Transcript Plantar Fasciitis - Shotgun Approach

Plantar Fasciitis
Dick Evans PT,OCS
Plantar Fascia
• Thick broad connective tissue that spans
the arch of the foot
• Originates on the medial tubercle of the
calcaneus and inserts onto the proximal
phalanges and flexor tendon sheaths
• Forms longitudinal arch of the foot and
functions as a shock absorber
• Supports the arch as weight is transferred
over the foot from heel strike to toe off
Fasciitis???
• A degenerative condition that may or may
not be associated with inflammatory
changes in the tissues
• Pain may be caused by repetitive micro
trauma to the fascia
Frequency
• Occurs in 10 % of runners and may be
associated with training errors
• Accounts for 11-15% of all foot symptoms
requiring medial care
Symptoms
• Classic presentation: heel pain in the
morning when first rising from bed
• May improve through the day but tends to
hurt again by afternoon and evening.
• Reoccurs upon standing after prolonged
sitting
• Worse with walking barefoot and walking
up stairs
Physical Exam
• Tenderness to palpation on the
anteromedial aspect of the heel
• Ankle dorsiflexion limited by calf tightness
• Pain increased by toe extension or by
standing on toes
Risk Factors
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Obesity
Occupation requiring prolonged standing
Pes planus or cavus
Calf tightness
Toe runners, running up hills or in sand
Rapid change in activity level: intensity or
duration
• Lack of warm up or cold weather
Differential Diagnosis
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Tarsal tunnel
Bone bruise or heel contusion
Sever disease
Calcaneal stress fracture
Fat pad atrophy / central heel pain
Inflammatory arthropathies
Neuropathic pain
Retrocalcaneal bursitis
Achilles insertional pain
Prognosis
• 80% are better in 12 months
• Surgical intervention is rare
Treatment
• Activity modification
• Shoe inserts / orthotics / taping / supportive
shoes
• Night splints
• Stretching program: arch, calf, soft tissue
massage, ice
• Modalities : iontophoresis, ultrasound
• NSAIDS
• Corticosteroid injections
• Shock wave therapy
Treatment Plan
• Take away source of irritation: boot /
crutches, if needed
• Stretching arch and calf and forefoot
• Ice
• Soft tissue massage: gentle to start,
advance to aggressive as tolerated
• Open chain strengthening: manual, bands
to both ankle and forefoot
Treatment Plan
• Advance to closed chain strengthening
and balance work as symptoms allow
• Brisk walking, cross training, pain free
• Add light impact
• Phase return to run program, watch
running form
• Gradual progressions : 10 % rule
• Sports specific return to activities
Mike Shaffer’s Concept of Dosing
of Rehab in Evidence Based
Medicine:
“The Black Box”
• JOSPT – April 2008 : Clinical Guidelines related
to Heel Pain-Plantar Fasciitis. Clinical practice
guidelines linked to international classification of
function, disability , and health from ortho
section of APTA
• Panel of experts did a scientific review of the
literature prior to may 2007, up for review again
in 2012.
• Grade level of evidence I-V, grade of evidence
A-F
Recommendations for
Interventions: Strength of Evidence
Summary
• Modalities: iontophoresis (dexamethasone 0.4%
or acetic acid 5%) can provide short term (2-4
weeks) pain relief and improved function
• Stretching: calf and PF stretching can be used
in short term (2-4 mo) for pain relief and
improved calf flexibility. Dose of calf stretching is
2-3 x day, either sustained 3 min hold or 20 sec
intermittent stretching hold time. . Both hold
times produced a beneficial effect.
• Taping: provided short term pain relief ( 7-10
days)
Continued summary of
recommendations
• Orthotics: Prefab or custom orthotics used
to provide short term (3 mo ) pain
reduction and improvement in function.
No difference in pain reduction or function
between the two types of orthotics. No
evidence to support long term use greater
than one year for pain management or
functional improvement.
Continued summary of
recommendations.
• Night splints: consider for patients with
symptoms > 6 mo. The desired length of
wearing time is 1-3 months. The type of
night splint did not matter. ( ant, post or
sock type).
• No super strong evidence for manual
therapy (joint mobilization).
Conclusion:
• When does a presentation or research
article “change how you practice” and
when does it “guide how you practice”
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A potential future topic
THANKS