Scott T. Doberstein, MS, ATC, LAT
Head Athletic Trainer/Senior Lecturer
University of Wisconsin – La Crosse
Wisconsin Athletic Trainers’ Association
Annual Meeting & Symposium
Wisconsin Dells, WI
April 12, 2013

THE FOLLOWING PRESENTATION HAS BEEN APPROVED FOR
[PROFESSIONAL AUDIENCES]
By the Wisconsin Athletic Trainers’ Association
THIS PRESENTATION HAS NOT YET BEEN RATED

where are we headed?
 Background
 Anatomy/Pathophysiology
 Etiology
 Differential Diagnosis
 Classic Presentation
 Treatment Interventions
 Prognosis
© Scott T. Doberstein, MS, ATC, LAT

 PF most common cause of heel pain
• 2 million pts seek Tx annually in US
(Riddle,
2003)
• PF accounts for 11-15% of all foot S/S seeking professional care
(Buchbinder, 2004)
• 10% of running related injuries
( Buchbinder, 2004)
 PF most common condition Tx by podiatric foot/ankle specialists
(APMA, 2001)
© Scott T. Doberstein, MS, ATC, LAT

 1/3 of pts have bilateral PF
(Neufeld, 2008)
 10% probability of getting PF in lifetime
(Crawford, 2003)
 Peak age of incidence is 40-60 y, especially women
(Riddle, 2003)
© Scott T. Doberstein, MS, ATC, LAT

 1812 – Wood first to describe PF as infection secondary to TB
(Neufeld, 2008)
 Fascial layer – not a tendon but…
 Interesting tissue to treat!!
© Scott T. Doberstein, MS, ATC, LAT

*(difficult to treat; resistant to commonly used treatments, Taber’s 2013)
© Scott T. Doberstein, MS, ATC, LAT

Other names for Recalcitrant heel pain (What it is?)
 Painful heel syndrome
 Runner’s heel
 Jogger’s heel
 Tennis heel
 Subcalcaneal pain
 Calcaneodynia
 Plantar faschiopathy
 PLANTAR FASCIOSIS (new school)*
© Scott T. Doberstein, MS, ATC, LAT

Other names for Recalcitrant heel pain (What it isn’t?)
 Heel spur syndrome
 Calcaneal periostitis
 PLANTAR FASCIITIS (old school)*
© Scott T. Doberstein, MS, ATC, LAT

 PF function = provide support to med long arch, dynamic shock absorber
 Windlass Effect = tensile force at proximal attachment with MTP extension
 PF is INFLEXIBLE – max elongation of 4%
(Lee,2007)
 ~ Age 40 – calcaneal fat pad breaks down = less shock absorption  more force on PF attachment
(Lee, 2007)
© Scott T. Doberstein, MS, ATC, LAT

 Actually continuous with the Achilles tendon
 Is it inflammation? Only acutely??
 Most of what we deal with is actually chronic!
 Lemont, 2003 = chronic degeneration
• Resection of PF shows histological evidence of PLANTAR FASCIOSIS not fasciitis!
© Scott T. Doberstein, MS, ATC, LAT

 Lemont, 2003 reported:
• Collagen necrosis and loss of collagen continuity
• Increased ground substance
• Increased vascularity
• Increased fibroblasts
• No inflammation markers or cells (similar to tendinosis)
 Caused by repetitive microtears of PF that overtake the body’s ability to repair itself
© Scott T. Doberstein, MS, ATC, LAT

RISK FACTORS REPORTED:
 Decreased ankle DF ROM
 Obesity
 Prolonged standing
 Pes planus (excessive pronation)
 Seronegative arthritis
© Scott T. Doberstein, MS, ATC, LAT

 Running is a risk factor:
• Increased distance/intensity
• Poor footwear
• Unyielding surface
• Pes cavus
• Shortened Achilles tendon
© Scott T. Doberstein, MS, ATC, LAT

