Plantar fasciopathy What are the risk factors?

Dr. Paul Beeson BSc, MSc, PhD, FCPodMed, FFPM RCPS(Glasg)

Economic burden

• 10% of people suffer heel pain during their life (Tong & Furia, 2010)

• 10 –20% plantar fasciopathy become recalcitrant (Rompe et el, 2007)

• Cost of delaying treatment

Negative impact of PF?

• Quality of Life (Irving et al, 2008)

• Physical inactivity (Beeson, 2014)

Potential long-term health consequences of chronic heel pain?

• Coronary artery disease

• Hypertension

• NIDD

• Foot osteoarthritis

Plantar fasciitis or fasciopathy?

• Terminology?

(Maffulli et al, 1988)

• Insertional or non-insertional

(Jeong et al, 2013)

Anatomy

Medial Central Lateral

Ligament structure

Ligament in relaxed state

Ligament under tension

Ligament composition

Collagen

Type 1

Type 3

Type 5

33%

Tendon % Ligament %

95

1

1

90

4

1

Elastin 2 4

Proteoglycans 0.25 0.5

Glycoprotein 0.75 0.5

Water

66%

Histological effects in PF

1) Neovascularization

1) Change in collagen composition:

( Type 1, Type 3, Type 5)

(Gonçalves-Neto, 2002)

3) Mucin content

4) Fibroblast hypercellularity

MRI – normal plantar fascia

Frontal Sagittal

M L

Ultrasound of Plantar fascia

Thickened Pf = >4mm Normal Pf: 2- 4mm

Function of Plantar Fascia

Demographics of Plantar fasciopathy

Sedentary + Athletic populations

Peak onset 40-60 yrs age

(Werner et al, 2010)

Unilateral involvement in up to 2/3rd cases (Irving et al, 2007; Sher et al, 2010)

PLANTAR FASCIOPATHY

(Prevalence 3.6 to 7%)

Gender association Findings vary between studies

Origin of chronic plantar heel pain?

Systemic

Neurological (nerve entrapment)

Traumatic (fracture)

Mechanical (Thomas et al, 2010).

What are the risk factors for PF?

Extrinsic

– load, environment, occupation, lifestyle, sport.

Intrinsic

– ligament changes

(Beeson, 2014)

Extrinsic risk factors

• Occupation (Riddle et al, 2003)

• Inappropriate footwear (Thomas et al, 2010)

• Physical load/ activity levels (Buckbinder, 2004)

• Sleeping posture (Bolivar et al, 2013)

Extrinsic risk factors

• Sports overuse injury:

Training errors/ surfaces (Kibler et al, 1991)

High intensity (Singh et al, 1997)

Muscle dysfunction/ inflexibility (Rome et al, 2011)

Poor technique/ fatigue (Taunton et al, 2002)

Intrinsic risk factors

• Middle/ older age (peak 40-60yrs)

degenerative changes within Pf. (Lemont et al, 2003)

• Gender?

Intrinsic risk factors

• Obesity (>30kg/m2) (Frey & Zamora, 2007; Riddle et al, 2003)

• Vascular perfusion (McMillan et al, 2009)

• Trauma (Penetrating injury/ laceration)

No reported associations.

Intrinsic risk factors

BIOMECHANICAL DYSFUNCTION

* Reduced AJ dorsiflexion

(Riddle et al, 2003; Huerta 2014; Sullivan et al, 2015)

Stress shielding of FDB? (Orchard, 2012)

Foot pronation (Riddle et al, 2007; Irving et al,

2007; Rome et al 2011)

Rearfoot eversion (Lee et al, 2010)

Reduced 1st MPJ extension

(Irving et al, 2006)

Intrinsic factors confused with PF

Systemic disease: • Ankylosing Spondylitis

• Psoriatic arthritis

• Reiter’s syndrome

• Reactive arthritis

Heel spur

• 10-15% normal population

• Present in 50-75% of those with heel pain (Karabay et al, 2007; McNally & Shetty, 2010)

Heel spurs

• Site FDB attachment

• Not a traction spur

Associated with: Increased age

Obesity

History heel pain

Menz et al (2008): Plantar calcaneal spurs in older people: longitudinal traction or vertical compression? J foot & Ankle Research. 1:7.

Genetic risk factors

Genetic studies have revealed:

• COL5A1 regulates tendon strength

• COL1A1 & COL3A1 painful tendinopathy

• TNC at myotendinous & osteotendinous junctions

• MMP’s

• TIMP’s

(Ireland et al, 2001; Alfredson et al,2003; Riley, 2008; Raleigh et al, 2014).

Gene

Imbalance alters tendon homeostasis

Candidate gene variants implicated

• COL5A1

• MMP1, MMP3, MMP8, MMP10 & MMP12

• GDF5

• TGFB

• ADAMTS1, ADAMTS2, ADAMTS4, ADAMTS5, ADAMTS15

• TIMP1, TIMP2, TIMP3, TIMP4

General Summary

• Quality of evidence?

• Precise mechanism of ligament injury?

• Numerous reported risk factors imply PF is a complex multifactorial soft tissue pathology.

Conclusions

• Economic burden to health services

• Ranking of + interaction between risk factors

• Research to establish a genetic basis for PF

References

See following article to access all PowerPoint references:

Beeson P: Plantar fasciopathy – Revisiting the risk factors. J Foot & Ankle Surgery. 2014; 20(3):160-165.