plantar fasciitis -...

Plantar Fasciitis:Plantar Fasciitis: Nonsurgical & Surgical Options for Nonsurgical & Surgical Options for Chronic Heel PainChronic Heel Pain

Mathew M. John, DPM, FACFASMathew M. John, DPM, FACFASAtlanta, GAAtlanta, GA

Heel Pain:Plantar fasciitisHeel Pain:Plantar fasciitis

Over 2 million Over 2 million Americans suffer Americans suffer from heel painfrom heel painMost common Most common cause of plantar cause of plantar heel painheel pain

AnatomyAnatomy

Plantar fasciaPlantar fascia–– Dense fibrous Dense fibrous

ligamentligament–– Collagen/elastin Collagen/elastin

fibersfibers–– 3 distinct bands3 distinct bands

CentralCentralLateralLateralMedialMedial

AnatomyAnatomy

Plantar fasciaPlantar fascia–– OriginOrigin

Medial calcaneal Medial calcaneal tuberositytuberosity

–– InsertionInsertionFlexor tendons / Flexor tendons / base proximal base proximal phalanxphalanx

AnatomyAnatomy

Muscle origins at Muscle origins at the calcaneusthe calcaneus–– Abductor hallucisAbductor hallucis–– Flexor digitorum Flexor digitorum

brevisbrevis–– Abductor digiti Abductor digiti

quintiquinti

AnatomyAnatomy

Origins near Origins near calcaneal tuberositycalcaneal tuberosity–– Quadratus plantaeQuadratus plantae–– Long plantar Long plantar

calcaneocuboid calcaneocuboid ligamentligament

AnatomyAnatomy

Subcalcaneal bursaSubcalcaneal bursa–– Between the Between the

calcaneal tuberosity calcaneal tuberosity and fat padand fat pad

AnatomyAnatomy

Tibial nerveTibial nerve–– Medial Calcaneal Medial Calcaneal

nervenerve–– Lateral plantar Lateral plantar

nervenerve11stst branchbranch

AnatomyAnatomy

11stst branch of the branch of the lateral plantar lateral plantar nervenerve–– Course deep to the Course deep to the

plantar fascia and plantar fascia and abductor hallucis abductor hallucis musclemuscle

Basic BiomechanicsBasic Biomechanics

100100--200% of body 200% of body weight with each weight with each heel strikeheel strikeWindlass Windlass mechanismmechanism

Basic BiomechanicsBasic Biomechanics

Windlass Windlass MechanismMechanism–– Dorsiflexion of the Dorsiflexion of the

halluxhallux–– Elevation of the Elevation of the

longitudinal archlongitudinal arch–– Midfoot lockedMidfoot locked

SymptomsSymptoms

Pain with prolonged Pain with prolonged standing or walking standing or walking or exerciseor exerciseNo specific traumaNo specific traumaDeep acheDeep acheOccasional Occasional burning/throbbingburning/throbbingRelief with restRelief with rest

SymptomsSymptoms

Post static dyskinesiaPost static dyskinesia–– Pain with initial Pain with initial

weightbearing after weightbearing after restrest

–– Initially improves but Initially improves but returns later in the dayreturns later in the day

SymptomsSymptoms

Chronic painChronic pain–– Typically >6 moTypically >6 mo

Plantar fasciosisPlantar fasciosis–– Pain constant with Pain constant with

weightbearingweightbearing–– Antalgic gaitAntalgic gait

Chronic vs. Acute PainChronic vs. Acute Pain

Plantar FasciosisPlantar Fasciosis–– Decreased edemaDecreased edema–– NoninflammatoryNoninflammatory–– Localized fibrosisLocalized fibrosis–– Collagen necrosisCollagen necrosis–– Fibroblastic Fibroblastic

hyperplasiahyperplasia

Plantar fasciitisPlantar fasciitis–– Localized edemaLocalized edema–– InflammationInflammation–– Microtearing of Microtearing of

fasciafascia–– Insertional Insertional

thickening of fasciathickening of fascia

Associated symptomsAssociated symptoms

Achilles tendonitisAchilles tendonitisPosterior tibial tendonitisPosterior tibial tendonitisLateral column painLateral column painLower leg muscle painLower leg muscle painKnee / back painKnee / back pain

