Dr Isstelle Joubert May 2011 Presenting History: Mr A, 39yo man bilateral painful feet one year history gradual onset no history of trauma or recent surgery lower limbs job: salesman Previous history: Surgical: both ankles, knee and right arm fracture
Medical: gout, chronic sinusitis Social: OH stop July 2010, non-smoker, 4L coke DAILY! Family history: dad died age 48 - myocardial infarction Clinical examination: BP - 130/90 BMI - 39.8 (W=138kg, H=184cm) Examination of feet: localized tenderness plantar aspects, especially medial calcaneal tuberosities Current chronic medication: Puricos 300 i od (raised u/a)
Glucophage 500mg i od (raised insulin) Lorien 20mg i od (depressive mood) Special investigations: X-ray of both feet - heel spurs seen on X-ray Heel spur Management: Local infiltration of steroid (both heels) Insoles in shoes Weight loss advised
Follow-up: one foot - totally pain free other one - some discomfort Three stage assessment: Biological change his current health status drastically diet, weight, level of exercise Personal/Psychological impact fear of loss of income if pain persists stays at home when pain is unbearable gets frustrated - conflict with clients Social/contextual impact expectations colleagues (not staying at home),
family (activity, diet - better quality of life) Problem list: Active - bilateral painful feet Passive obesity hyperinsulinaemia family history - MI increased blood levels of uric acid unhealthy diet no exercise Differential diagnosis:
Plantar fasciitis Tibialis posterior syndrome Referred pain as a result of a S1-radiculopathy Stress fracture - calcaneal or navicular Fat pad injury Peripheral neurogenic pain: tibial nerve related Trigger point pain Synonyms: painful heel syndrome heel spur syndrome runners heel subcalcaneal bursitis
periostitis policemans heel (most of day-time on their feet)1 Definition: musculoskeletal disorder affecting the plantar aponeurosis or fascia (inflammation) mostly infero-medial aspect Prevalence: young and old athletes and non-athletes not gender specific2
United States3,4 600 000 outpatient visits annually athletes, 5 - 14%5 of running injuries Anatomy of the foot and plantar fascia: arises: medial process of calcaneal tuberosity attachment: distally to plantar aspect of the forefoot, medial and lateral intermuscular septa mechanoreceptors respond to mechanical loading
noci-ceptors transmit info on pain and inflammation6 Pathophysiology: not well understood mechanical overload and excessive strain microscopic tears in the fascia triggering the inflammatory repair processes entesal fibrocartilage - prone to degenerative change increase cartilage cell clustering formation of fissures within the fibrocartilage ossification = spurs
tumors osteomalacia, Pagets vascular insufficiency disease, sickle cell disease Symptoms and signs: pain inferior on heel worse on weight bearing worse: first few steps in the morning
persisting from months to years character: throbbing or piercing improves after resting - worsens again with continued activity throughout the day limiting daily activities - walking barefoot, on toes or climbing stairs tenderness localised to medial aspect of the calcaneal tuberosity assessing gait: excessive supination or pronation
plantar fascia tight stretching reproduce pain Possible causes7: Possible causes7... Anatomical Pes planus (flat feet): strain - fascia try maintain stable arch during the propulsive phase of gait Pes cavus (high arch): strain - decreased eversion - absorb shock Activities running / dancing: max plantarflexion ankle + dorsiflexion MTP joints
Elderly persons - non-supportive / inappropriate footwear 10 Obesity / increased work-related weight bearing study found NO association for BMI11 Special investigations: aim confirm the diagnosis modalities available
ultrasound plain x-rays of feet bone-scan MRI nerve conduction studies blood tests Special investigations: Ultrasound useful non-invasive technique increased thickness + hypo-echoic fascia
Special investigations: Plain x-rays of feet generally unhelpful rule out stress fractures of calcaneus calcifications noticed + osteophytes (heel spurs) study: osteophytes visible 50% with plantar fasciitis, 19% without plantar fasciitis12 Special investigations: Bone-scan increased uptake at the calcaneus not very specific technique
very sensitive potential malignant bony lesions Special investigations: Magnetic Resonance Imaging (MRI) thickening of the plantar fascia detecting tears or rupture of the fascia Special investigations: Nerve conducting studies no improvement in three months of conservative Rx ? other causes: nerve entrapment / tarsal tunnel syndrome
