planter fascitis

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by dra tahmeed nizami


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Presentation Transcript

PLANTAR FASCIITIS: Evidence-Based Review of Diagnosis and Therapy : 

PLANTAR FASCIITIS: Evidence-Based Review of Diagnosis and Therapy Dr Tahmeed Nizami Family Medicine Specialist SAAD SPECIALIST HOSPITAL


PLANTAR FASCIITIS Most Common cause of inferior heel pain. 10% US population affected More than 600,000 out patients visits annually Affects active and sedentary adults of all ages. Women affected twice than men More likely in obese, people most of the day on feet, with limited ankle flexion

What is plantar fasciitis? : 

What is plantar fasciitis? Plantar fasciitis is an inflammation of the plantar fascial tissue, often adjacent to its insertion into the heel. This may be associated one or more of the following: Pain Swelling Warmth of the affected area Redness of the adjacent skin

Anatomy of the Plantar Fascia : 

Anatomy of the Plantar Fascia The plantar fascia is a fibrous sheath which extends from the base of the toes to the heel. It runs between the skin/ subcutaneous fat, and the deeper muscles, tendons, and bones

Bony Origin of Plantar Fascia : 

Bony Origin of Plantar Fascia The plantar fascia arises from the bottom and inside of the heel bone (medial calcaneal tuberosity), along with some of the small intrinsic muscles of the foot.

MRI Image (sagittal) of Plantar fascia : 

MRI Image (sagittal) of Plantar fascia This is an MRI (magnetic resonance image) of the insertion of the plantar fascia into the heel bone (Calcaneus)


PATHOPHYSIOLOGY Excessive stretch of plantar fascia can result in microtrauma (microtears) of the plantar fascia at its insertion on the medial calcaneal tuberosity or along the course of the fascia. This microtrauma, if repetitive, can result in chronic inflammation and degeneration of the plantar fascia fibers.


DIAGNOSIS Diagnosed on history and physical examination Inferior heel pain on weight bearing Persists for months/years Throbbing or piercing Especially first few steps in morning or after periods of inactivity Improves after further ambulation, increases with continued activity Pain exacerbates if walk bare foot, on toes or upstairs Tenderness around medial calcaneal tuberosity


DIAGNOSIS Palpation of the medial calcaneal tubercle usually elicits pain in patients with plantar fasciitis.


DIAGNOSIS Diagnostic imaging is not helpful in diagnosis, only when strong suspicion of other diagnosis Xrays – show calcification in soft tissue around heel or heel spurs 50% with plantar fasciitis and 19% without have heel spurs Presence or absence of heel spurs not helpful in diagnosis

What is a Heel Spur : 

What is a Heel Spur Chronic strain in the area where the plantar fascia attaches to the heel bone creates small tears in the membrane around the bone. Over time new bone is laid down forming what appears to be a bone spur when seen on a side-view x-ray of the foot. In reality, this is actually a shelf of bone across a portion of the heel.

Heel Spur on X-ray : 

Heel Spur on X-ray The spur projects forward, not down. The pain from a heel spur is due to the inflammation of the adjacent fascia, not from walking on a bony “tack”.


DIAGNOSIS Radioisotope bone scan can show  uptake at calcaneus MRI can show thickening of plantar Fascia Accuracy of these tests inconclusive


DIFFERENTIAL DIAGNOSIS NEUROLOGIC Abductor digiti nerve entrapment: Burning in heel pad Tarsal tunnel Syndrome: pain and tingling sole of foot Lumbar spine disorders: radiating pain, weakness, abnormal reflexes Neuropathies: alcohol abuse, DM. Diffuse foot pain, night pain


DIFFERENTIAL DIAGNOSIS SOFT TISSUE Achilles tendonitis: Retrocalcaneal pain Fat pad atrophy: Pain in area of atrophic heel pad Heel contusion: Trauma history Plantar fascia rupture: Tearing sensation bottom of foot Retrocalcaneal bursitis: Pain is retrocalcaneal


DIFFERENTIAL DIAGNOSIS SKELETAL Calcaneal epiphysitis (Sever’s disease): Heel pain in adolescents Calcaneal stress fracture: Calcaneal swelling, warmth, tenderness Infections: Osteomyelitis. Systemic symptoms Inflammatory arthropathies: More likely bilateral , multiple joints affected


PROGNOSIS Most Patients with plantar fasciitis eventually improve. In a study, 80% treated conservatively, complete resolution after 4 yrs.