Associated ConditionsAssociated Conditions

Pes planusPes planusPes cavusPes cavusEquinusEquinusLimb length differenceLimb length difference

Aggravating FactorsAggravating Factors

ObesityObesityRunning / aerobic Running / aerobic exerciseexerciseProlonged standing Prolonged standing on hard surfaceson hard surfacesPoor shoewearPoor shoewear

BiomechanicsBiomechanics

Normal Gait (walk)Normal Gait (walk)Stance Phase Stance Phase (60%)(60%)–– Heel strikeHeel strike–– MidstanceMidstance

PronationPronation

–– SupinationSupination–– Push offPush off

Swing Phase (40%)Swing Phase (40%)


EquinusEquinus–– Decreased ankle Decreased ankle

joint dorsiflexionjoint dorsiflexion<10 degrees<10 degrees

–– Compensatory Compensatory pronationpronation

Increased strain on Increased strain on plantar fascia plantar fascia ligamentligament


OverOver--PronationPronation–– Not Not ‘‘flat feetflat feet’’–– eversion / eversion /

dorsiflexiondorsiflexion–– Weak posterior tibial Weak posterior tibial

tendontendon–– Increased subtalar Increased subtalar

joint motionjoint motion


Pes planusPes planus–– Increased plantar Increased plantar

fascia strainfascia strain

Pes cavusPes cavus–– Tight plantar fasciaTight plantar fascia

Physical ExamPhysical Exam

PalpationPalpation–– Engage Windlass Engage Windlass

mechanismmechanism–– Proximal plantar medial Proximal plantar medial

heelheel–– Medial heelMedial heel

BaxterBaxter’’s nerves nerve

–– Proximal medial heelProximal medial heelMedial calcaneal nerveMedial calcaneal nerve

–– Proximal plantar lateral Proximal plantar lateral heelheel


PalpationPalpation–– Central plantar fasciaCentral plantar fascia–– Side to side Side to side

compression calcaneuscompression calcaneus–– Central calcaneusCentral calcaneus

BursaBursa

–– Posterior tibial tendon Posterior tibial tendon insertioninsertion

NavicularNavicular

Palpate/percussionPalpate/percussion–– Tarsal tunnelTarsal tunnel


Range of MotionRange of Motion–– SubtalarSubtalar

inversion / inversion / plantarflexionplantarflexioneversion / eversion / dorsiflexiondorsiflexion

–– MidtarsalMidtarsal–– AnkleAnkle

dorsiflexiondorsiflexion


Ankle dorsiflexionAnkle dorsiflexion–– Evaluate for equinusEvaluate for equinus–– Supinate foot and Supinate foot and

dorsiflexdorsiflex–– With knee straight With knee straight

and flexedand flexedGastroc equinusGastroc equinusGastrocsoleus Gastrocsoleus equinusequinus


Gait ExamGait Exam–– antalgicantalgic–– Early heel liftEarly heel lift

EquinusEquinus

–– OverpronationOverpronation–– Compensatory gaitCompensatory gait

EquinovarusEquinovarus

–– Shoulder dropShoulder dropLimb length Limb length differencedifference

Radiographic SignsRadiographic Signs

Plantar calcaneal Plantar calcaneal spurspur–– NOT source of NOT source of

symptomssymptoms–– Formed due to Formed due to

tension fromtension fromFasciaFasciaMusclesMuscles

Radiographic SignsRadiographic Signs

Plantar calcaneal Plantar calcaneal spurspur–– Present in over 50% Present in over 50%

of patients who of patients who suffer from PFsuffer from PF

–– Also present in Also present in asymptomatic asymptomatic patientspatients

Other Diagnostic TestsOther Diagnostic Tests

Bone scanBone scanMRIMRIUltrasoundUltrasound

Bone ScanBone Scan

4 phase 4 phase TechnetiumTechnetium–– Increased uptake:Increased uptake:

Calcaneal fracturesCalcaneal fracturesInfectionInfectionBone tumorsBone tumors

MRIMRI

Soft tissue tumorsSoft tissue tumorsBone tumorsBone tumorsMarrow edemaMarrow edemaLocalized soft tissue Localized soft tissue edemaedemaPlantar fascia Plantar fascia thickeningthickening