Special investigations: Blood tests CRP - ? infection HLA B27-genes - ? HLA-B27-spondyloarthropaties (psoriatic arthritis or ankylosing spondylitis) uric acid - gout raised ALP, normal PO4 + Ca2+ - ? Pagets disease Management: Avoidance of aggravating activities Cryotherapy NSAID Stretching
Night splinting Taping Soft tissue therapy Foot orthoses Corticosteroid injection Iontophoresis16 Extracorporeal shock wave therapy17,18 Surgery
Management: Avoidance of aggravating activities Cryotherapy8 pain by motor, sensory nerve conduction velocity swelling, cellular metabolism methods reusable cold packs / crushed ice bags ice massage / endothermal cold packs (towel between bag and skin - avoid nerve damage/ frostbite) on area of pain - 5 - 30 minutes NSAID: orally / topically / injection (1st month of Rx) local inflammation
Management: Stretching7: Focus on calf and Achilles tendon or plantar fascia itself Key-component in Rx
Short term benefits pain relief increased calf flexibility Long-term benefits decrease in pain and functional limitations high rate of satisfaction effective inexpensive
easy to implement-tool Management: Taping: designed to provide inversion of the calcaneus
improving the biomechanical position and stability limits the range of motion increase proprioception
increase reduction of intensity of pain Biomechanical correction with foot orthoses: pain associated with plantar fasciitis14 prefabricated foot orthoses + stretching = pain
silicone heel pads / well supported arches and midsoles Management: Night splints or Strasbourg sock: maintains ankle dorsiflexion and toe extension constant mild stretch of fascia
allows heal at a functional length indicated no improvement after 6 months wearing - 3 months
Management: Soft tissue therapy: manual therapeutic techniques aim - restore normal muscle length + joints movement Corticosteroid injection15
advantages inflammatory process outpatient basis fast recovery pain risk of rupture of the plantar mixture: 4ml of local anaesthetic 1ml of corticosteroid Management: Iontophoresis16 topically applied steroid
Dexamethasone 0.4% or acetic acid 5% delivered topically propelled into the injured tissue with a small electric charge short term pain relief (2 - 4 weeks) Management: Extracorporeal shock wave therapy17,18 what: stimulation healing of the soft tissue reduction of calcification inhibition of pain receptors or denervation to achieve pain relief
proposed responses due to release of enzymes hyperstimulation of axons release of nitrous oxide and growth factors Three devices OssaTron Epos Ultra Sonorex ... Extracorporeal shock wave therapy17,18 How? conversion of electrical energy to mechanical energy
Management: ... Extracorporeal shock wave therapy17,18 four main goals 50% improvement in pain from baseline pain on rising, walking in morning of at least 50% activity level + self-assessed ability to move pain free for time + distance discontinuation of pain meds Successful when: all criteria are met in 3 - 12 months after treatment Management:
Surgery: Options isolated, partial or complete release with or without the resection of the calcaneal spur excision of abnormal tissue or nerve decompression Open or via endoscopic approach Who? moderate to severe symptoms persistent resistant in spite of conservative management at least six months
Endoscopic procedures more rapid recovery return to pre-surgery activities What is new / controversial in plantar fasciitis? Shock waves Elastography20 Botulinum toxin A21 Bipolar radiofrequency22 Acupunture23 Platelet rich plasma therapy24,25 What is new / controversial
in plantar fasciitis? Shock waves: sound waves create vibrations cause controlled injury to tissue healing ability
repair process Intracorporeal pneumatic shock19 therapy vs extracorporeal shock wave therapy energy generated inside / outside the body
when extracorporeal shock devices are not available cheap, readily available, effective, safe What is new / controversial in plantar fasciitis? Elastography20 new modality measures tissue elasticity of plantar fascia
detect early stages of plantar fasciitis ultrasonography (U/S): U/S: 65.8% sensitivity, 75% specificity elastography: 95% sensitivity, 100% specificity sono-elastography accuracy of dx from 68% to 96%
staging of disease What is new / controversial in plantar fasciitis? Botulinum toxin A21: improve pain relief and overall foot function ease severe muscle contractions decrease inflammatory reactions
