Orthotics and Stretching forHeel Pain are BETTER than Injections and Procedures

Jacob Wynes DPM, MS, FACFAS

Assistant Professor, Department of Orthopaedics

University of Maryland School of Medicine

• Chief of Podiatric Surgery at U Penn

• Everyone’s second / third opinion

• An authority on foot and ankle

surgery

• Countless Publications

• Accomplished Lecturer

Key Word Average Monthly Searches

foot problems 170

plantar fasciitis 8100

podiatrist 3600

bunion 2400

heel pain 1300

heel spur 1300

foot pain 1000

swollen feet 1000

foot doctor 880

bunion surgery 590

orthotics 590

flat feet 590

• Medial Calcaneal Neuritis

– Rose et al. JFAS 2003

• Bone Stress Reaction

– Davey et al. Osteoporos Int 2016

– Pester et al. Orthop Rev 1992

• Sub-calcaneal bursitis

– Crawford et al. Cochrane Database Syst Rev 2003

Risk Factors for Developing Plantar Fasciitis Rome et al. Phys Ther Rev 1997

Buchbinder NEJM 2004

Problem

Limited Ankle DF

Limb Length Discrepancy

Diminished heel pad thickness

Excess pronation

Limited range of motion first MTPJ

Solution

Stretching

Orthotics / Could do surgery

Definitely NOT surgery

Orthotics / stretching

Orthotics / ? Surgery

• SPECT / CT for heel pain shows arthritis of midfoot

– Lee et al. Clin Nucl Med 2018

• Changes occur in the midfoot with custom orthoses

– Williams et al. Phys Ther 2000

• Abnormal arch mechanics as contributing factor

– Wearing et al. Sports Med 2006

• Hindfoot valgus as a contributing factor

– Chang et al. J Biomech 2014

• Over pull from windlass mechanism as a contributing

factor

– Cheng et al. J Biomech 2008 www.bodyclinic.com

• Custom orthoses reduce strain at the plantar fascia (mostly at the aponeurosis)

– Kogler et al. Clin Biomech 1996

– Ferber et al. J Foot Ankle Res 2011

• Higher heel reduces tension on plantar fascia

– Kogler et al. FAI 2001

• Questionable added benefit of heel pads

– Winemiller et al. JAPMA 2003

– Pfeffer et al. FAI 1999

• Blinded RCT: Prefabricated and custom orthoses revealed relief compared to sham

orthoses at 3 months of treatment

– Landorf et al. Arch Int Med 2006

• Off the shelf / Pre fab effective in reducing arch

strain by 30%

Crawford et al. Cochrane Database Syst Rev 2003

• Cochrane Review of RCT’s

• 11 trials N= 1,332

• Sham vs. no intervention vs. manipulation / stretching vs. night splints vs. hallux valgus

surgery vs. pre fabricated orthoses

• INITIALLY Custom orthoses (CMO) found to be more effective > than sham orthoses in

reducing pain

• As effective as night splints and stretching AND improved effectiveness of night splints

• AFTER 2-3 MONTHS, pre fabricated orthoses as effective as CMO

Prospective Randomized Study- N= 34 VA patients with FF / MF pain, Excluding

neurologic issues, RA, counfounding trauma, osseous block, irreducible deformity (5 DM pts)

- 34 randomly selected controls- Avg weight 183 lbs

- 2X increase of EQUINUS in symptomatic patients

• Patel et al. FAI 2011

– Acute vs. Chronic P. Fascitis (N = 254)

– 2 year prospective trial

– 10% progress to chronic fascitis after stretching ( ~ 9 months)

• DiGiovanni B and Malay D JBJS 2006 (Level II evidence)

– 2 year prospective randomized tissue specific stretching modality (plantar fascial vs. tendo-achilles)

– (N = 33 men / 68 women enrolled)

– 94% pts had decreased pain

– Equivalent response at 2 years

– Recommendation for 6 month total of stretching

• RCT of 40 recruited patients (home

exercise with home exercise + night

splint)

• Average BMI 30.8 kg/m2

• 6 week and 3 month appointment f/u

• Pain > 4 months / unilateral

• 1.5 point improvement in VAS

• FFI improvement

– Wheeler et al. BMJ 2017

Bohannon et al 1994

WB static 5 minutes

Knight et al 2001

WB static 20 seconds ON / 10 seconds OFF 4 x

3x / week for 6 weeks

Peres et al 2002

NWB static stretch with pulley (1/3 patient weight)