Magnetic Resonance Magnetic Resonance Imaging Imaging --MRIMRI

Diagnostic UltrasoundDiagnostic Ultrasound

Thickening of Thickening of plantar fascia plantar fascia insertioninsertionSoft tissue massesSoft tissue masses

Diagnostic UltrasoundDiagnostic Ultrasound

Diagnostic TestsDiagnostic Tests

Help to identify differential diagnosesHelp to identify differential diagnosesDiagnosis of plantar fasciitis mainly Diagnosis of plantar fasciitis mainly clinicalclinicalDoes not dictate treatment Does not dictate treatment management of plantar fasciitismanagement of plantar fasciitis

Differential DiagnosesDifferential Diagnoses

Calcaneal apophysitisCalcaneal apophysitisCalcaneal bursitisCalcaneal bursitisTarsal tunnel syndromeTarsal tunnel syndromeCalcaneal stress fractureCalcaneal stress fractureInflammatory arthritisInflammatory arthritisSoft tissue or bone neoplasmSoft tissue or bone neoplasmInfectionInfectionLower lumbar radiculopathyLower lumbar radiculopathyNeuritisNeuritis

Calcaneal ApophysitisCalcaneal Apophysitis

Severs diseaseSevers disease–– Inflammatory Inflammatory

condition of the condition of the calcaneal epiphysiscalcaneal epiphysis

–– Age 8Age 8--1212–– Pain aggravated Pain aggravated

with activitywith activity–– Relief with rest, Relief with rest,

NSAIDsNSAIDs

Calcaneal BursitisCalcaneal Bursitis

Inflammation of Inflammation of plantar bursaplantar bursaPain more central Pain more central to calcaneal to calcaneal tuberositytuberosityAssociated fat pad Associated fat pad atrophyatrophy

Tarsal Tunnel SyndromeTarsal Tunnel Syndrome

Compression of Compression of neurovascular neurovascular structures in tarsal structures in tarsal tunneltunnelPain at the tarsal Pain at the tarsal tunneltunnelRadiating to medial Radiating to medial heel and archheel and archPain constantPain constant

Calcaneal Stress FractureCalcaneal Stress Fracture

Pain with side to Pain with side to side compression of side compression of the calcaneusthe calcaneusAxial calcaneal Axial calcaneal radiographradiographBone scanBone scan

Inflammatory ArthritisInflammatory Arthritis

Rheumatoid arthritisRheumatoid arthritisPsoriatic arthritisPsoriatic arthritisGoutGout–– Acute pain/swellingAcute pain/swelling

Reiter's syndromeReiter's syndrome–– Conjunctivitis/urethritis/arthritisConjunctivitis/urethritis/arthritis

Ankylosing spondylitisAnkylosing spondylitisSystemic lupus erythematosus(SLE)Systemic lupus erythematosus(SLE)

Bone NeoplasmsBone Neoplasms

Aneurysmal bone Aneurysmal bone cystcystUnicameral bone Unicameral bone cystcystOsteoid osteomaOsteoid osteoma–– Night painNight pain

ChondroblastomaChondroblastoma

Soft tissue neoplasmSoft tissue neoplasm

Plantar fibromaPlantar fibromaNeurilemomaNeurilemomaAngiolipomaAngiolipomaFibrolipoma Fibrolipoma FibrosarcomaFibrosarcoma

InfectionInfection

AbscessAbscessOsteomyelitisOsteomyelitis

SymptomsSymptoms–– Constant painConstant pain

Mild to severeMild to severe

–– ErythemaErythema–– Localized edemaLocalized edema

Lower Lumbar Lower Lumbar RadiculopathyRadiculopathy

Compression of Compression of lower lumbar lower lumbar nervesnerves–– L4L4--5, S15, S1--22

Sciatica painSciatica painNCV/EMG requiredNCV/EMG required

Medial Calcaneal NeuritisMedial Calcaneal Neuritis

Medial heel painMedial heel painIncreased pain the Increased pain the longer they walklonger they walkPain at nightPain at nightOrthotics may Orthotics may increase painincrease painNeurosensory test Neurosensory test to confirm diagnosisto confirm diagnosis

