Hi, I'm Dr. Randale Sechrest, your host for eOrthopod.TV. And today we're talking once again remotely with Dr. Brett Fink. Dr. Fink is an orthopedic foot and ankle surgeon who practices foot and ankle surgery in Indianapolis at the Community Health Network. Dr. Fink completed his medical school training at Washington University in St. Louis. And from there completed an orthopedic residency in the Portsmouth Naval Hospital. And from there did a fellowship in two places. One at Boston University and the other at the University of Miami, specializing in foot and ankle surgery. Thanks for joining us today Dr. Fink.
Dr. Brett Fink: Thank you, Randale. It's a pleasure being here.
Dr. Sechrest: Well, Dr. Fink, what I thought we would talk about today is a very common foot and ankle problem, and that problem is plantar fasciitis. It goes by lots of names. Some people refer to this as a heel spur, in the past. Some people refer to this simply as heel pain, because that's where the pain is. Can you begin by telling us a little bit about the current thinking about plantar fasciitis. What are, what do we know today about that disease process?
Dr. Fink: Well, like you said, Randale, this is a very, very common problem. Plantar fasciitis at some point in a person's life will effect 10% of people, if not more. Because many people with plantar fasciitis come in and do not even see a ah doctor because the pain often goes away by itself. Plantar fasciitis is a um, degenerative condition. It is a inflammation or deterioration of a very important ligament in the bottom of the foot called the plantar fascia. The planter fascia connects the base of the proximal phalanx, which is the bone in the toe, that is at the ball of the foot, to the heel. It runs as a thick band of connective tissue, which you can feel if you bring your toes up. And connects right on the bottom of the heel. And most commonly when people have plantar fasciitis, they feel the pain on the inside and front portion of the weight bearing surface of their foot, near the heel. And like you said, it is extremely common and is uh, the cause of probably 95% of heel pain.
Dr. Sechrest: Well, lets talk a little bit more about the symptoms. When you see a patient in the office that is complaining of this type of heel pain that ultimately you think is probably going to end up being diagnosed as plantar fasciitis, what sort of story do they tell you in the office? What type of symptoms are they reporting?
Dr. Fink: Usually the pain begins kind of gradual in onset. It often, it usually does not occur with any trauma. Although some people will note some type of of event, usually very small event that might initiate the pain. Um, the pain, once again, assaults in the front portion of the weight bearing surface of the heel, on the bottom of the heel. And um, often people will notice that the pain is much worse after they get up from a sitting position, or when they wake up in the morning. There is a very uh, uh old saying 'the first step is the worst step,' and that is very common with plantar fasciitis. Is that the first couple of steps when coming out of bed, perhaps getting from the bed into the uh bathroom is very uncomfortable. And then the pain will uh decrease and often the pain will resume again if the person has been up on their feet for a long period of time.
Dr. Sechrest: Well, lets talk a little bit about the anatomy. I think you've mentioned that the plantar fascia is this very thick, uh tendon or ligament that runs across the bottom of the foot, um, that sort of supports our arch. Can you tell us a little bit more about how that, that ligament functions?
Dr. Fink: Yes, the the ligament once again attaches onto the toes at the very base of the toes, near the ball of the foot and attaches onto the front portion of the heel, or what doctors call the calcaneus. Um, and as you shift weight from the heel to the ball of the foot and the toes come up, this ligament tightens. And as it tightens, it uh, it forms a tough band which more or less supports the arch of the foot and it keeps the arch of the foot from collapsing as you place weight on the ball of the foot. Um, if you didn't have the, the plantar fascia, your arch would collapse down and it would probably wear out your joints very quickly. So it is an extremely important protector of the joints, bones, and smaller ligaments in the foot.
Dr. Sechrest: Now, how about the cause of plantar fasciitis? Are we any closer to really understanding what actually causes the pain and causes the condition? You know during the last 30 years that I've been practicing orthopedics, there have been a lot of theories about why heel pain occurs, and specifically why we're having problems with plantar fasciitis. Can you explain to us the current thinking about what the causes are of that disease?
