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Plantar Fasciopathy

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Other Names

  • Plantar Fasciitis
  • Plantar Fasciopathy
  • Plantar Fasciosis
  • Plantar heel pain syndrome (PHPS)

Background

  • This page refers to fasciopathy of the the Plantar Fascia of the foot, most commonly referred to as 'Plantar Fasciitis' (PF)

History
Epidemiology

  • General
    • Peak age is between 45 and 65 years[1]
    • About 1 in 3 patients will have bilateral symptoms[2]
    • An estimated $284 million is spent each year on plantar fasciitis treatments (need citation)
  • Prevalence
    • Affects 1 in 10 people in their lifetime (need citation)
    • 2 million people receive treatment for this condition annually around the world[1]

Introduction

General

  • Defined by pain and structural changes at the proximal insertion of the plantar fascia on the calcaneus
  • It is the most common cause of chronic heel pain in adults (need citation)
  • Generally thought to occur due to degeneration of the plantar fascia as a result of repetitive microtears of the fascia
  • This leads to an inflammatory reaction, and is not a primary inflammatory process (as often thought to be)
  • Approximately 90-95% of cases resolve within 12 months with conservative treatment[3]

Terminology

  • Fasciitis: describes inflammation of the plantar fascia
  • Fasciosis: degenerative changes of the plantar fascia
  • Fasciopathy: describes more chronic thickening and degenerative process
  • Fasciopathy is more appropriate as the vast majority of patients have findings consistent with chronic injuries including thickening and degeneration
  • Note that patients often do not seek healthcare until their symptoms can be classified as chronic

Etiology

  • General
    • Overall, this condition is poorly understood
    • Tensile strength of the plantar fascia appears to be a key feature of pathogenesis[4]
    • Known to be associated with several limiting biomechanical risks
    • Often due to either overuse (runners, military personnel) or excessive loading (obesity, sedentary)[5]
  • Tight gastrocnemius
    • Increases Achilles tendon tension and dorsiflexion stiffness of the ankle
    • Thus increasing plantar fascia tension during weight-bearing activities
  • Histopathology[4]
    • The increased fascial load is sensed by the gap junctions between fibrocytes (mechanotransduction)
    • This mediates changes in the extracellular matrix
    • Subsequently, there is myxoid degeneration and fragmentation of the plantar fascia and perifascial structures.

Associated Conditions

Anatomy of the Plantar Fascia

  • Band of connective tissue originating at the calcaneus and inserting on the tendons of the forefoot and proximal phalanges
  • Function: support the arch of the foot, act as a shock absorber for pressure placed on the foot[6]

Risk Factors

  • Demographic
    • Increasing age[7]
    • Gender: No differences between men and women[7]
    • Obese patients have a 1.4 fold increased risk[8][9]
  • Orthopedic/ Anatomic
    • Calcaneal enthesophytes (heel spurs) do not appear to increase the risk of PF (need citation)
      • One study found neither the shape nor size of the spur has a correlation with function or pain before or after treatment[10]
    • Baxters Neuropathy may co-exist and increase risk[11]
  • Systemic/ Intrinsic
    • Spondyloarthropathy
    • Genetic
  • Sports
  • Occupational
    • Military Service[14]
    • 'Weight Bearing Tasks'
    • Long periods of standing
  • Biomechanical
    • Tight gastrocnemius muscle[15]
    • Planovalgus feet
    • Gastrocnemius contracture
    • Severe hallux valgus[16]
    • Limited ankle dorsiflexion
      • 83% of patients with recalcitrant PF have limited ankle dorsiflexion[17]
    • Pes Cavus
    • Tight intrinsic foot muscles
    • Leg length discrepancy
    • Poor fitting shoes
    • Improper gait[18]