diminish wrinkles + tension headaches Dr Brodsky, president of American Orthopaedic Foot and Ankle Society pain relief lasted at least one year larger study under way cost-effectiveness - $$ refractory patients What is new / controversial in plantar fasciitis? Bipolar radiofrequency22: minimally invasive technique
viable surgical treatment option not improve on conservative measures Acupunture23: enhances inhibitory processes by stimulation of trigger points muscles and peripheral nerves increase the concentration of endorphins in the CNS decreasing local inflammation What is new / controversial
in plantar fasciitis? Platelet rich plasma therapy24,25 (autologous growth factors) new therapy mid 1990s for the discipline of maxillofacial surgery pain relief long lasting healing of musculoskeletal conditions sample of patients blood - centrifuge separates platelets from other components concentrated platelet rich plasma injected into site of injury initiates an increased healing response lasting results Plantar Fasciitis
In conclusion... think on your feet... Be aware of many reasons for painful feet Be aware of many management options References: 1.Akhtar A, Abbasie SH, Shami A et al. A comparative study of conventional versus interventional treatment in patients of plantar fasciitis. Ann Pak Inst Med Sci 2009; 5(2): 81-83 2.DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissue specific
plantar fascia stretching exercise enhances outcomes in patients with chronic heel pain. The Journal of Bone and Joint Surgery 2003;85A:127077 3.Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int 2004; 25:303-10 4.Cole C, Seto C, Gazewood J. Plantar Fasciitis: evidence-based review of diagnosis and therapy. Am Fam Physician 2005;72:2237-42 5.Noakes T. Lore of Running. Human Kinetics 2001 6.Wearing SC, Smeathers JE, Urry SR et al. The pathomechanics of plantar fasciitis. Sports Med 2006;36 (7):585-611 7.Leaque AC. Current concepts Review: Plantar Fasciitis. Foot and Ankle international. 2008;29 (3) 358-366
References: 8.Brukner P, Khan K. Clinical Sports Medicine 3rd edition. McGraw Hill 2002. 9.Murphy C. Plantar Fasiitis. Sportex.net 10.Riddle DL, Pulisic M, Pidcoe P, et al. Risk factors for plantar fasciitis: a matched case-control study. J Bone Joint Surg Br. 2003;85B (5): 872-7 11.Irving DB, Cook JL, Menz HB. Factors associated with chronic plantar heel pain: a systematic review. Journal of Science and Medicine in Sport 2006;9:11-22 12.DiMarcangelo MT, Yu TC. Diagnostic imaging of heel pain and plantar fasciitis. Clin Podiatr Med Surg 1997;14:281-301. 13.Potter AJ. Investigating plantar Fasciitis. Foot and Ankle online Journal. Nov 2009 2(11):4.
14.Hume P, Hopkins W, Rome K et al. Effectiveness of Foot orthoses for treatment and prevention of lower limb injuries. Sports Med 2008; 38 (9): 759-779 References: 15.Wen-Chung T, Chih-Chin Hsu, Carl PC et al. Plantar fasciitis treated with local steroid injection: comparison between sonographic and palpation guidance. Journal of Clinical U/S Jan 2006 ; 34 (1) 12-16 16.Foye PM, Lorenzo CT. Physical medicine and rehabilitation for plantar fasciitis treatment and management. Sep 2010. 17.Kaltenborn JM. The Efficacy of Extracorporeal shock-wave treatment: a new perspective. Human Kinetics. 2005;6:50-51 18.Moretti B, Garofalo R, Patella V et al. Extracorporeal shock wave
therapy in runners with a symptomatic heel spur. Knee Surg Sports Traumatol Arthrose 2006; 14:1029-1032 19.Dogramaci Y, Kalaci A, Emir A, Yanat AN, Gkce A. Intracorporeal pneumatic shock application for the treatment of chronic plantar fasciitis: a randomized, double blind prospective clinical trial. Arch Orthop Trauma Surg. 2010 Apr; 130 (4): 541-6. Epub 2009 Aug 11 20.Kapoor A, Sandhu HS, Sandhu PS et al. Realtime elastography in plantar fasciitis: comparison with ultrasonography and MRI. Current orthopaedic practice. Nov/Dec 2010; 21(6): 600-608 References: 21.Zablocki E. Botulinum toxin injection decreases plantar fascia pain. Medscape medical news. Nov 2005.
22.Weil L Jnr, Glover JP, Weil LS Sr. A new minimally invasive technique for treating plantar fasciosis using bipolar radiofrequency: a prospective analysis. Foot Ankle Spec Feb 2008; 1 (1): 13-18 23.Perez-Millan R, Foster L. Low frequency electro-acupuncture in the management of refractory plantar fasciitis: a case series. Medical Acupuncture: a Journal for physicians by physicians. 2001(13) nr 1. 24.Creaney L, Hamilton B. Growth factor delivery methods in management of sports injuries: the state of play. Br. J. Sports Med. Nov 2007. 25.Barrett SL, Erredge SE . Growth Factors for Chronic Plantar Fasciitis? Podiatry Today. Nov 2004.
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