_fasciitis uniformed services university of the 足底筋膜炎的统一服务大学课件

Plantar Fasciitis Kevin deWeber, MD Primare Care Sports Medicine Objectives Review the patho-physiology of PF Review the underlying causes Review the numerous treatment methods Describe a rehabilitation program Recommend a return-to-play program Magnitude of the problem Affects 10% of runners Affects numerous other athletes soldiers soccer, basketball, tennis, gymnastics, others 2 million Americans treated per year Significant interference in athletics Patho-physiology Micro-tears of fascia from repetitive trauma Degeneration of collagen More similar to tendonosis than -itis Clinical features Severe plantar foot pain aggravated by weight bearing with first steps of the AM May improve after a few minutes of running, then worsen Deep ache over anteromedial calcaneus TTP over plantar medial calcaneal tubercle Tight heel cord a common finding Predisposing factors Extrinsic factors Training errors Improper footwear (300 mile rule) Unyielding running surfaces Intrinsic factors Pes planus w/ hyperpronation Pes cavus w/ supination Tight heel cords Weak intrinsic foot muscles History Training regimen (any changes prior?) Exacerbating activities Duration Past treatments Other medical problems Miles on running shoes Examination Establish point of maximal tenderness Evaluate for other tenderness Ankle ROM (tight Achilles?) Evaluate longitudinal arches Look at running shoes/boots Ankle ROM Radiology? Rarely useful; not needed in most cases What about heel spurs? Probably negligible 13% prevalence only 5% of those c/o heel pain Differential Diagnosis Calcaneal stress fracture FHL tendonitis Tarsal tunnel syndrome Fat pad insufficiency Pagets disease of bone Midfoot DJD Reiters syndrome (inflammatory arthritis) Overuse Injury Management Pyramid 1. Make accurate patho-anatomical diagnosis 2. Control inflammation 5. Rehab exercise 4. Correct predispositions 3. Control abuse/promote healing Sports participation 1. Control inflammation Ice massage NSAID Iontopheresis Steroid injection Control inflammation (cont): Ice Massage 15 minutes rolling on frozen juice can Ice baths After activity, several times a day Control inflammation (cont): NSAID Short course, 2 weeks Largely analgesic properties Useful, but MINOR role in treatment Control inflammation (cont): Iontopheresis Ultrasound using corticosteroid cream Six treatments over 2 weeks One study: Ionto vs sham more rapid sx relief and improvement at 2 wks no better than sham at 1 month Gudeman et al, Am J Sports Med 1997 Marginal benefit Consider cost and compliance Control inflammation (cont): Steroid Injection Quicker pain relief at 1 mo but no long-term advantage Crawford et al, Rheum 1999. Predisposes to PF rupture, which causes chronic pain Acevedo JI et al, 1998: 765 pts txd for PF Those txd w/ injection: 44 ruptures (10%) Others: 7 ruptures (1%) Plantar fascia injection 5 ml 1% lidocaine AND 40 mg triamcinolone/Prednisolone OR 6 mg Betameth/Dexameth 2. Protect from ongoing abuse Only do activity that is NON-painful cross training useful, e.g. bike, deep pool running if running, less distance/hills/speed Increase 10% a week, if improving Expect 8-12 weeks to resume full activity for athletes 3. Promote healing Tension night splint Studies on tension night splints Batt et al, 1996 32 pts, randomized to 2 months tx NSAID/heel cup/stretching: 35% “cured” failures crossed-ever to TNS: 73% “cured” Above + TNS: 100 /heel cup: 100% “cured” Probe et al, 1999 116 pts randomized to 3 months tx NSAID/stretching/shoe changes: 68% improved Above + TNS: 68% Studies on tension night splints (cont) Barry et al, 2002 160 pts in retrospective study Achilles stretching TNS TNS group had stat-sig shorter recovery time fewer f/u visits fewer other interventions required Studies on tension night splints (cont) Martin JE at al, 2001 255 pts randomized to 3 months tx Custom orthoses OTC arch pads TNS NO stat-sig differences Night splint conclusions Mixed results in studies May try if initial response poor 4. Correct predisposing factors Work on Achilles inflexibility Change running surface? New shoes? OTC arch pads consider custom orthotics if no response Educate on training principles (10% rule) Which type of orthotic is best? Pfeffer et al, Foot Ankle Int 1999. 236 patients, txd w/ Achilles and PF stretching Randomly assigned to 5 groups: stretching alone: 72% improved custom 3/4 length polypro orthoses: 68% OTC arch pads (full length, felt): 81% rubber heel cups: 88% silicone heel inserts: 95% Study problem: custom orthoses only 3/4 length no motion control Which type of orthotic is best? (cont) Martin JE at al, 2001 255 pts randomized to 3 months tx Custom orthoses OTC arch pads TNS NO stat-sig differences Which type of orthotic is best? (cont) Lynch et al, J Am Pot Med Assoc 1998 103 patients randomized to 3 months tx silicone heel cup plus APAP: 58% improved steroid injection plus NSAID: 77% Arch pads f/b custom orthosis: 96% Good to fair improvement seen in 70% of orthosis group vs 30% other groups Which type of orthosis is best? Conclusions: Use low-cost orthoses first OTC arch pads, OR Heel cups, OR Silicone heel pads Consider custom arch pads if good response 5. Rehabilitative exercise: Principles Overall flexibility puts less strain on PF Achilles, longitudinal arch Intrinsic foot muscles support the PF Ankle stability reduces stress on PF Improved running form protects the PF lower leg strength and flexibility Rehabilitative exercises 1-2x/day Achilles stretching Daily eccentric (stair edge) heel exs 2 sets of 15 to fatigue Barefoot heel/toe/backward walking while carrying weights Towel toe-grabbing (intrinsic foot muscles) Ankle tubing strength exs (inv/ev/DF) Typical treatment protocol New patient Profile to control abuse 2 wks piroxicam Ice massage 4x/day OTC arch pads or gel heel cup Handout for exercises, esp heel stretching f/u 2 wks; reinforce need for rehab exs; modify profile Poor response after 1 month Add tension night splint (brace shop) Refer for custom orthotics Refer to Physical Therapy for more instruction on rehab Consider steroid inje