Differential Diagnosis

Differential Diagnosis Foot Pain


Clinical Features

History

  • The diagnosis is often made clinically
  • The pain is located on the plantarmedial aspect of the heel
  • Post Static Dyskinesia: classically, perhaps pathognomonic, patients report pain upon first waking and standing up in the morning
    • This tends to improve after a walking for a while
    • It improves with activity initially, then worsens as the activity becomes prolonged
  • Pain is described as dull aching or throbbing pain

Physical Exam: Physical Exam Foot

  • Tenderness is located at the plantar aspect of the medial calcaneal tuberosity at the fascia insertion

Special Tests


Evaluation

Radiographs

  • Standard Radiographs Foot
    • Often reveal calcaneal enthesophytes (heel spurs)
      • A sign of calcification at the origin of the flexor digitorum brevis muscle, thought to be a response to chronically tight achilles tendon
      • Although here is a higher incidence of heel spurs in patients suffering from PF (75% vs 63% in asymptomatic patients)
      • There is no apparent correlation between spurs and pain[19]

Ultrasound

  • Can be considered to exclude other soft tissue pathology
  • Potential Findings
    • Plantar fascia is softer using sonoelastrography in patients with typical clinical manifestations of plantar fasciitis[20]
    • Thickness tends to be greater than 4 mm on diagnostic ultrasound[21]
    • A plantar fascia thickness >4.5 mm and the presence of hypoechoic areas are specific for PF[22]
    • Subcalcaneal bone spurs (24%), peritendinous edema (5%), subcalcaneal bone erosion (4%), intratendinous calcification (3%), and retrocalcaneal bursitis are associated with PF but are not specific[23][22]

MRI

  • Can be considered to exclude other soft tissue pathology
  • Findings
    • Increased signal intensity and proximal plantar fascia thickening[24]
    • Thickening of the plantar fascia, although there does not appear to be a correlation between thickness and pain[25]

Classification

  • Not applicable

Management

General

  • Indications
    • All cases
  • Explanation to patients
    • Explain to patients that pain will likely settle over time and manage expectations
  • Ice Therapy
    • Many clinicians recommend 'rolling' the arch with a frozen water bottle
  • Heat Therapy
    • Was superior to sham therapy for plantar fascia pain[26]
  • NSAIDS
  • Physical Therapy
    • First line choice and primary treatment modality
    • Calf-stretching exercises with eccentric loading may be the most important treatment[27]
    • Benefits from strengthening extrinsic and intrinsic foot muscles, strengthening abductor and lateral rotator hip muscles, and stretching[28]
    • Plantar fascia specific therapy is superior to EWST[29]
  • Foot Orthotic
    • Goals: decrease pronation, off-load the proximal insertion of the fascia
    • RCT comparing over-the-counter shoe inserts with customized shoe inserts found no difference in pain relief 12-month follow-up[30]
    • Can also consider Heel Cup
    • More effective when combined with night splint[31]
    • When compared to extra corporeal shock wave therapy, both groups improved with no differences between groups[32]
  • Nocturnal Splint (Tension Night Splint)
    • Goal: stretch the fascia to prevent morning stiffness and pain[33]
    • Multiple studies show benefit, but patients do not tolerate well and compliance can be problematic[34][35][36]

