber’s 2013)
© Scott T. Doberstein, MS, ATC, LAT
Other names for Recalcitrant heel pain (What it is?)
Painful heel syndromePainful heel syndromeRunner’s heelRunner’s heelJogger’s heelJogger’s heelTennis heelTennis heelSubcalcaneal painSubcalcaneal painCalcaneodyniaCalcaneodyniaPlantar faschiopathyPlantar faschiopathyPLANTAR FASCIOSIS (new school)*PLANTAR FASCIOSIS (new school)*
© Scott T. Doberstein, MS, ATC, LAT
Other names for Recalcitrant heel pain (What it isn’t?)
Heel spur syndromeHeel spur syndromeCalcaneal periostitisCalcaneal periostitisPLANTAR FASCIITIS (old school)*PLANTAR FASCIITIS (old school)*
© Scott T. Doberstein, MS, ATC, LAT
Anatomy/Pathophysiology
PF function = provide support to med long PF function = provide support to med long arch, dynamic shock absorberarch, dynamic shock absorber
Windlass Effect = tensile force at proximal Windlass Effect = tensile force at proximal attachment with MTP extension attachment with MTP extension
PF is INFLEXIBLE – max elongation of 4% PF is INFLEXIBLE – max elongation of 4% (Lee,2007)(Lee,2007)
~ Age 40 – calcaneal fat pad breaks ~ Age 40 – calcaneal fat pad breaks
down = less shock absorption down = less shock absorption more more force on PF attachment force on PF attachment (Lee, 2007)(Lee, 2007)
© Scott T. Doberstein, MS, ATC, LAT
Anatomy/PathophysiologyActually continuous with the Achilles Actually continuous with the Achilles
tendontendon Is it inflammation? Only acutely??Is it inflammation? Only acutely??Most of what we deal with is actually Most of what we deal with is actually
chronic!chronic!Lemont, 2003 = chronic degeneration Lemont, 2003 = chronic degeneration
• Resection of PF shows histological evidence Resection of PF shows histological evidence of PLANTAR FASCIOSIS not fasciitis!of PLANTAR FASCIOSIS not fasciitis!
© Scott T. Doberstein, MS, ATC, LAT
Anatomy/PathophysiologyLemont, 2003 reported: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 No inflammation markers or cells (similar to
tendinosis) tendinosis)
Caused by repetitive microtears of PF that Caused by repetitive microtears of PF that overtake the body’s ability to repair itselfovertake the body’s ability to repair itself
© Scott T. Doberstein, MS, ATC, LAT
Etiology = MULTIFACTORIAL
RISK FACTORS REPORTED:RISK FACTORS REPORTED:Decreased ankle DF ROMDecreased ankle DF ROMObesityObesityProlonged standingProlonged standingPes planus (excessive pronation)Pes planus (excessive pronation)Seronegative arthritisSeronegative arthritis
© Scott T. Doberstein, MS, ATC, LAT
Etiology = MULTIFACTORIAL
Running is a risk factor:Running is a risk factor:• Increased distance/intensityIncreased distance/intensity• Poor footwearPoor footwear• Unyielding surfaceUnyielding surface• Pes cavusPes cavus• Shortened Achilles tendonShortened Achilles tendon
© Scott T. Doberstein, MS, ATC, LAT
Etiology – What it isn’t!
Heel Spur – significant evidence that bony Heel Spur – significant evidence that bony exostosis does not cause PFexostosis does not cause PF• However, quite common to have an exostosis However, quite common to have an exostosis
simultaneously with PF but…the spur is NOT simultaneously with PF but…the spur is NOT the cause of PFthe cause of PF
© Scott T. Doberstein, MS, ATC, LAT
Differential Diagnosis (What it isn’t!)
NeurologicNeurologic (tarsal tunnel syndrome, lateral plantar n. (tarsal tunnel syndrome, lateral plantar n. entrapment, medial calcaneal n. entrapment, peripheral neuropathy, entrapment, medial calcaneal n. entrapment, peripheral neuropathy, S1 radiculopathy)S1 radiculopathy)
Soft tissueSoft tissue (PF rupture, enthesopathies, fat pad atrophy, (PF rupture, enthesopathies, fat pad atrophy, Achilles tendinitis, flexor hallucis longus tendinitis, posterior tibialis Achilles tendinitis, flexor hallucis longus tendinitis, posterior tibialis tendinitis, plantar fibromatosis)tendinitis, plantar fibromatosis)
SkeletalSkeletal (calcaneal stress fracture, bone contusion, infection (calcaneal stress fracture, bone contusion, infection (osteomyelitis, etc), subtalar arthritis, inflammatory arthropathies)(osteomyelitis, etc), subtalar arthritis, inflammatory arthropathies)
MiscellaneousMiscellaneous (neoplasm, vascular insufficiency, (neoplasm, vascular insufficiency, osteomalacia, Paget’s disease, sickle cell disease)osteomalacia, Paget’s disease, sickle cell disease)
© Scott T. Doberstein, MS, ATC, LAT
Classic Presentation Classic Presentation (What it is!)(What it is!)