10 minutes / day X 14 days

Pratt & Bohannon 2003

Static platform drop 3 minutes

3 days

Youdas et al 2003

WB static stretch 30 seconds vs. 1 minute vs. 2 minutes

5 days / week for 6 weeks

• Prospective study: Use of DF assist dyna-splint

for plantar fasciitis

– Berlet et al. Orthopedics 2002

• Quicker recovery compared to standard

stretching

– Barry et al. JFAS 2002

• Prospective RCT: 32 patients completed study/

33 feet

– Only 3 failures

– Stat sig improvement with night splint p < 0.05

– Batt et al. Clin J Sports Med 1996

31 RCTs (n=2450 patients) no evidence of one modality over another yet PLACEBO and SHAM are least effective

Exercise good for long term relief

Medline, EMBASE, CINAHL, AMED, PEDro, Cochrane Database, Web of Science and WHO Clinical Trials PlatformBabatunde et al. Br. J Sports Med 2018

• Taping for plantar fasciosis

– Van de Water et al. JAPMA 2010

• RCT calcaneal taping vs. sham for heel pain

– Hyland et al. J Orthop Sports Phys Ther 2006

• RCT blinded control

– Porter et al. FAI 2002

• Successful for chronic plantar fasciitis (N= 82

patients / 115 heels)

• F/U at 42 +/- 22 months

• 74% good - excellent results

• 87% stating “sucessful”

• Better pain relief in non-active duty military

– Purcell JFAS 2018

• Meta-analysis of RCTs

• Improvement in VAS with greatest reduction in pain

• Improvement of pain by 60% +

• Best for chronic refractory plantar fasciitis

– Aqil et al. CORR 2013

• Double-blinded, placebo

controlled, mulit-center, RCT

• ESWT group (n=115) vs. Placebo

group (n=57)

• No adverse events

• Improvement in VAS reduction 3.39

vs. 1.78 for placebo group

Kudo et al. J Orthop Res 2006

• 58% of patients out of 75 had Plantar Fasciitis

• VAS improvement 7.08 2.71

• 86.7% satisfied

• RCT: Manual Therapy, Patient Education, Stretching

– McClinton et al. Phsiother Theory Pract 2018

• Predictors of response of physical therapy @ 6 month

follow up

– N=60 (6 visits over 4 weeks)

– Age and BMI not predictive of healing

– Numeric pain scale improvement by 3 points (95%

CI, 2.4-3.6)

– Symptoms less than 7.2 months were likely to

respond

– McClinton et al. FAI 2015

• Post injection: Ultrasound

investigation revealed plantar fascia

thickening as having no impact on

prognosis (N=174) @ mean 9.7 year

follow up

• Average of 3.8 treatments

• Time decreases fascial thickness at

5,10, and 15 years in both groups

– Hansen et al. Orthop J. Sports Med

2018

• Chronic degeneration without

inflammation

• Myxoid degeneration

• Increased abnormal fibroblasts /

mitochondrial defects

• 10% reported rate

– Acevedo et al. FAI 1994

– Sellman FAI 1994

– Crawford et al. Rheumatology 1999

– Kalaci et al. JAPMA 2009

• Non operative management with rest, massage, NSAIDS,

night splints, heel pads, ESWT achieves healing in 90% of

patients

• Recommended with symptoms of at least 6-12 months

– Neufeld et al. JAAOS 2008

• Athletes 9 weeks to

return to activity after

complete tear

– Fullem et al. 2016

• Brugh et al. JFAS 2002

– 25 - 50 - 66% of plantar

fascia released

– Open 72%

– EPF 28%

– 15/47 patients with LCS

– Greater than 50% release

correlated

Why Does This Happen?Anderson et al. JFAS 2001

• Releasing 25% of plantar fascia with

greatest effect

• Increased strain noted at bifurcate

ligament, cervical and talocalcaneal

ligaments

• Lateral fascial band takes up stress

• Recommendation for only 25% cut of

fascia

Anderson et al. JFAS 2001

Recommendation for aggressive immobilization post operatively to avoid these complications

Downey Biomechanics 1998

One More Time?

Beware Calcaneal Stress FractureJerosch et al. FAI 2000

• Improvement in 12 months ~ 90%

– Riddle et al FAI 2004, DiGiovanni et al. JBJS 2003

• Elevated BMI / Bilateral involvement / Duration > 6 months

– Wolgin et al. FAI 1994

• Duration lasts longer with certain independent variables: female and bilateral

heel pain

– Hansen et al. Orthop J. Sports Med 2018

• Systemic involvement contributes to persistent pain

– Furey JG. JBJS Am 1975

• Long Term Patient Outcomes over 10 years

• N=30 patients / 33 feet

• Ages 42.4 - 46.2 years old

• Average 3.1 years prior to surgical intervention

With Sincere Appreciation!

Thank You!

THANK YOU