BaxterBaxter’’s Neuritiss Neuritis

Przylucki 1981Przylucki 1981Baxter 1992Baxter 1992–– Entrapment of the 1Entrapment of the 1stst

branch of the lateral branch of the lateral plantar nerveplantar nerve

–– Also referred to as the Also referred to as the inferior calcaneal nerveinferior calcaneal nerve

Compressed between Compressed between the proximal plantar the proximal plantar fascia and abductor fascia and abductor hallucis musclehallucis muscle

BaxterBaxter’’s Neuritiss Neuritis

Up to 20% of heel painUp to 20% of heel painTypically pain more Typically pain more medial than plantarmedial than plantarCan be present with Can be present with plantar fasciitis/ plantar fasciitis/ fasciosisfasciosisSeen in recalcitrant Seen in recalcitrant heel painheel pain

TreatmentTreatment

8585--90% success with conservative 90% success with conservative treatmenttreatment–– ACFAS Heel Pain Guide 2001ACFAS Heel Pain Guide 2001

3 phase treatment protocol3 phase treatment protocol

No one universal treatment successfulNo one universal treatment successful–– Combination of treatment optionsCombination of treatment optionsConservative treatment for at least 6 Conservative treatment for at least 6 months prior to surgical optionsmonths prior to surgical options

Treatment Treatment ––Phase 1Phase 1

NSAIDsNSAIDsStretchingStretchingcryotherapycryotherapyAppropriate shoewearAppropriate shoewear–– Athletic running shoeAthletic running shoe–– OTC arch supportOTC arch support

Padding/strappingPadding/strappingCorticosteroid injection Corticosteroid injection Activity limitationActivity limitation

Treatment Treatment –– Phase 1Phase 1

Nonsteroidal AntiNonsteroidal Anti--inflammatory Drugsinflammatory Drugs–– CelebrexCelebrex–– ibuprofenibuprofen–– diclofenacdiclofenac

Provides reduction Provides reduction of symptoms onlyof symptoms only

NSAIDsNSAIDs

Donley et al. (2007)Donley et al. (2007)–– 29 patients29 patients–– Mild improvement in Mild improvement in

overall treatment overall treatment vs. no use of NSAIDvs. no use of NSAID


StretchingStretching–– Focused on Focused on

gastrocsoleus / gastrocsoleus / Achilles tendonAchilles tendon

–– Plantar fascia Plantar fascia ligamentligament

–– HamstringsHamstringsReduce forefoot Reduce forefoot loadingloading

Plantar Fascia StretchPlantar Fascia Stretch

DiGiovanni et al. (2003)DiGiovanni et al. (2003)–– Prospective study showed plantar fascia Prospective study showed plantar fascia

stretching to be more be more beneficial stretching to be more be more beneficial than weightbearing Achilles stretchthan weightbearing Achilles stretch


CryotherapyCryotherapy–– Various methodsVarious methods–– TherapistTherapist’’s s

‘‘wonder drugwonder drug’’–– IntermittentIntermittent

10 min on/off/on10 min on/off/on


Appropriate Appropriate shoewearshoewearReplace old Replace old shoewearshoewearAvoid going Avoid going barefootbarefoot


OTC arch supportOTC arch support–– SoftSoft–– SemiSemi--flexibleflexible

Low dye strappingLow dye strapping–– With or without With or without

metatarsal padmetatarsal pad–– Plantar fascia Plantar fascia

supportsupport

Low Dye StrappingLow Dye Strapping

Landorf et al. (2005)Landorf et al. (2005)–– 65 low dye strapping65 low dye strapping–– 40 patients with no strapping40 patients with no strapping–– 33--5 days5 days–– ResultsResults

Significant improvement in pain levelsSignificant improvement in pain levels

Low Dye StrappingLow Dye Strapping


Corticosteroid Corticosteroid injectioninjection–– Mixture of Mixture of

anesthetic/short anesthetic/short acting steroid/ long acting steroid/ long acting steroidacting steroid

