Orthotics and Stretching for Heel Pain are BETTER than Injections and Procedures

Transcription

1 Orthotics and Stretching for Heel Pain are BETTER than Injections and Procedures Jacob Wynes DPM, MS, FACFAS Assistant Professor, Department of Orthopaedics University of Maryland School of Medicine

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4 Chief of Podiatric Surgery at U Penn Everyone s second / third opinion An authority on foot and ankle surgery Countless Publications Accomplished Lecturer

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6 Key Word Average Monthly Searches foot problems 170 plantar fasciitis 8100 podiatrist 3600 bunion 2400 heel pain 1300 heel spur 1300 foot pain 1000 swollen feet 1000 foot doctor 880 bunion surgery 590 orthotics 590 flat feet 590

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8 Medial Calcaneal Neuritis Rose et al. JFAS 2003 Bone Stress Reaction Davey et al. Osteoporos Int 2016 Pester et al. Orthop Rev 1992 Sub-calcaneal bursitis Crawford et al. Cochrane Database Syst Rev 2003

9 Risk Factors for Developing Plantar Fasciitis Rome et al. Phys Ther Rev 1997 Buchbinder NEJM 2004 Problem Solution Limited Ankle DF Limb Length Discrepancy Diminished heel pad thickness Excess pronation Limited range of motion first MTPJ Stretching Orthotics / Could do surgery Definitely NOT surgery Orthotics / stretching Orthotics /? Surgery

10 SPECT / CT for heel pain shows arthritis of midfoot Lee et al. Clin Nucl Med 2018 Changes occur in the midfoot with custom orthoses Williams et al. Phys Ther 2000 Abnormal arch mechanics as contributing factor Wearing et al. Sports Med 2006 Hindfoot valgus as a contributing factor Chang et al. J Biomech 2014 Over pull from windlass mechanism as a contributing factor Cheng et al. J Biomech

11 Custom orthoses reduce strain at the plantar fascia (mostly at the aponeurosis) Kogler et al. Clin Biomech 1996 Ferber et al. J Foot Ankle Res 2011 Higher heel reduces tension on plantar fascia Kogler et al. FAI 2001 Questionable added benefit of heel pads Winemiller et al. JAPMA 2003 Pfeffer et al. FAI 1999 Blinded RCT: Prefabricated and custom orthoses revealed relief compared to sham orthoses at 3 months of treatment Landorf et al. Arch Int Med 2006

12 Off the shelf / Pre fab effective in reducing arch strain by 30%

13 Crawford et al. Cochrane Database Syst Rev 2003 Cochrane Review of RCT s 11 trials N= 1,332 Sham vs. no intervention vs. manipulation / stretching vs. night splints vs. hallux valgus surgery vs. pre fabricated orthoses INITIALLY Custom orthoses (CMO) found to be more effective > than sham orthoses in reducing pain As effective as night splints and stretching AND improved effectiveness of night splints AFTER 2-3 MONTHS, pre fabricated orthoses as effective as CMO

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17 Prospective Randomized Study - N= 34 VA patients with FF / MF pain, Excluding neurologic issues, RA, counfounding trauma, osseous block, irreducible deformity (5 DM pts) - 34 randomly selected controls - Avg weight 183 lbs - 2X increase of EQUINUS in symptomatic patients

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19 Patel et al. FAI 2011 Acute vs. Chronic P. Fascitis (N = 254) 2 year prospective trial 10% progress to chronic fascitis after stretching ( ~ 9 months) DiGiovanni B and Malay D JBJS 2006 (Level II evidence) 2 year prospective randomized tissue specific stretching modality (plantar fascial vs. tendo-achilles) (N = 33 men / 68 women enrolled) 94% pts had decreased pain Equivalent response at 2 years Recommendation for 6 month total of stretching

20 RCT of 40 recruited patients (home exercise with home exercise + night splint) Average BMI 30.8 kg/m2 6 week and 3 month appointment f/u Pain > 4 months / unilateral 1.5 point improvement in VAS FFI improvement Wheeler et al. BMJ 2017

21 Bohannon et al 1994 WB static 5 minutes Knight et al 2001 WB static 20 seconds ON / 10 seconds OFF 4 x 3x / week for 6 weeks Peres et al 2002 NWB static stretch with pulley (1/3 patient weight) 10 minutes / day X 14 days Pratt & Bohannon 2003 Static platform drop 3 minutes 3 days Youdas et al 2003 WB static stretch 30 seconds vs. 1 minute vs. 2 minutes 5 days / week for 6 weeks

