Dr Isstelle JoubertMay 2011

Presenting History:

Mr A, 39yo manbilateral 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

runner’s heel

subcalcaneal bursitis

periostitis

policeman’s 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

Neurologic nerve entrapment

neuropathies

lumbar spine disorders

tarsal tunnel syndrome

Soft tissue achilles tendonitis

plantar fascia rupture

retrocalcaneal bursitis

fat pad atrophy

heel contusion

posterior tibial tendonitis

Skeletal calcaneal epiphysitis

inflammatory arthropathies

subtalar arthritis

calcaneal stress fracture

infections (osteomyelitis)

Other metabolic disorders:

osteomalacia, Paget’s

disease, sickle cell disease

tumors

vascular insufficiency

Differential diagnosis4,8,9:

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:

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 footwear10

  Obesity / increased work-related weight bearing

study found NO association for BMI11

 

Possible causes7...

Special investigations:

•aim

confirm the diagnosis

•modalities available

ultrasound plain x-rays of feet bone-scan MRI nerve conduction studies blood tests

• 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+ - ? Paget’s disease

Special investigations:

Management: 

•Avoidance of aggravating activities 

•Cryotherapy

•NSAID

•Stretching

•Taping

•Foot orthoses

• Night splinting

• Soft tissue therapy

• 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

• Soft tissue therapy:

manual therapeutic techniques aim - restore normal muscle length + joints movement

 

Management: 

• Corticosteroid injection15

advantages ↓ inflammatory processoutpatient basisfast recoverypain ↓

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

 

How?conversion of electrical energy to mechanical energy

... Extracorporeal shock wave therapy17,18

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

• 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 1990’s for the discipline of maxillofacial surgery

pain relief

long lasting healing of musculoskeletal conditions

sample of patient’s blood - centrifuge

separates platelets from other components

concentrated platelet rich plasma injected into site of injury

initiates an increased healing response

lasting results

What is new / controversial in plantar fasciitis?

In conclusion...

think on your feet...

Be aware of many reasons for painful feet

Be aware of many management options

Plantar Fasciitis

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): 81-832.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:1270-773.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; 25:303-104.Cole C, Seto C, Gazewood J. Plantar Fasciitis: evidence-based review of diagnosis and therapy. Am Fam Physician 2005;72:2237-425.Noakes T. Lore of Running. Human Kinetics 20016.Wearing SC, Smeathers JE, Urry SR et al. The pathomechanics of plantar fasciitis. Sports Med 2006;36 (7):585-6117.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.net10.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): 872-711.Irving DB, Cook JL, Menz HB. Factors associated with chronic plantar heel pain: a systematic review. Journal of Science and Medicine in Sport 2006;9:11-2212.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) 12-1616.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;6:50-5118.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; 14:1029-103219.Dogramaci Y, Kalaci A, Emir A, Yanat AN, Gökce 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 1120.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): 13-1823.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.