Inferior heel pain (self limiting!)Inferior heel pain (self limiting!) Increased pain w/ first steps in morning =Increased pain w/ first steps in morning =
Post Static DyskinesiaPost Static Dyskinesia (McNally, 2010)(McNally, 2010)
Increased pain upon standing after Increased pain upon standing after prolonged sittingprolonged sitting
Increased pain during prolonged standingIncreased pain during prolonged standing Increased pain with barefoot walkingIncreased pain with barefoot walkingPain worsens near end of the dayPain worsens near end of the day
© Scott T. Doberstein, MS, ATC, LAT
Classic Non-Presentation Classic Non-Presentation (What it isn’t!)(What it isn’t!)
Inferior heel pain with multi-joint pain or Inferior heel pain with multi-joint pain or other ligament/tendon painother ligament/tendon pain
Nocturnal painNocturnal painFoot pain anywhere besides medial Foot pain anywhere besides medial
tubercle or medial longitudinal archtubercle or medial longitudinal archRadiating or neurological S/SRadiating or neurological S/S
© Scott T. Doberstein, MS, ATC, LAT
Treatment Options ReportedTreatment Options Reported
Rest/modification of activityRest/modification of activity IceIceHeatHeatUltrasoundUltrasoundE-stimE-stim IontophoresisIontophoresisStrengthening Strengthening
© Scott T. Doberstein, MS, ATC, LAT
Treatment Options ReportedTreatment Options Reported
MassageMassageNSAID’sNSAID’sStretching (both calf and PF specific)Stretching (both calf and PF specific)Night splintsNight splintsHeel cups/padsHeel cups/padsTapingTapingCastsCasts
© Scott T. Doberstein, MS, ATC, LAT
Treatment Options ReportedTreatment Options Reported
Orthoses (custom and off the shelf)Orthoses (custom and off the shelf) Injections (corticosteroids, PRP, botulinum Injections (corticosteroids, PRP, botulinum
toxin)toxin)AccupunctureAccupunctureShockwave therapyShockwave therapyMagnetsMagnetsNutritional ConsiderationsNutritional ConsiderationsSurgerySurgery
© Scott T. Doberstein, MS, ATC, LAT
Evidence - Based OutcomesEvidence - Based Outcomes
20-30 interventions out there being used20-30 interventions out there being usedDifficult to research with RCT’sDifficult to research with RCT’s
• Many management strategies are used Many management strategies are used simultaneously = too many variablessimultaneously = too many variables
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
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
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
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
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, FInjections (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
Other Interventions
Extracorporeal Shock Wave Therapy CAutologous Platelet Rich Plasma CIt’s the SHOES (ADL’s vs. activity) E,FNutritional Considerations (Roxas, 2005) E, F
• Vitamin C• Zinc CT repair/regen• Glucosamine• Bromelain (pineapple enzyme) • Fish oil anti-inlam
© Scott T. Doberstein, MS, ATC, LAT
What does all this mean for us as clinicians treating patients with plantar fasciosis/fasciopathy?
© Scott T. Doberstein, MS, ATC, LAT
© Scott T. Doberstein, MS, ATC, LAT
What it isn’t!
Where science meets art….???Where science meets art….???
OROR
© Scott T. Doberstein, MS, ATC, LAT
What is it?
Where art meets science…….??Where art meets science…….??
““No evidence strongly supports the No evidence strongly supports the effectiveness of any treatment of PF, effectiveness of any treatment of PF, and most patients improve without and most patients improve without specific therapy or by using specific therapy or by using conservative measures.” conservative measures.” (Cole, 2005)(Cole, 2005)
Intervention Algorithms?x4
Young, 20011. Correct training errors, relative rest, ice post
activity, inspect footwear 2. Correct biomechanical factors with stretching
and strengthening3. Night splints and orthotics4. 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
Intervention Algorithms?
Cole, 20051. 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
Intervention Algorithms?
Neufeld, 20081. 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
Intervention Algorithms?
Neufeld, 20084. 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
Intervention Algorithms?
Rompe, 20091. 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
© Scott T. Doberstein, MS, ATC, LAT
Prognosis
Hastened recovery if Tx initiated w/in 6 Hastened recovery if Tx initiated w/in 6 wks of onset wks of onset (Young, 2001)(Young, 2001)
Non-surgical mgmt success rate = 90% Non-surgical mgmt success rate = 90% (Neufeld, 2008)(Neufeld, 2008)
80% of pts have favorable results w/in 12 80% of pts have favorable results w/in 12 months months (Rompe, 2009)(Rompe, 2009)
Further Research
We need more research on many We need more research on many interventions to get a better handle on this interventions to get a better handle on this significant problem!!!significant problem!!!
On the horizon…..??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
© Scott T. Doberstein, MS, ATC, LAT
Thank You
Enjoy the rest of the
Symposium!