–– Limited to no more Limited to no more than 3 injections to than 3 injections to one area/6 moone area/6 mo--1yr1yr

Tissue atrophyTissue atrophyPlantar fascia rupturePlantar fascia rupture

Corticosteroid InjectionCorticosteroid Injection

Reduces inflammatory response to Reduces inflammatory response to injuryinjuryInhibits leukocyte & macrophage Inhibits leukocyte & macrophage proliferationproliferationInhibits vasoactive kinin releaseInhibits vasoactive kinin releaseInhibits destructive enzyme releaseInhibits destructive enzyme releaseDecreases prostaglandin formationDecreases prostaglandin formation

Corticosteroid InjectionCorticosteroid Injection

Crawford et al. (1999)Crawford et al. (1999)–– 160 patients160 patients

Steroid + lidocaineSteroid + lidocaineTibial nerve block, steroid + lidocaineTibial nerve block, steroid + lidocaineLidocaine onlyLidocaine onlyTibial nerve block, lidocaine onlyTibial nerve block, lidocaine only

–– Significant pain relief at 1 mo f/uSignificant pain relief at 1 mo f/u–– But no difference at 3, 6 month f/uBut no difference at 3, 6 month f/u

Corticosteroid InjectionsCorticosteroid Injections

Varied Varied combinations and combinations and approachesapproaches–– MedialMedial–– Plantar Plantar

Post injection flarePost injection flareElevated glucose in Elevated glucose in DM patientsDM patients


Activity limitationActivity limitation–– Cut workouts in halfCut workouts in half–– Stop all high impact Stop all high impact

workoutsworkoutsNo runningNo runningNo aerobicsNo aerobics

Activity LimitationActivity Limitation

Riddle et al. (2003)Riddle et al. (2003)–– Working in a standing position all day Working in a standing position all day

increases risk for plantar fasciitis to increases risk for plantar fasciitis to developdevelop

–– Increase in BMI = increase incidence of Increase in BMI = increase incidence of plantar fasciitis plantar fasciitis


Physical TherapyPhysical Therapy–– UltrasoundUltrasound–– IontophoresisIontophoresis–– PhonophoresisPhonophoresis–– Interferential Interferential

currentcurrent–– AnodyneAnodyne–– StretchingStretching–– Deep massageDeep massage

IontophoresisIontophoresis

Gudeman et al. (1997)Gudeman et al. (1997)–– 36 patients36 patients

0.4% dexamethasone vs. placebo0.4% dexamethasone vs. placebo6 treatments over 2 weeks6 treatments over 2 weeksSignificant decrease in symptoms for treated Significant decrease in symptoms for treated groupgroupNo difference 1 mo after end of treatmentNo difference 1 mo after end of treatment


Symptoms should resolve within 6 Symptoms should resolve within 6 weeksweeksIf improvement is noted treatment If improvement is noted treatment should be continued until symptoms should be continued until symptoms are resolvedare resolvedIf symptoms plateau Phase 2 If symptoms plateau Phase 2 treatment should be initiatedtreatment should be initiated


Continuation of Phase 1 treatmentContinuation of Phase 1 treatmentCustom molded orthoticsCustom molded orthoticsNightsplintNightsplintCast boot walkerCast boot walker


Custom molded Custom molded orthotics(orthoses)orthotics(orthoses)–– Neutral castNeutral cast–– Proper rearfoot / Proper rearfoot /

forefoot postingforefoot posting–– Type of orthotic Type of orthotic

patient/activity patient/activity dependantdependant

OrthosesOrthoses

Pfeffer et al (1999)Pfeffer et al (1999)–– 200 patients200 patients

Silicone heel padSilicone heel padFelt arch padFelt arch padTullis rubber heel cupTullis rubber heel cupCustom molded polypropylene orthoticCustom molded polypropylene orthotic

–– Prefabricated inserts provided better pain Prefabricated inserts provided better pain relief than custom orthosesrelief than custom orthoses

OrthosesOrthoses

Rome et al. (2004)Rome et al. (2004)–– Compared functional orthoses vs. Compared functional orthoses vs.

accommodative insertsaccommodative inserts–– Prefabricated orthosesPrefabricated orthoses

Functional orthoses provided significant Functional orthoses provided significant improvement in pain relief compared with improvement in pain relief compared with accommodative insertsaccommodative inserts

OrthosesOrthoses

Collins et al. (2007)Collins et al. (2007)–– “…“… insufficient evidence to support or insufficient evidence to support or

refute the use of foot orthoses, custom or refute the use of foot orthoses, custom or prefabricated, in the treatment of lower prefabricated, in the treatment of lower limb overuse injuries.limb overuse injuries.””