 Heel Spur – significant evidence that bony exostosis does not cause PF
• However, quite common to have an exostosis simultaneously with PF but…the spur is NOT the cause of PF
© Scott T. Doberstein, MS, ATC, LAT

Differential Diagnosis
(What it isn’t!)
 Neurologic
(tarsal tunnel syndrome, lateral plantar n. entrapment, medial calcaneal n. entrapment, peripheral neuropathy,
S1 radiculopathy)
 Soft tissue
(PF rupture, enthesopathies, fat pad atrophy,
Achilles tendinitis, flexor hallucis longus tendinitis, posterior tibialis tendinitis, plantar fibromatosis)
 Skeletal
(calcaneal stress fracture, bone contusion, infection
(osteomyelitis, etc), subtalar arthritis, inflammatory arthropathies)
 Miscellaneous
(neoplasm, vascular insufficiency, osteomalacia , Paget’s disease, sickle cell disease)
© Scott T. Doberstein, MS, ATC, LAT

Classic Presentation
(What it is!)
 Inferior heel pain (self limiting!)
 Increased pain w/ first steps in morning =
Post Static Dyskinesia
(McNally, 2010)
 Increased pain upon standing after prolonged sitting
 Increased pain during prolonged standing
 Increased pain with barefoot walking
 Pain worsens near end of the day
© Scott T. Doberstein, MS, ATC, LAT

Classic Non-Presentation
(What it isn’t!)
 Inferior heel pain with multi-joint pain or other ligament/tendon pain
 Nocturnal pain
 Foot pain anywhere besides medial tubercle or medial longitudinal arch
 Radiating or neurological S/S
© Scott T. Doberstein, MS, ATC, LAT

 Rest/modification of activity
 Ice
 Heat
 Ultrasound
 E-stim
 Iontophoresis
 Strengthening
© Scott T. Doberstein, MS, ATC, LAT

 Massage
 NSAID’s
 Stretching (both calf and PF specific)
 Night splints
 Heel cups/pads
 Taping
 Casts
© Scott T. Doberstein, MS, ATC, LAT

 Orthoses (custom and off the shelf)
 Injections (corticosteroids, PRP, botulinum toxin)
 Accupuncture
 Shockwave therapy
 Magnets
 Nutritional Considerations
 Surgery
© Scott T. Doberstein, MS, ATC, LAT

 20-30 interventions out there being used
 Difficult to research with RCT’s
• Many management strategies are used simultaneously = too many variables
© Scott T. Doberstein, MS, ATC, LAT

 Grades of Evidence (McPoil, 2008)
A = strong evidence
B = moderate evidence
C = weak evidence
D = conflicting evidence
E = theoretical/foundational evidence
F = expert opinion
© Scott T. Doberstein, MS, ATC, LAT

Evidence - Based Outcomes
(McPoil, 2008)
 Most significant risk factors are limited DF
ROM and obesity  B
 S/S including pain in plantar medial heel, post static dyskinesia, prolonged standing, pain w/ initial steps following inactivity  B
 Evaluation findings including decreased DF
ROM, palpable pain at proximal PF attachment, + Windlass test  B
© Scott T. Doberstein, MS, ATC, LAT

Evidence - Based Outcomes
(McPoil, 2008)
 Iontophoresis (dexamethasone or acetic acid)
 B
• Only short term relief of 2-4 weeks
 Manual Therapy (specific ankle/foot/MTP joint mobilizations)
 E
 Taping (calcaneal and low dye)
 C
• Only short term relief of 7-10 days
© Scott T. Doberstein, MS, ATC, LAT

Evidence - Based Outcomes
(McPoil, 2008)
 Stretching (both calf/Achilles and PF specific)
 B
• ST relief for 2-4 months
• Remember Achilles and PF have continuous fibers!
 Orthoses (both custom and prefabricated)
• ST relief for ~ 3 months  A
• LT relief at 1year  F
© Scott T. Doberstein, MS, ATC, LAT

