Plantar fasciopathy What are the risk factors? Dr. Paul Beeson BSc, MSc, PhD, FCPodMed, FFPM RCPS(Glasg)
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1 Plantar fasciopathy What are the risk factors? Dr. Paul Beeson BSc, MSc, PhD, FCPodMed, FFPM RCPS(Glasg)
2 Economic burden 10% of people suffer heel pain during their life (Tong & Furia, 2010) 10 20% plantar fasciopathy become recalcitrant (Rompe et el, 2007) Cost of delaying treatment
3 Negative impact of PF? Quality of Life (Irving et al, 2008) Physical inactivity (Beeson, 2014)
4 Potential long-term health consequences of chronic heel pain? Coronary artery disease Hypertension NIDD Foot osteoarthritis
5 Plantar fasciitis or fasciopathy? Terminology? (Maffulli et al, 1988) Insertional or non-insertional (Jeong et al, 2013)
6 Anatomy Medial Central Lateral
7 Ligament structure Ligament in relaxed state Ligament under tension
8 Ligament composition Collagen Type 1 Type 3 Type 5 Tendon % Ligament % % Elastin Proteoglycans Glycoprotein Water 66%
9 Histological effects in PF 1) Neovascularization 1) Change in collagen composition: ( Type 1, Type 3, Type 5) (Gonçalves-Neto, 2002) 3) Mucin content 4) Fibroblast hypercellularity
10 MRI normal plantar fascia M L Frontal Sagittal
11 Ultrasound of Plantar fascia Thickened Pf = >4mm Normal Pf: 2-4mm
12 Function of Plantar Fascia
13 Demographics of Plantar fasciopathy Sedentary + Athletic populations Peak onset yrs age (Werner et al, 2010) PLANTAR FASCIOPATHY (Prevalence 3.6 to 7%) Gender association Findings vary between studies Unilateral involvement in up to 2/3 rd cases (Irving et al, 2007; Sher et al, 2010)
14 Origin of chronic plantar heel pain? Systemic Neurological (nerve entrapment) Traumatic (fracture) Mechanical (Thomas et al, 2010).
15 What are the risk factors for PF? Extrinsic load, environment, occupation, lifestyle, sport. Intrinsic ligament changes (Beeson, 2014)
16 Extrinsic risk factors Occupation (Riddle et al, 2003) Inappropriate footwear (Thomas et al, 2010) Physical load/ activity levels (Buckbinder, 2004) Sleeping posture (Bolivar et al, 2013)
17 Extrinsic risk factors Sports overuse injury: Training errors/ surfaces (Kibler et al, 1991) High intensity (Singh et al, 1997) Muscle dysfunction/ inflexibility (Rome et al, 2011) Poor technique/ fatigue (Taunton et al, 2002)
18 Intrinsic risk factors Middle/ older age (peak 40-60yrs) degenerative changes within Pf. (Lemont et al, 2003) Gender?
19 Intrinsic risk factors Obesity (>30kg/m 2 ) (Frey & Zamora, 2007; Riddle et al, 2003) Vascular perfusion (McMillan et al, 2009) Trauma (Penetrating injury/ laceration) No reported associations.
20 Intrinsic risk factors BIOMECHANICAL DYSFUNCTION * Reduced AJ dorsiflexion (Riddle et al, 2003; Huerta 2014; Sullivan et al, 2015) Foot pronation (Riddle et al, 2007; Irving et al, 2007; Rome et al 2011) Rearfoot eversion (Lee et al, 2010) Reduced 1 st MPJ extension (Irving et al, 2006) Stress shielding of FDB? (Orchard, 2012)
21 Intrinsic factors confused with PF Systemic disease: Ankylosing Spondylitis Psoriatic arthritis Reiter s syndrome Reactive arthritis
22 Heel spur 10-15% normal population Present in 50-75% of those with heel pain (Karabay et al, 2007; McNally & Shetty, 2010)
23 Heel spurs Site FDB attachment Not a traction spur Associated with: Increased age Obesity History heel pain Menz et al (2008): Plantar calcaneal spurs in older people: longitudinal traction or vertical compression? J foot & Ankle Research. 1:7.
24 Genetic risk factors Genetic studies have revealed: COL5A1 regulates tendon strength Gene COL1A1 & COL3A1 painful tendinopathy TNC at myotendinous & osteotendinous junctions MMP s TIMP s Imbalance alters tendon homeostasis (Ireland et al, 2001; Alfredson et al,2003; Riley, 2008; Raleigh et al, 2014).
25 Candidate gene variants implicated COL5A1 MMP1, MMP3, MMP8, MMP10 & MMP12 GDF5 TGFB ADAMTS1, ADAMTS2, ADAMTS4, ADAMTS5, ADAMTS15 TIMP1, TIMP2, TIMP3, TIMP4
26 Quality of evidence? General Summary Precise mechanism of ligament injury? Numerous reported risk factors imply PF is a complex multifactorial soft tissue pathology.
27 Conclusions Economic burden to health services Ranking of + interaction between risk factors Research to establish a genetic basis for PF
28 References See following article to access all PowerPoint references: Beeson P: Plantar fasciopathy Revisiting the risk factors. J Foot & Ankle Surgery. 2014; 20(3):
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