Night splintNight splint–– Static dorsiflexionStatic dorsiflexion–– DynamicDynamic

Prolonged low load Prolonged low load stretch of tendo stretch of tendo AchillesAchilles

Orthoses / Night splintOrthoses / Night splint

Roos et al. showed significant Roos et al. showed significant improvement in symptoms:improvement in symptoms:–– Custom orthoticCustom orthotic–– Custom orthotic + night splintCustom orthotic + night splint–– Night splint aloneNight splint alone

Long term pain relief noted with Long term pain relief noted with continued use of orthoticscontinued use of orthotics

Night SplintNight Splint

Batt et al. (1996)Batt et al. (1996)–– 34 patients34 patients–– All 17 patients wearing dorsiflexion night All 17 patients wearing dorsiflexion night

splint showed improvement in symptomssplint showed improvement in symptoms

Powell et al. (1998)Powell et al. (1998)–– 37 patients37 patients–– After 1 mo treatment group showed After 1 mo treatment group showed

significant improvementsignificant improvement

Night SplintNight Splint

Probe et al. (1999)Probe et al. (1999)–– 116 patients116 patients–– NSAIDs, Achilles stretch, shoe wearNSAIDs, Achilles stretch, shoe wear–– Above treatment + night splint x 3 moAbove treatment + night splint x 3 mo

–– Did not find any significant difference Did not find any significant difference with use of night splintwith use of night splint


Cast immobilizationCast immobilization–– Removable Removable

pneumatic bootpneumatic boot–– FWBFWB–– RockerbottomRockerbottom

Eliminates windlass Eliminates windlass mechanismmechanism


Symptoms typically resolve in 2Symptoms typically resolve in 2--3 3 months (4months (4--6 mo from initial treatment)6 mo from initial treatment)If improvement noted continue If improvement noted continue treatment from both Phase 1 and treatment from both Phase 1 and Phase 2 until symptoms resolvePhase 2 until symptoms resolveIf symptoms plateau or do not If symptoms plateau or do not improve then proceed to Phase 3improve then proceed to Phase 3


Nonweightbearing cast immobilizationNonweightbearing cast immobilizationSurgical plantar fasciotomySurgical plantar fasciotomyEndoscopic plantar fasciotomy (EPF)Endoscopic plantar fasciotomy (EPF)Extracorporeal shockwave therapy Extracorporeal shockwave therapy (ESWT)(ESWT)CoblationCoblation--based fasciotomybased fasciotomy


Nonweightbearing Nonweightbearing cast immobilizationcast immobilization–– RemovableRemovable–– FiberglassFiberglass

Limitation on Limitation on stretchingstretching


Plantar fasciotomyPlantar fasciotomy–– TraditionalTraditional–– Duvries 1957Duvries 1957

Medial approachMedial approachRemoval of spurRemoval of spurTransect medial and Transect medial and central bandscentral bands


Instep fasciotomyInstep fasciotomy–– Direct visualizationDirect visualization–– Reduced risk of Reduced risk of

nerve entrapmentnerve entrapment–– Allows immediate Allows immediate

PWB to FWBPWB to FWB–– Incision parallel to Incision parallel to

relaxed skin tension relaxed skin tension lineslines

Instep Plantar Instep Plantar FasciotomyFasciotomy


Postoperative CoursePostoperative Course–– 22--3 weeks in sterile bandages3 weeks in sterile bandages–– PWB to FWB in CAM walkerPWB to FWB in CAM walker–– Physical Therapy initiated once incision Physical Therapy initiated once incision

healedhealed–– No high impact activity x 6 weeksNo high impact activity x 6 weeks–– Full recovery may take 12 weeksFull recovery may take 12 weeks