22 Prospective study: Use of DF assist dyna-splint for plantar fasciitis Berlet et al. Orthopedics 2002 Quicker recovery compared to standard stretching Barry et al. JFAS 2002 Prospective RCT: 32 patients completed study/ 33 feet Only 3 failures Stat sig improvement with night splint p < 0.05 Batt et al. Clin J Sports Med 1996

23 31 RCTs (n=2450 patients) no evidence of one modality over another yet PLACEBO and SHAM are least effective Exercise good for long term relief Medline, EMBASE, CINAHL, AMED, PEDro, Cochrane Database, Web of Science and WHO Clinical Trials Platform Babatunde et al. Br. J Sports Med 2018

24 Taping for plantar fasciosis Van de Water et al. JAPMA 2010 RCT calcaneal taping vs. sham for heel pain Hyland et al. J Orthop Sports Phys Ther 2006 RCT blinded control Porter et al. FAI 2002

25 Successful for chronic plantar fasciitis (N= 82 patients / 115 heels) F/U at 42 +/- 22 months 74% good - excellent results 87% stating sucessful Better pain relief in non-active duty military Purcell JFAS 2018 Meta-analysis of RCTs Improvement in VAS with greatest reduction in pain Improvement of pain by 60% + Best for chronic refractory plantar fasciitis Aqil et al. CORR 2013

26 Double-blinded, placebo controlled, mulit-center, RCT ESWT group (n=115) vs. Placebo group (n=57) No adverse events Improvement in VAS reduction 3.39 vs for placebo group Kudo et al. J Orthop Res 2006

27 58% of patients out of 75 had Plantar Fasciitis VAS improvement % satisfied

28 RCT: Manual Therapy, Patient Education, Stretching McClinton et al. Phsiother Theory Pract 2018 Predictors of response of physical 6 month follow up N=60 (6 visits over 4 weeks) Age and BMI not predictive of healing Numeric pain scale improvement by 3 points (95% CI, ) Symptoms less than 7.2 months were likely to respond McClinton et al. FAI 2015

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30 Post injection: Ultrasound investigation revealed plantar fascia thickening as having no impact on prognosis mean 9.7 year follow up Average of 3.8 treatments Time decreases fascial thickness at 5,10, and 15 years in both groups Hansen et al. Orthop J. Sports Med 2018

31 Chronic degeneration without inflammation Myxoid degeneration Increased abnormal fibroblasts / mitochondrial defects

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33 10% reported rate Acevedo et al. FAI 1994 Sellman FAI 1994 Crawford et al. Rheumatology 1999 Kalaci et al. JAPMA 2009

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35 Non operative management with rest, massage, NSAIDS, night splints, heel pads, ESWT achieves healing in 90% of patients Recommended with symptoms of at least 6-12 months Neufeld et al. JAAOS 2008

36 Athletes 9 weeks to return to activity after complete tear Fullem et al. 2016

37 Brugh et al. JFAS % of plantar fascia released Open 72% EPF 28% 15/47 patients with LCS Greater than 50% release correlated

38 Why Does This Happen? Anderson et al. JFAS 2001 Releasing 25% of plantar fascia with greatest effect Increased strain noted at bifurcate ligament, cervical and talocalcaneal ligaments Lateral fascial band takes up stress Recommendation for only 25% cut of fascia

39 Anderson et al. JFAS 2001

40 Recommendation for aggressive immobilization post operatively to avoid these complications Downey Biomechanics 1998

41 One More Time?

42 Beware Calcaneal Stress Fracture Jerosch et al. FAI 2000

43 Improvement in 12 months ~ 90% Riddle et al FAI 2004, DiGiovanni et al. JBJS 2003 Elevated BMI / Bilateral involvement / Duration > 6 months Wolgin et al. FAI 1994 Duration lasts longer with certain independent variables: female and bilateral heel pain Hansen et al. Orthop J. Sports Med 2018 Systemic involvement contributes to persistent pain Furey JG. JBJS Am 1975

44 Long Term Patient Outcomes over 10 years N=30 patients / 33 feet Ages years old Average 3.1 years prior to surgical intervention

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46 With Sincere Appreciation!

47 Thank You!

48 THANK YOU