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Plantar Fasciitis


PLANTAR FASCIITIS --728.71

PATHOPHYSIOLOGY
inflammation of fascia on plantar surface of foot
usu localized @ calcaneous attachment
calcaneal spurs with bursa can develop
may be extension of inflammation of achilles
microtears, chondroid metaplasia, matrix calcification, angiogenesis, collagen degeneration
Theory: degenerative fasciosis without inflam, demonstrating myxoid degeneration, fibrocartilage fiber fragmentation, and vascularisation at the enthese on histological specimens from heel spur surgery.

INCIDENCE
in 10% of US pop over lifetime
most in men 40-70

ETIO/RISK FACTORS
usudt trauma, walking in flip flops or other shoes with poor support
weight bearing, high BMI
valgus @ knees, eversion @ calcaneous, hip instability
arch probs: flat feet or high arch
long distance runners, uneven sfc
tight achilles tendon
improper footwear
pregnancy
cigarette smokers

DDX
osteoarthritis, RA, gout
low back or disk problems incl spondylolisthesis at L4-5-S1 (S1-2 nerve root)
achilles tendonitis
neuralgias, neuritis, neuropathies esp diabetic
Morton's neuroma (btw 2nd-3rd digit) or other neuromas
injury or entrapment of posterior tib nerve (tarsal tunnel) or lat calcaneal nerve (Baxter's neuritis)
stress fractures of metatarpals, calcaneous
intermetatarsal bursitis
Reiter's (Lover's Heels)
ankylosing spondylitis, Crohns, SLE
infx of soft tissue or bone
charcot foot (syph, dm)
calcaneal spur, aka "heel spur" (never dx as cause, is a result)
metatarsalgia (usu in #1 near sesamoid) considered a capsulitis
inflamed flexor digitorum brevis muscle belly (deep to fascia)
in children consider: calcaneal apophysitis (kids)
in older adults consider: pagets, osteop, mets if fx from minor trauma
bone cyst

SX
usu unilateral heel pain, sometimes bilateral
pain worse in am, first steps, on stairs, after intense activity
limping
stiffness esp after inactivity
most sensitive first thing in morning, needs carpet or shoes by bed
PE: tenderness on bottom of foot, sensitive to vibration, mb swelling, flat or high arches

DX
generally clinical
if pain not on medial calcaneous consider imaging
xrays rule out other conditions but do not dx PF
neuropathic pn worse at bedtime, may waken, mb no pain c hallux major dorsiflex or palp @ calceaneal insertion
pain w/ pressure on bottom of heel or arch
foot type: low arch, pronation
xray: spur? ultrasound, nerve conduction velocity study

PROGNOSIS
good with compliance
mb slow to resolve if chronic
acute bouts resolve within 12 weeks

TX
90% resolve with conservative care
TX PAIN: ice/heat, cold laser, stiff shoes, night splint, DMSO, traumeel, capsaicin, peppermint/wintergreen oil, kava
short term foot support, orthotic, longterm use superior footwear, consider barefoot shoes
hydro: alternating hot and cold
NUTRITION: vit C, zinc, Se, boron, GAGs, hydration, proline, lysine, glycine, chondroitin/glucosamine, methyl donors
improve calcium utilization: vit D, mineral supplementation
LOWER INFLAM IF SYSTEMIC: proteolytic enzymes, anti-inflam diet, curcumin
physical activity, resolve blood sugar imbalance
weight loss
stretching: lengthen achilles, gastrocs, soleus, toe extension
STIMULATE CHONDROCYTES: prolotherapy, acupuncture, graston technique, exercise
massage? careful, not when acute, good for later stages, cross fiber massage
transition out of stiff shoes, into barefoot shoes
ultrasound? cold laser known to help with healing
OTHER
prolotherapy
extracorporeal shock wave therapy ESWT ("ultrasound on steroids and it hurts")
autologous platelet concentrate APC injx (PRP = platelet rich plasma)
cryosurgery, radiofrequency techniques

Conventional: NSAIDS, heel stretching exercises, rest for 1 week, supportive shoes, ice 2x/day 10-15mins, heel cups/pads, night splits to stretch fascia, if severe boot cast 3-6 weeks, custom orthotics and steroid injx, surgery is last resort

Prevention: keep achilles and calf long

NMT FOR THE FOOT
Ankle and Foot Osseous Mobilization
Calcaneus Anterior Glide prone
Superior Glide Tarsals pt prone, talus on leg, thumbpad contact knife drive, plantarflex
Inferior Glide Tarsals pt supine, stack midfingers on bone, dorsiflex and pull
Superior Shear Metatarsals pt prone, dorsum of foot on doc thigh, thumbpad & knifeedge
Inferior Shear Metatarsals dorsiflex and stack midfingers grade 3+, free form grade 1-2
Sup/Inf Glides Phalanges grasp sup and inf on both bones & check lig integrity
Med/Lat Glides Phalanges grasp med and lat both bones

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