Plantar fasciopathy (PFs)

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Victoria Lang
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1 Plantar fasciopathy (PFs) Jung-Soo Lee, M.D., Ph.D. Department of Rehabilitation Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea

2 Anatomy of Plantar Aponeurosis(PA) layers of flat broad tendons vs band or sheet of connective tissue

3 Nerve innervation to PA

4 Plantar Aponeurosis(PA) aponeurosis maintains the medial longitudinal arch of the foot assists in absorbing loading forces across the mid-tarsal joints and is involved in the push-off phase of gait.

5 Windlass mechanism

6 Risk of PFs High BMI Age DM various rheumatologic processes : seronegative spondyloarthropathies, rheumatoid arthritis Foot deformity(pes cavus & pes planus) Minor trauma Achilles shortening resulting in reduced ankle dorsiflexion Decreased motion of subtalar joint mobility

$diagnoses of heel pain: heel pad atrophy (1), plantar fasciitis (2), Baxter nerve entrapment (3), calcaneal stress fracture (4), and tarsal tunnel$

7 Differential Diagnosis Clinical photographs of the medial (A) and plantar (B) aspects of a left foot demonstrating locations of tenderness for five diagnoses of heel pain: heel pad atrophy (1), plantar fasciitis (2), Baxter nerve entrapment (3), calcaneal stress fracture (4), and tarsal tunnel syndrome (5).

8 Differential Diagnosis

9 Classic symptom post static dyskinesia *more than 80% of patients experiencing resolution within 12 months, regardless of management

10 Case-Lo, C. plantar fascitis symptoms. Available from:

11 Tenderness tenderness may be localized centrally along the plantar fascia (orange oval), along the plantar medial tuberosity (red circle), or directly plantar to the calcaneal tuberosity (yellow oval).

12 Diagnostic Imaging Mostly, is not helpful in diagnosing PF, but it should be considered to rule out other causes of heel pain or to establish the diagnosis of PF when in doubt.

13 MRI findings increased signal intensity consistent with edema in perifascial soft tissue on T2-weighted images mild to moderate thickening of the PA calcaneal marrow edema ->chronic plantar fasciitis PA rupture : at the proximal origin and at the midsubstance of the fascia, but acute ruptures are more commonly proximal

14 MRI findings

15 Ultrasound Imaging Normal appearance of the plantar fascia has been reported to be 2-4 mm thick Fascial thickening (>4 mm), generally of the central portion, close to its calcaneal origin If plantar fascia to be less than 25 % thicker than unaffected side, look for other causes of plantar heel pain.

16 Insertional vs Non-insertional Eighty-two of the 125 feet (66 %) - pure insertional disease at the medial calcaneal tuberosity. The more distal fascia was normal. Twelve percent (15 feet) had pure distal disease, with nine feet having fusiform thickening of the plantar fascia distal to the insertion and with normal appearances at the insertion. Six feet had distal fibromata only, in midsubstance or distal parts of the fascia. The insertion was normal. Twenty-two percent(28 feet) had mixed disease. Of the 28 feet that had mixed disease, six feet had widespread diffuse thickening and 22 feet had insertional thickening with distal fibromata in addition.

17 Biomechanics Consideration Relieving Strain on the plantar aponeurosis reduce pronation of the foot reduce collapse of the foot arch redistribute plantar pressure and transfer pressure from the rear foot to the midfoot region or reproduce the medial and anterior longitudinal arches of the foot without load, thereby maintaining the best physiological shape possible.

18 The effect of medial arch support on strain of PA

19 Insole design

20 Orthosis

21 Meta-analysis result of improvement of pain for different follow-up sessions

22 Meta-analysis result of improvement of foot function for different follow-up sessions

23 Meta-analysis result There is evidence that orthosis intervention has short, intermediate, and long-term effects on decreasing pain and foot function in patients with plantar fasciitis. On the other hand, the control group (night splint group) we considered for comparison showed substantial improvement in pain, but not for selfreported foot function

24 Achilles Stretching Program

Plantar Fascia-Specific Stretching Program Cross your affected leg over your other leg. Using the hand on your affected side, take hold of your affected foot and pull your toes back towards shin.

25 Plantar Fascia-Specific Stretching Program Cross your affected leg over your other leg. Using the hand on your affected side, take hold of your affected foot and pull your toes back towards shin. This creates tension/stretch in the arch of the foot/plantar fascia. Check for the appropriate stretch position by gently rubbing the thumb of your unaffected side left to right over the arch of the affected foot. The plantar fascia should feel firm, like a guitar string. Hold the stretch for a count of 10. A set is 10 repetitions. Perform at least three sets of stretches per day. You cannot perform the stretch too often. The most important times to stretch are before taking the first step in the morning and before standing after a period of prolonged sitting.

26 The Evidence of Treatment Injection Steroid Autologous whole blood(awb) Extra corporeal shock wave therapy Orthosis

27 Steroid vs Placebo

28 Forest plot for visual analogue score between corticosteroid and placebo injection

29 Steroid vs AWB

30 Forest plot of standardized mean differences for the assessment of pain relief in the short term (2-6 weeks after treatment)

31 Forest plot of standardized mean differences for the assessment of composite outcomes in the intermediate term (8-13 weeks after treatment)

32 Forest plot of standardized mean differences for the assessment of pain relief in the medium term (24-26 weeks after treatment)

33 Forest plot of standardized mean differences for the assessment of composite outcomes in the medium term(24-26 weeks after treatment) composite outcomes : questionnaires that assessed at least the pain intensity and functional disability

34 Pathophysiology & etiology of Pfs a lack histological evidence of inflammation in cases of plantar fasciopathy thickening and fibrosis and degeneration of the plantar fascia, with no evidence of inflammation chronic recalcitrant plantar fasciopathy pain showed collagen necrosis, angiofibroblastic hyperplasia, chondroid metaplasia, and matrix calcification, with no cellular proof of inflammation caution with regards to the use of steroid injection for plantar fasciopathy there is evidence that plantar fasciopathy is in fact a degenerative process, not an inflammatory one the risk of plantar fascia rupture has been reported to be in the region of 10 %.

35 Extra corporeal shock wave vs Placebo

36 Forest plot of 10 cm VAS scores for morning pain at 12 weeks

AMG Virtual CME Series Plantar Fasciitis Brian T. Dix, DPM, FACFAS Board Certified in Foot and Reconstructive Hindfoot & Ankle Surgery

AMG Virtual CME Series Plantar Fasciitis 11-9-17 Brian T. Dix, DPM, FACFAS Board Certified in Foot and Reconstructive Hindfoot & Ankle Surgery Anatomy 3 bands of dense connective tissue, which originate