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Partial tear of the plantar fascia

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Stanley, Apr 14, 2008.

  1. Stanley

    Stanley Well-Known Member


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    Colleagues,

    I have found my most frustating cases of plantar fasciitis are those in which MRI's show a partial tear of the plantar fascia.

    What do you think are the best treatment(s) for this?

    I'm apologize if this has already been discussed.

    Regards,

    Stanley
     
  2. Craig Payne

    Craig Payne Moderator

    Have them stomp on it until its a complete tear ....from what I understand is that it works really well. :wacko: ... at least the pain is gone soon after its ruptures!

    St Kilda AFL footballer, Robert Harvey, did this in a much reported case in the media here. He just kept jumping of the kitchen table until it totaly ruptured. The expected 8 week layoff due to the partial rupture was reduced.
     
  3. David Smith

    David Smith Well-Known Member

    Craig

    Is this true?

    Stanley

    I had a customer (male 46yrs old) who came in 8 weeks ago with what appeared to be a strained or partially torn PF. He could barely weight bare on it and there was bruising across the sole just distal to the heel. He did it the day before while playing Badminton. I taped it and got him to ice it daily 2 x 20mins and non w/b as much as possible. I booked him for a diagnostic u/s but it couldn't be done for 1 week or so. (MRI much to expensive). I reviewed him after one week and I was quite suprised that he was almost pain free. He did have a allegric reaction to the zinc oxide rigid tape with huge blisters on the sole. I thought this reaction may have speeded up the healing of the PF also. Anyway he had not been for the u/s so I cancelled it and fitted OTC orthoses with some mods and reviewed him after 6 weeks, he was totally pain free and could do light badminton training again. I gave him stretching and strenghtening exercises and mobilised his ankles. Job done.
    Now after reading Craig's post I'm wondering if I should have had the u/s done anyway. If the PF was ruptured it might have settled down pain free and the resolution Dx was a misinterpretation.:confused:

    If not, the Tx seemed quite effective, if so, what do you think? should I review him and go for a u/s scan.

    Cheers Dave
     
  4. Craig Payne

    Craig Payne Moderator

  5. Adrian Misseri

    Adrian Misseri Active Member

    I find taping most effective for the acute tears, provided they ice it or contrast pack/bath it and rest it. Did have a really stubborn one recently that did not repspond to taping, rest, ice, footwear mods, orthoses or even camm walker for 6 weeks. She ended up seeing a good deep tissue masseur to gave it a good rub down whilst she was awaiting an appointment with a surgeon. It was agony for her and for the next couple of days, however a week later she is almost pain free. Are we overlooking massage as a treatment modality?
     
  6. To tear or not to tear, that is the question.....

    I wouldn't recommend the treatment that Robert Harvey did to himself since there is a big difference biomechanically between a partial tear and a complete tear of the plantar fascia. In a partial tear, generally the most medial fibers of the central component of the plantar aponeurosis (i.e. plantar fascia) are torn with the remaining lateral fibers being left relatively uninjured. This will produce much the same biomechanical effect that a partial surgical plantar fasciotomy will have in the treatment for chronic plantar fasciitis in that the medial 1/3rd to medial 1/2 of the plantar fascia are transected during surgery. I don't know of anyone in the States who would recommend a complete plantar fasciotomy for treatment of a partial plantar fascial tear (i.e. "to complete the tear"). Why? Here, again, are the ten functions of the plantar fascia.

     
  7. drsarbes

    drsarbes Well-Known Member

    Hi Stanley:

    First, please don't have your patient "STOMP" down on the injured foot!

    I agree with Kevin, these are usually on the medial slip. Also common and less appreciated are herniated fascias (sometimes from acute injury, sometimes from overzealous cortisone injections for fasciitis)

    If it is truely "torn" the patient will have difficulty putting any pressure on the injured foot. These you can try to treat via immobilization followed by support and PT if they are resolving.

    Most of the tears I see that end up in the operating room are of the Herniated variety along the muscle belly of the AHB. There is normally a "bulge" in the area as compared to the contralateral foot and frequently a compressed nerve. These are very painful and any direct pressure (bandage, arch support, wt. bearing) cannot be tolerated. While in training we repaired three of these with a gor-tex mesh, but scar tissue was a problem. Since those days I have repaired many herniated fascias (since I have quite a few podiatrists in my area who love giving repeated injections for non responsive fasciitis and quite an obese population) and find it responds well to simply suturing the fascia as you might an inguinal hernia.