Complications / risksComplications / risks–– Lateral column painLateral column pain

Alteration of biomechanicsAlteration of biomechanics

–– Nerve entrapmentNerve entrapment–– Painful hypertrophic scarPainful hypertrophic scar

Plantar FasciotomyPlantar Fasciotomy

Lane & London (2004)Lane & London (2004)–– Retrospective studyRetrospective study–– 29 patients29 patients–– 96% success rate96% success rate

Ave 21 months postopAve 21 months postopVAS reduced from 8.4 to 1.2VAS reduced from 8.4 to 1.2

Plantar FasciotomyPlantar Fasciotomy

Fishco et al. (2000)Fishco et al. (2000)–– Retrospective studyRetrospective study–– 83 patients83 patients

Heel pain ave 14 months prior to surgeryHeel pain ave 14 months prior to surgery

–– 21 months postop21 months postop–– 93.6% success93.6% success


Endoscopic Plantar Endoscopic Plantar Fasciotomy (EPF)Fasciotomy (EPF)–– Release of fascia Release of fascia

ligament through ligament through uniuni or two portal or two portal endoscopeendoscope

Endoscopic Plantar FasciotomyEndoscopic Plantar Fasciotomy

Postoperative CoursePostoperative Course–– 1010--14 days incision healing14 days incision healing–– FWB in CAM walkerFWB in CAM walker–– Physical Therapy initiated 1Physical Therapy initiated 1--2 weeks2 weeks–– No exercise activity x 6 weeksNo exercise activity x 6 weeks–– Full recovery up to 12 weeksFull recovery up to 12 weeks

Endoscopic Plantar FasciotomyEndoscopic Plantar Fasciotomy

AdvantagesAdvantages–– Minimally invasiveMinimally invasive–– Quicker recoveryQuicker recovery

DisadvantagesDisadvantages–– Risk of nerve Risk of nerve

entrapmententrapment–– Learning curveLearning curve–– Risk of reoccurrence Risk of reoccurrence

of heel painof heel pain


Extracorporeal Extracorporeal Shockwave Therapy Shockwave Therapy (ESWT)(ESWT)–– Propagation of Propagation of

shockwave shockwave transmitted through transmitted through to injured tissueto injured tissue

Extracorporeal Extracorporeal Shockwave TherapyShockwave Therapy

NeovascularizationNeovascularizationLocal hyperemiaLocal hyperemia

tissue growth tissue growth factorsfactorsInhibition of pain Inhibition of pain receptorsreceptors


Developed from Developed from lithotripsylithotripsyEarly 1990s Early 1990s –– Orthopedic use Orthopedic use

(orthotripsy)(orthotripsy)–– FDA approved for FDA approved for

chronic plantar chronic plantar fasciitis (fasciosis)fasciitis (fasciosis)


3 types3 types–– ElectrohydraulicElectrohydraulic

OssaTronOssaTron

–– ElectromagneticElectromagneticDornier EposDornier Epos

–– PiezoelectricPiezoelectricPiezosonPiezoson


ElectrohydraulicElectrohydraulic–– ‘‘spark plugspark plug’’ principleprinciple–– High voltage applied High voltage applied

to water filled to water filled ellipsoid reflective ellipsoid reflective housinghousing

–– Shockwave Shockwave generated between generated between tips of electrodetips of electrode


ElectromagneticElectromagnetic–– Electric current Electric current

passed through coil passed through coil generating a generating a magnetic fieldmagnetic field

–– Shockwave Shockwave generated from generated from water immersed water immersed conductive conductive membranemembrane


PiezoelectricPiezoelectric–– Piezoelectric crystals Piezoelectric crystals

charged with high charged with high voltagevoltage

–– Crystals Crystals expand/contract expand/contract generating generating shockwaveshockwave


High EnergyHigh Energy–– OutpatientOutpatient–– IV MAC sedationIV MAC sedation–– Local blockLocal block–– One treatmentOne treatment

Low EnergyLow Energy–– Office settingOffice setting–– No anesthesiaNo anesthesia–– Multiple treatmentsMultiple treatments