THERAPY General Measures Taping Shoe Inserts Night Splints Stretching Corticosteroid Injections Extracorporeal Shock Wave Therapy Casting Surgery


THERAPY GENERAL MEASURES Treatment protocols in most studies; Ice and NSAIDS No studies on examining effectiveness alone TAPING No studies on evaluating effectiveness


THERAPY SHOE INSERTS Many types of shoe inserts 1 RCT, magnet embedded insoles no more effective than placebo for pain relief Study comparing custom orthotics and prefabricated shoe inserts (silicone heel pad, felt pad, rubber heel cup) combined with stretching, prefabricated shoe inserts superior. NNT 5


THERAPY NIGHT SPLINTS Posterior tension night splints maintain ankle dorsiflexion and toe extension a constant mild stretch heal at functional length Cochrane review – Showed limited evidence in treatment of pts with symptoms>6 months Improvement seen with custom made night splints but not with prefabricated ones


THERAPY STRETCHING Stretching protocols focus on calf muscles and Achilles tendon or plantar fascia. Prospective RCT - Both groups showed overall in pain. Better results with the later in terms of  pain at its worst and with first morning steps.


THERAPY Plantar fascia-specific stretch. Patient crosses affected foot over contra lateral leg, grasps the base of toes, and pulls the toes back towards the shin until a stretch in the arch is felt. The stretch is held for 10 seconds and repeated. Three sets of 10 repetitions are performed daily.


THERAPY CORTCOSTEROID INJECTIONS Limited evidence supports the use Cochrane review- improved symptoms at one month but not at 6 months when compared with placebo Caution- associated with plantar fascia rupture long term discomfort


THERAPY EXTRACORPOREAL SHOCK WAVE THERAPY 2 RCTS- Compared ESWT with placebo in chronic plantar fasciitis. No significant difference between two after 3 months. 1 RCT- 45 runners with heel pain>12 months, 3 weekly treatment significantly reduced morning pain at 6 and 12 months when compared with placebo


THERAPY CASTING Case series- 32 pts with chronic heel pain, no response to multiple treatments. Fibreglass walking cast 6 months , at long term follow up, 25% complete resolution of pain and 61%, some improvement. ? over estimation of benefits.


THERAPY SURGERY No RCTS have evaluated surgery. 5 retrospective case series, 278 pts with pain for 14 months, 75-95% had long term improvement. 27% still had significant pain, 20% had some activity restriction and 12% had moderate pain impairing functions. Recovery time 4-8 months.


RECOMMENDATIONS No evidence strongly supports the effectiveness of any treatment, most pts improve without specific therapy or by conservative treatment. Shoe inserts and stretching exercises may be beneficial and should be the first step in treatment. Custom made night splints may help pts not responding to initial therapy, benefits with prefabricated ones not proven.


RECOMMENDATIONS Corticosteroid injection may provide short term benefit who do not improve after initial treatment. No long term benefits. May cause plantar fascia rupture. ESWT not beneficial except in runners with heel pain >1 yr. Guidelines, American College of Foot and Ankle Surgeons, consider surgery if pain persists after 3 months of treatment


RECOMMENDATIONS Effectiveness surgery vs conservative treatment, not proven but long term improvement reported in many pts after surgery A substantial no. of patients with long recovery period and continued limited pain Limited data suggest, casting may be beneficial alternative to surgery

Remember……. : 

Remember……. Proper treatment begins with a correct diagnosis Follow-up visits may be necessary to monitor progress Alternative therapies may be employed



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