    Steve
     
  8. Stanley

    Stanley Well-Known Member

    Dear Colleagues,

    Craig, I see the validity of this approach. Here in the US, we would surgically do the same thing.

    I have treated completely torn fascias. One of my patients was a baseball pitcher, who won the Cy Young award 2 years later.
    I am not talking about this, as these do heal in a few weeks with good care (Orthoses, physical therapy, Rocker platform shoes).

    Dave, how did you determine this was a partial tear vs. a complete tear?

    Adrian, thank you for your input. Are you sure you didn't have a problem with the Flexor digitorum brevis? This muscle is involved with a subluxed calcaneus (posterior-lateral ).

    Kevin, the surgical approach is to cut the medial and central bands of the fascia.
    http://www.podiatrytoday.com/article/6296
    The patient I was referring to had a prior surgery, and what was left was a small superficial band of the medial and central band. I didn't see where you recommended a treatment for a partial tear.
    Thanks Steve, I have the patient in a cast, and was planning to do what you were recommending.

    Thank you all for your replies. From what I gather, the way to treat this is either to complete the tear, or try to let it heal. The healing process is aided by immobilization and physical therapy.
    I was also looking at the platelet injections as a means to stimulate healing.
    Does anyone have any experience with this?

    Thanks and regards,

    Stanley
     
  9. Stanley:

    I was not aware that there was only one surgical approach to partial plantar fasciotomy....."the surgical approach". I think that you will find that the authors of the article you provided to us clearly state that there is current controversy regarding how much of the central component of the plantar aponeurosis to transect during plantar fasciotomy.
    Therefore, you should have said "one surgical approach is to cut the medial and central components of the plantar aponeurosis". Then you would have been correct in your statement regarding what the authors actually stated in their paper.
     
  10. David Smith

    David Smith Well-Known Member

    Stanley


    Exactly!

    I didn't that is why I originally ordered a u/s scan. But as it became pain free before he had had his scan I presummed that it had healed and so therefore was not fully ruptured. Craigs post made me think - what if it had fully ruptured and the short lived pain was due to this and not healing. I was not aware that a fully ruptured PF would become pain free. That is why I asked do you think it is worth doing an US scan anyway.

    Cheers Dave
     
  11. Stanley

    Stanley Well-Known Member

    Kevin,

    I remembered that because releasing the lateral band caused lateral column disease, the plantar fasciotomy was modified to not include releasing the lateral band of the plantar fascia, hence the medial and central bands were transected. I Googled for an article on plantar fasciotomies, and the Karlock-Kirk article was the first one I saw, so I attached the link to it.
    Wolfer sectioned the complete central band (I would presume for central heel pain), and Fishko sectioned the medial one-third (the medial band). I didn't see where it said to section one half of the central band (in addition to the medial band) which is what you implied when you said:

    This seems to be an illogical way to surgically approach the problem, as it would increase the tension of the central band of the plantar fascia. Do you do this procedure? If you do, then I assume you get good results. If not, can you get me a reference for partial fasciotomies of a band would be a good bit of information to have for the previous treating podiatrist of the patient I have, just in case it ever goes to court.

    Regards,

    Stanley
     
  12. Stanley

    Stanley Well-Known Member



    Dave,

    Sorry I missed your question, but I thought it was a little rhetorical.
    If you want to make a diagnosis, then the scan would do you well. Seeing that the patient is Job done there really isn't any point, except to see if it is ruptured, which is what I would expect. :drinks

    Regards,

    Stanley
     
  13. How do you, then, do the surgery, Stanley?
     
  14. Stanley

    Stanley Well-Known Member

    I haven't done one in 15 years. I used to do a complete fasciotomy, and there were too many patients that were incapacitated for extended periods of time. Biomechanically, it is not a logical thing to do, so I just work harder at conservative care.
    Again, the problem patients are the ones that are shown to have a partial tear in the plantar fascia on their MRI.
    After reading the posts I am going to try casting with or without ESWT or platelet injections. I still have to figure out the criteria of each.
     
  15. Peter1234

    Peter1234 Active Member

    hi,

    I saw a lecture where the speaker said that ESWT was good for plantar fascia problems especially when the tissue has become calcified- when there are calcifications in the plantar fascia. Does anyone know anything about this?
     
  16. Peter1234

    Peter1234 Active Member

    oh, and also- will there always be swelling in the case of a partial tear?
     
  17. leanne machielse

    leanne machielse Welcome New Poster

    what would be the expected time frame for a person with a partial tear to the plantar fascia to be able to jog?
     
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