ESWT Postop CourseESWT Postop Course

Immediate weightbearing in athletic Immediate weightbearing in athletic shoe w/ orthosesshoe w/ orthosesNo NSAIDsNo NSAIDsContinue nightsplint, stretchingContinue nightsplint, stretching11--2 weeks of continued heel pain2 weeks of continued heel painFull recovery up to 12 weeksFull recovery up to 12 weeks


ComplicationsComplications–– Localized swellingLocalized swelling–– Localized bruisingLocalized bruising–– Reoccurrence of Reoccurrence of

heel painheel pain


AdvantagesAdvantages–– NoninvasiveNoninvasive–– Quick recoveryQuick recovery–– Minimal to no Minimal to no

complicationscomplications

DisadvantagesDisadvantages–– High costHigh cost–– Insurance coverageInsurance coverage–– No universally No universally

accepted protocolaccepted protocol


Buchbinder et al. (2002)Buchbinder et al. (2002)–– DoubleDouble--blind prospective studyblind prospective study–– 160 patients diagnosed with plantar 160 patients diagnosed with plantar

fasciitis for at least 6 weeksfasciitis for at least 6 weeks–– Low energy deviceLow energy device

Weekly treatment x 3 weeksWeekly treatment x 3 weeks

–– No significant difference in symptomsNo significant difference in symptoms


Ogden et al. (2004)Ogden et al. (2004)–– Prospective studyProspective study–– 293 patients293 patients–– High energy ESWTHigh energy ESWT–– 47% success at 3 months47% success at 3 months


Malay et al. (2006)Malay et al. (2006)–– Prospective doubleProspective double--blind studyblind study–– 172 patients (115:57)172 patients (115:57)–– Electrohydraulic device (high energy)Electrohydraulic device (high energy)–– No anesthesiaNo anesthesia–– Overall reduction of pain on VASOverall reduction of pain on VAS–– 43% ESWT group vs. 19.6% placebo43% ESWT group vs. 19.6% placebo


Efficacy still controversialEfficacy still controversialNo standardized treatment protocolNo standardized treatment protocolHigh energy vs. low energyHigh energy vs. low energyRetrospective studies reveal 60% Retrospective studies reveal 60% success ratesuccess rateProspective studies vary in success Prospective studies vary in success rates dependant on type of ESWTrates dependant on type of ESWT


CoblationCoblation--based based fasciotomy / fasciotomy / microtenotomymicrotenotomy–– Use of bipolar Use of bipolar

radiofrequencyradiofrequency–– Evolved from Evolved from

cardiology researchcardiology research

Coblation fasciotomyCoblation fasciotomy

Stimulates Stimulates inflammatory inflammatory responseresponseAngiogenesisAngiogenesisAntinociceptive Antinociceptive effecteffect–– Rapid pain Rapid pain

reductionreduction


IndicationsIndications–– Plantar fasciosisPlantar fasciosis

>6 months heel pain>6 months heel pain

TechniquesTechniques–– OpenOpen–– PercutaneousPercutaneous

Postop coursePostop course–– PWBPWB--FWB in CAM FWB in CAM

walker 2walker 2--3 weeks3 weeks


AdvantagesAdvantages–– Rapid recoveryRapid recovery–– Less invasiveLess invasive

percutaneouspercutaneous

RisksRisks–– Plantar fascia Plantar fascia

rupturerupture–– Nerve entrapmentNerve entrapment


Tendon coblation has shown over 90% Tendon coblation has shown over 90% improvement in VAS pain scaleimprovement in VAS pain scaleInitial studies show significant improvement Initial studies show significant improvement in pain levels as early as 2 weeksin pain levels as early as 2 weeksPain continued to improve up to 6 monthsPain continued to improve up to 6 monthsLarger, prospective studies needed to Larger, prospective studies needed to assess effect on plantar fascia ligamentassess effect on plantar fascia ligament

SummarySummary

Diagnosis of heel pain etiology Diagnosis of heel pain etiology essential for proper treatmentessential for proper treatmentA combination of conservative A combination of conservative treatment requiredtreatment requiredTreatment can extend for months, no Treatment can extend for months, no quick fixesquick fixesSurgery: last option Surgery: last option

Thank youThank you

plantar fasciitis -...

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