Evidence - Based Outcomes
(McPoil, 2008)
 Night Splints (posterior, anterior, sock type)
• Only use after 6 months of S/S and use only for
1-3 months  B
 NSAID’s – no RCT studies at all  E, F
 Injections (corticosteroids only)  C
• Only ST relief up to 2 weeks
• Significant risk of PF rupture (better with US guided technique)
© Scott T. Doberstein, MS, ATC, LAT

 Extracorporeal Shock Wave Therapy  C
 Autologous Platelet Rich Plasma  C
 It’s the SHOES (ADL’s vs. activity)  E,F
 Nutritional Considerations
(Roxas, 2005)
 E, F
• Vitamin C
• Zinc
• Glucosamine
• Bromelain
(pineapple enzyme)
• Fish oil
CT repair/regen anti-inlam
© Scott T. Doberstein, MS, ATC, LAT

What does all this mean for us as clinicians treating patients with plantar fasciosis/fasciopathy?
© Scott T. Doberstein, MS, ATC, LAT

Where science meets art….???
© Scott T. Doberstein, MS, ATC, LAT

Where art meets science…….??
“No evidence strongly supports the effectiveness of any treatment of PF, and most patients improve without specific therapy or by using conservative measures.”
(Cole, 2005)
© Scott T. Doberstein, MS, ATC, LAT

x4
 Young, 2001
1. Correct training errors, relative rest, ice post activity, inspect footwear
2. Correct biomechanical factors with stretching and strengthening
3. Night splints and orthotics
4. All other Tx options considered
 NSAID’s used throughout Tx but… pt educated that meds are used for pain control and not curative!
© Scott T. Doberstein, MS, ATC, LAT

 Cole, 2005
1. Shoe inserts, stretching, NSAID’s, ice
(because it works for other musculoskeletal conditions making it reasonable to do)
2. Corticosteroid injection or dexamethasone iontophoresis
3. Night splints, ESWT (but only for runners w/ S/S
> 1 year)
4. Possible surgery
© Scott T. Doberstein, MS, ATC, LAT

 Neufeld, 2008
1. ADL’s as tolerated, NSAID’s , heel pads, prefabricated orthotics, calf & PF stretching, night splint, pt assured surgery uncommon, dispel myths about heel spur not causing PF,
4-6 weeks
2. Corticosteroid injection followed by cast or cam walker
3. Custom orthoses w/ deep heel cup, Rx strength NSAID’s, lateral x-ray to r/o other pathology cont.
© Scott T. Doberstein, MS, ATC, LAT

 Neufeld, 2008
4. Continue above if improvement is progressing  d/c
5. If no improvement, MRI to confirm PF, ESWT or other alternative Tx
6. Surgery if S/S > 1 year
© Scott T. Doberstein, MS, ATC, LAT

 Rompe, 2009
1. R/O neuro and osseous pathologies
2. PF specific stretching for 6-12 weeks
3. continue stretching, modify activity, soft heel pads for another 6-12 weeks
4. continue above, night splints, ionto 6-12 wks
5. continue above, ESWT, corticosteroid injection
6. botulinum toxin
7. Surgery after 6-12 months of unsuccessful mgmt
© Scott T. Doberstein, MS, ATC, LAT

 Hastened recovery if Tx initiated w/in 6 wks of onset
(Young, 2001)
 Non-surgical mgmt success rate = 90%
(Neufeld, 2008)
 80% of pts have favorable results w/in 12 months
(Rompe, 2009)
© Scott T. Doberstein, MS, ATC, LAT

 We need more research on many interventions to get a better handle on this significant problem!!!
 On the horizon…..??
• Injections of botulinum toxin
• Injections of autologous platelet rich plasma
• Anything else you can think of??????
© Scott T. Doberstein, MS, ATC, LAT

© Scott T. Doberstein, MS, ATC, LAT