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Plantar Fasciitis

Discussion in 'Biomechanics, Sports and Foot orthoses' started by timbogates, Jun 27, 2015.

  1. timbogates

    timbogates Member

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    What about cortisone injections for PF? Inject wait 6 weeks and do in if problem returns? Your thoughts? How beneficial is a gait analysis study? Should we highly consider orthotics after 1 year of struggle of PF? Many patients stretch for 6-9 months routinely without any relief so what are thoughts on other options mentioned above. Do the cortisone injections after 2 of them help 75% of the patients?
  2. Griff

    Griff Moderator

  3. Ina

    Ina Active Member

    I have recently talked to a person who has plantar fasciitis, he said he has been doing gastrocnemius stretching for over 2 years to no avail (as he's a medical worker I assume he really does it every day), he gets by with heel pads/lifts. Although it's anecdotal evidence but I wonder isn't any possible positive effect of approximately 9-10 min daily gastrocnemius/soleus stretching is anyway bound to be reduced to zero by simultaneous wearing of heel pads/lifts or moderate-heeled shoes all day long?

    Couldn't be 10 min daily stretching futile in the light of this evidence?..

    "Regardless of particular pathological processes, a minimal of 6 hours passive stretching is required to permanently change the length of a muscle within humans."
  4. Ian Linane

    Ian Linane Well-Known Member

    There are many intrinsic and extrinsic factors in developing a plantar fascial problem, not least quite where it is in the plantar fascia.

    Certainly, for me, getting patients to loading is more significant than stretching and so my treatment care pathway emphasises the move to loading, educating tissue to take loading and removing extrinsic contributors that may inhibit this. Stretching plays a small but useful part in this.
  5. timbogates

    timbogates Member

    Do you utilize cortisone injections? If yes max of 2 in a 4 month period? If no, how about heel lifts not heel cups what is a good starting size on lifts? I have used heel cushions Tulis and it did not help. What is a good brand?
  6. timbogates

    timbogates Member

    Thanks and this is full of good information. What is your experience with cortisone injections do you get at least 75% better after 1-2 injections.
  7. Ian Linane

    Ian Linane Well-Known Member

    Only referred for cortisone injections twice in my career.

    Assessment for me starts with functional assessment at the pelvis and works down to the foot, assessing possible extrinsic contributors, which are frequently deficits such as gluteal / calf weakness / ROM issues. In terms of the calf these will be assessed whilst with soft tissue palpation whilst the person is loading the muscles in both concentric and eccentrically.

    Need to determine then whether the PF is of a compressive nature (more enthesis) or involves more tensile issues (which seems to show further away from the enthesis). I may well assess individual fascial slips into the toes as well.

    In the fascia itself I try to look at which direction of applied loading elicits discomfort using treatment directed tests e.g. medial to lateral loading of the medial aspect of the central band etc and where along it that deficit shows, whilst also increasing applied loading and taking the foot and leg through varied ranges of movement.

    BMX will also be assessed in case of orthotic intervention (wedge, device, footwear adaptation / change).

    Once these are determined I will build my rehab programme, which generally aims at managing a loading programme.

    The programme will consist of a combination of any of the following: soft tissue work, mobilisation, functional exercise, orthotics, dry needling for TrPs. It is quite common for me to end up applying specific soft tissue mobilisation direct to the fascia when a person is fully weight bearing up on the balls of their feet, or, if athletic then in a running propulsive phase stance fully loaded. Equally I will apply it to the areas of calf that need it whilst they also undertake eccentric and concentric loading.

    Just my take on this and offered in good faith. There may well be easier ways.
  8. Raphael1974

    Raphael1974 Member

    I see a lot of these in my practice and my own protocol is:

    1) Is it truly PF (or Baxter's nerve impingement/Tib Post pain) - I utilise Point of Care MSK US to help determine this as well as check for any evidence of fascial tears
    2) What were the causative factors and, if ongoing, has an attempt to address these been done
    3) Has an attempt to offload the structure been attempted and if so, was it done correctly
    4) What have they been advised re: promoting tissue healing - e.g. stretches/massage/night splints
    5) Optimise and reiterate all the above and ensure compliance

    THEN.....if I'm happy that all the above has been attempted AND if the pain is really severe, then I'll consider a steroid injection (I do mine under USG given the risk of fat pad atrophy or fascial rupture - placement does appear to be key, I go just superior to where the fascia starts to meet the calcaneum). I consider this an analgesic intervention only as there is no evidence that it promotes tissue healing in itself and they invariably wear off if the biomechanical issues aren't addressed. I advise the patient of this along with the risks of injection. It can be enough to dissuade those who believe that all they need is an injection to magically make it disappear (which is a LOT of patients).

    If I feel that the tissue healing is stagnant then I'm much more likely to do USG dry needling and am looking at RSWT and possible PRP as an adjunct to this, but again I push biomechanics again and again.

    If there is evidence of a tear (then I certainly don't do a corticosteroid injection) and have a lower threshold for surgical referral if benefit isn't being obtained with all the above.

    I've heard anecdotal evidence about trigger point release in gastroc (I think this relates to the myofascial lines but am not really versed in this) and have sometimes just done a nerve block to deal with the pain.

    In the UK this is something which is often managed in 'silos' with a lot of time delay in between each clinician and sometimes the quality of what they've previously been advised to do or given wasn't up to par so you have to re-convince them of the benefit of doing it again but getting it right this time.

    This would be a condition which would benefit hugely from a single site, one stop, MDT approach.
  9. W J Liggins

    W J Liggins Well-Known Member

    I go along with all of the above. However, a consistent finding in my part of the world (God's own country, the West Midlands) is the aetiology of 40 years+ males, overweight, standing for long periods on a concrete surface. Most of them have gone through a process of stretching/night splints and offloading without benefit. Having had U/S examination to rule out tears and other potential Dx. I do proceed to depomedrone infiltration over the area of greatest tenderness. I carry this out under tibial block and use bupivacaine in addition to the cortisone. The results of a pilot study of 25 patients using bupivacaine alone over a five week period demonstrated 44% total resolution of symptoms and a mean percentage reduction in pain of 76.8% (British Journal of Podiatry 2001, 4(3) 90-94).
    Although there was no long term follow up, other studies suggest that after 18 months the resolution is largely maintained. I added the depomedrone later since anecdotally only one infiltration is necessary to achieve similar results. I have not carried out the procedure under USG but agree that placement is important, hence the tibial block to allow painless infiltration, USG would be even better!

    Bill Liggins

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