Therapeutic Modalities

  • Dry Cupping
    • Dry cupping on calf muscle myofascial trigger points combined with stretching was superior to stretching only[37]
    • No difference between dry cupping and electrical stimulation after 4 weeks of treatment[38]
  • Dry Needling (DN)
    • DN plus stretching was superior to stretching alone up to 6 weeks[39]
    • DN improved pain and plantar fascia thickness but had no effect on range of motion[40]
    • Adding electrical DN manual therapy, exercise and ultrasound was more effective manual therapy, exercise and ultrasound at 3 months[41]
    • DN was similar to corticosteroids early, but superior at 6 and 12 months[42]
    • Trigger point DN improved heel pain but not range of motion compared to controls[43]
    • Compared to sham injections, trigger point DN provided a non statistically significant improvement in symptoms with more adverse effects[44]
  • Extracorporeal Shock Wave Therapy (ESWT)
    • Meta-analysis suggests focused shock wave (FSW) can relieve pain but no firm conclusions of general ECSWT and radial shock wave (RSW)[45]
    • In an open label study, ESWT was superior to botulinum toxin in the control of pain in patients with PF.[46]
    • Patients improved with ESWT, however there was no difference between low, medium, or high levels of ESWT in terms of pain, foot functions, fascia thickness[47]
    • Similar improvements in symptoms between the control and ESWT groups[48]
    • High energy ESWT for high number of sessions is more effective than Low energy ESWT for low number of sessions on pain, quality of life, physical function, fatigue, and disability in patients with PF[49]
    • No difference when adding ESWT to usual care (exercise and orthotic support) when compared to usual care alone[50]
    • ESWT combined with dry needling was superior to ESWT alone at 1 month[51]
    • ESWT provided similar but longer lasting relief compared to corticosteroid injection[52]
    • When compared to custom foot orthotics, both groups improved with no differences between groups[32]
    • ESWT superior to corticosteroids for plantar fascia thickness, symptoms at 12 weeks[53]
    • ESWT combined with topical corticosteroids was superior to ESWT alone[54]
    • Compared to controls, ESWT was effective up to 2 years for chronic PF[55]
    • Using ultrasound did not improve outcomes with ESWT[56]
    • ESWT was superior to corticosteroid injections at 2 months, although both groups demonstrated improvement[57]
    • ESWT combined with orthopedic insole was superior to EWST alone[58]
    • ESWT was inferior to manual plantar fascia specific stretching[29]
  • Acupuncture
    • Patients who received electroacupuncture plus warm needling (EAWN) had improved VAS scores up to 8 weeks compared to controls[59]
    • Electroacupuncture (EA) and manual acupuncture (MA) both appear to provide relief with no differences up to 28 weeks[60]
    • Electro-acupuncture plus conventional treatments provided a success rate of 80%, which was more effective than conventional treatments alone[61]
    • Standard therapy + acupuncture was superior to standard therapy alone[62]
    • Patients improved with acupuncture to acupoint PC 7[63]
    • Acupuncture + Chinese herbs pyrogenic dressing was superior to acupuncture alone[64]
  • Low Dye Taping
  • Low Level Laser Therapy
  • Neuromuscular Electrical Stimulation
  • Radiofrequency Radiation/ Therapy
  • Therapeutic Ultrasound (TUS)
    • TUS was superior to extracorporeal shock wave therapy for improvement in foot function index[65]
  • Radiation Therapy
    • Thought to have anti-inflammatory effects that reduce inflammatory mediators and pain
    • Small risk of carcinogenesis
    • Superior to corticosteroid injections for pain relief at 3 and 6 months[66]
  • Iontophoresis
    • Iontophoresis with 5% acetic acid was superior to dexamethasone or saline when combined with LowDye taping and home exercises[67]
  • Mini Scalpel Needle
    • Was similar to corticosteroid injection at 1 month and superior at 6 and 12 months[68]

