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 at the medial tubercle of the calcaneus and fan distally to insert into the base of each proximal phalanx. 3 1 2 3
Anatomy First described by Hicks in 1954 as the windlass mechanism, the plantar fascia tenses during the terminal stance to toe-off phases of gait. 3,4 This tension elevates and reinforces the medial longitudinal arch, which in turn allows the foot to function as a rigid lever for forward propulsion. 5
Pathophysiology Chronic degenerative process involving the plantar aponeurosis of the foot, most commonly at its insertion into the medial tubercle of the calcaneus. The process involves repetitive strain that seems to cause microtearing, which induces a repair response. 4,6
Histology Thickening and fibrosis of the plantar fascia along with collagen necrosis, chondroid metaplasia, and calcification. 6,7 Historically it was assumed to be an inflammatory process. May be a degenerative mechanism, leading some to suggest that plantar fasciosis may be a more accurate. 6,8
Epidemiology About 1 million each year 1 Most initially seek PCP 1 Peak incidence 45 64 yo Women more common 1,9 Higher incidence flat or high-arched feet, longdistance runners, military, occupations with prolonged standing, obese or sedentary. 9-11 1/3 of patients have bilateral plantar fasciitis.
Clinical diagnosis! Medial plantar heel pain Most intense first few steps in the morning or after sitting for a while. 3,12 Ankle range of motion should also be assessed. Dorsiflexion less than 10 beyond neutral is indicative of an equinus contracture. Most have a gastrocnemius equinus. 13 Diagnosis
Differential Diagnosis
2,3,12-18 Differential Diagnosis
Treatment 85% -90% get better without surgery.6 80% have no longterm recurrence1,16 Use a multimodal evidence-based approach2
Treatment Rest NSAIDs 22,23 Stretching: Achilles, plantar fascia, and intrinsics 24,25 Ice is better than heat!23
Treatment Insoles with stretching showed better shortterm improvement than stretching alone.28 A RCT comparing OTC insoles with customized insoles found no significant difference in pain at 12-month follow up. 29 The long-term effectiveness of shoe inserts for plantar fasciitis is uncertain.30
Night splints have been helpful with chronic plantar fasciitis.16,31 Maintenance of ankle dorsiflexion and toe extension. Constant stretch to heal at a functional length.16,30 Treatment
Treatment Corticosteroid injections provided better relief at 1 month but not at 6 months in a RCT. 32 Risks: skin and fat pad atrophy, infection, and plantar fascia rupture.32,33 2.4% had a rupture following an average of 2.67 injections in retrospective review of 120 pts. Corticosteroid injections appears to be a safe and effective treatment with minimal complications and a relatively low incident of plantar fascia rupture.4
Treatment Extracorporeal shockwave therapy (ESWT) Therapeutic mechanism is unknown. Randomized double-blinded clinical trial, the addition of 1 application of 3800 high-energy shock waves to standard therapies demonstrated a statistically significant improvement in symptoms at 3 months compared with standard therapies without ESWT.35
Treatment Plantar fasciotomy is indicated only after at least 6 to 12 months of failed conservative treatment.2 Surgical release of greater than 40% of the plantar fascia may have detrimental effects on other ligamentous and bony structures in the foot.38 75% of patients who underwent surgical intervention reported substantial or complete reduction in heel pain. 39
Treatment
Conclusions History and Physical Examination Findings Medial plantar heel pain Pain is most intense during first few step Pain improves with rest Nonoperative Management Initial: NSAIDs, stretching, footwear modification, and orthotics Chronic: Corticosteroid injections, ESWT, and ultrasound therapy
Conclusions Operative Management Plantar fasciotomy is indicated only after failed conservative treatment for at least 6 to 12 months
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References
References 40. Foot Ankle Spec. 2010 Dec;3(6):335-7. doi: 10.1177/1938640010378530. Epub 2010 Sep 3. Incidence of plantarfascia ruptures following corticosteroid injection. Kim C, Cashdollar MR, Mendicino RW, Catanzariti AR, Fuge L.