Injections

  • Corticosteroid Injection
    • Cochrane review shows low quality evidence of benefits for 1 month, but none after[69]
    • Risks: heel pad atrophy, plantar fascia rupture
    • Consider alternative treatment options
    • Strongly consider use of ultrasound to avoid risks
    • 20 mg of methylprednisolone was similar 40 mg at 3 weeks following injection[70]
    • Use of ultrasound guided injection improves outcomes compared to palpation guided injections[71]
    • There was no benefit to corticosteroid injections when added to standard management compared to standard management alone[72]
    • A single dose of dexamethasone provided pain relief up to 4 weeks, but not any longer past that[73]
    • Steroid injection, with or without ultrasound, showed benefit at 6 and 12 weeks[74]
  • Dextrose Prolotherapy (DXP)
    • Inferior to corticosteroid injection early, no differences between groups at 12 weeks[75]
    • Similar benefits when compared to extracorporeal shockwave therapy at 3 months[76]
    • Compared to control group, the DXP group did significant better at 7 and 15 weeks[77]
    • Adding 5% DXP to standard corticosteroid injection decreased VAS symptoms[78]
    • Platelet Rich Plasma was superior at 2 weeks however there was no difference at 2 and 6 months follow up[79]
  • NSAID Injections
    • Both Tenoxicam and corticosteroids provided relief at 6 and 12 months with no difference between groups[80]
  • Ozone Injection
  • Autologous Blood Injection
    • One small prospective study of 35 patients showed some benefit[81]
  • Botulinum Toxin
    • A small RCT showed statistically significant changes in the treatment group[82]
    • Study by Ahadi et al showed similar outcomes when compared to CSI, however the botulinum toxin group had longer lasting relief[83]
    • Another study comparing Botulinum Toxin A, Corticosteroid, and Anesthetic Injection for Plantar Fasciitis found relief up to 6 months with no difference between groups[84]
    • Injection into the medial gastroc provided relief for PF up to 1 year[85]
    • Compared to saline control, patients who received botulinum toxin had better relief up to 6 months[86]
    • Botulin toxin plus stretching was superior to corticosteroids plus stretching[87]
    • A small study found botulinum toxin superior to corticosteroids up to 6 months[88]
    • Compared to placebo, ultrasound guided botulinum toxin injections were superior up to 3 months[89]
    • A small RCT found botulinum toxin was superior to placebo up to 8 weeks[90]
  • Platelet Rich Plasma
    • A systematic review and meta-analysis found benefit at 3 months compared to placebo[91]
  • Allogeneic Growth Factors
    • A small study showed superiority to control saline injections at 3 months follow up[92]
    • Platelet Rich Plasma was superior at 2 weeks however there was no difference at 2 and 6 months follow up[79]
  • Cryopreserved Human Amniotic Membrane (c-hAM)
    • A very small study showed similar outcomes compared to corticosteroid, limited by a small N[93]
    • Improved outcomes compared to placebo injection at 3 months follow up[94]
    • Improved compared to placebo, no difference between 0.5 cc and 1.25 cc dose[95]
  • Hyaluronic Acid (HA)
    • Although HA showed early benefit, it was inferior to corticosteroids at 6 weeks with no difference between groups at 24 weeks[96]
    • High Molecular weight HA was superior to low molecular weight HA[97]
  • Tibial Nerve Block
    • Inferior to corticosteroid for symptom relief, may provide benefit in combination[98]
  • Polydeoxyribonucleotide Injection (PDRN)
    • Corticosteroid injection was superior at 2 and 6 weeks however this was no difference between groups at 6 months[99]
    • Compared to placebo, PDRN was superior at 12 weeks for VAS and MOXFQ scores[100]

Operative

  • Indications
    • Failure of at least 12 months of conservative therapy
  • Technique
    • Medial open release of approximately the medial third of the fascia (fasciotomy)
    • Release of the first branch of the lateral plantar nerve (nerve decompression)
    • Isolated proximal medial gastrocnemius release
    • Ultrasound guided EPF release
    • Endoscopic plantar fascial release
    • Open plantar fascial release

Rehab and Return to Play

Rehabilitation

  • Typical postoperative course
    • 3 weeks of immobilization
    • Followed by 3 weeks of partial weight bearing

Return to Play/Work

  • General
    • Typically gradual with emphasis on avoiding training through pain
    • Often cross training with non-impact activities

Complications & Prognosis

Prognosis

  • Nonoperative management
    • Approximately 95% of patients will be pain free at 12 months without surgery[101]
  • Comparing surgical technique
    • Monteagudo et al found more patients improved with complete gastrocnemius release (95%) than those who had partial plantar fasciotomy (60%)[102]

Complications

  • Surgical
    • Infection
    • Nerve injury
    • Plantar fascia rupture

See Also

Internal

External


References

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Created by:
John Kiel on 7 July 2019 08:17:07
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28 April 2023 07:37:14
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