Dr. Fink: Well, there are a lot of studies that look at common associated conditions. And anything that causes vasculopathy, hardening of the arteries, heart disease, will also cause connective tissue problems. Um, so, if someone has a lipid disorder or um has diabetes, um, they'll have a higher rate of this plantar fasciitis because it effects the arteries and the connective tissue in a way which causes it to wear out. It is a degenerative condition, for the most part, it effects people more commonly as they get older. But interestingly, it seems to be the middle ages where the, where it's most common. People that have a very tight heel cord, have a higher incidence of plantar fasciitis. As a matter of fact, if you have if you are unable in physical exam, to bring your foot up into a position that allows your heel to get on the ground – what we call neutral position – there's a three time increased incidence of plantar fasciitis in that group. And, in addition, people that have contracture of their hamstring, have tight hamstring muscles, it's actually an 8 times increase incidence in those people. And so, it seems to be a combination of mechanical overload, your body's own physiology, and um, ah and just age related changes that occur that uh, make the ligament break down. And what happens around the ligament is that you get small areas of tearing or scarring that just don't seem to heal very well.
Dr. Sechrest: So this is a disease process similar to tennis elbow, for example. Where we've sort of come to the, to the notion that the tendon is beginning to degenerate. And for people that don't understand what we say with degeneration, it's just beginning to tear off the bone and not healing back. And sort of gets to a point to where that healing doesn't go ahead and completely heal with normal tissue. Is that relatively accurate?
Dr. Fink: That's, that's exactly right. As a matter of fact, people with tennis elbow or rotator cuff um, uh, irritation, people with tendonitis in the knees, hips, or in the back of the ankle, known as the Achilles tendon, will also have plantar fasciitis much more frequently than people that don't. And it effects the exact same population. More of less, very rare in the 20s and 30s, but becomes more common as you get into the 40s, 50s and 60s, and then becomes less common in the uh elderly age.
Dr. Sechrest: And your point about people with vascular diseases – like hardening of the arteries – is that what leads to the inability of this tendon to actually heal? They just can't get the blood supply there to actually support the healing process?
Dr. Fink: There's probably a lot to it, including just the body's own decreased ability to heal problems and the fact that mechanically our connective tissue kind of deteriorate and don't, and don't become, and become less resilient with age. But you're right, I think that probably uh, vascular um, vascular damage uh, also effects this tendon very much and can cause it to not heal properly.
Dr. Sechrest: Now that brings up the notion of the heel spur. You know, for years I think we've all seen patients who come in and you get an x-ray of the side of the foot and you see this spur growing from the heel. And I would say for a lot of years, and some patients still believe that that it's the heel spur causing their pain. Can you talk a little bit about the significance of the heel spur and what it means when we see that on x-ray?
Dr. Fink: Yes, I spent a lot of time when I first see patients discussing the significance of a heel spur. And it is also this, this problem is also called heel spur syndrome. But, the heel spur, I think the important thing about dispelling the idea that the heel spur is causing the pain, because the logical conclusion is that if you have a heel spur that it needs to come off before the pain will go away, and that's not true with plantar fasciitis. As a matter of fact, the heel spur is con, is present if you look at people in their 40s and 50s and just x-rayed everyone, whether they had heel pain or not, it would be present in about 20 or 30% people. But if you have plantar fasciitis, it's present in 50% or people. So there's a slight increase in the percentage of people that have heel pain and heel spur as opposed to those that have the heel spur and don't have heel pain. Um, the heel spur is actually non within the plantar fascia, it's actually deep to the plantar fascia. And probably is a reaction of the bone to the inflammation in the soft tissues in the plantar fascia itself. When bone senses that there is a repairative process going around, it does what bone does naturally, which is to lay down more bone. The results have been some evidence that these heel spurs may just be more common in people that are overweight, and people with plantar fasciitis have a tendency to be overweight. And so, therefore, I mean they're associated. But it's not necessary, it's not necessarily true that the heel spur causes the heel pain. As a matted of fact, when you do surgery uh, there's not been found any improvement in people's outcomes if you remove the heel spur as opposed to doing what is typically done for plantar fasciitis.
Dr. Sechrest: Well, lets talk about , a , ah little , a little bit about other things that may cause heel pain. I'm assuming that not all things that cause heel pain are plantar fasciitis. When you're going through a differential diagnosis as a surgeon, what other things are you concerned about ruling out?
Dr. Fink: Well, there are a couple of other serious things that you need to think about when someone has heel pain. Um, first of all, ah, I think probably the most important differentiation is separating plantar fasciitis from a calcaneal stress fracture. And a stress fracture is a fracture that occurs because the body has been putting enough stress on a structure and damaging it in a small and incremental fashion, to the point where the structure is actually starting to break. And people can develop stress fractures, they can be painful in a very similar place – not exactly the same place. And that's probably the most important distinction. Other than that there are some nerve problems that can occur that can be associated with plantar fasciitis as well as the, become separate issues that are completely unrelated to plantar fasciitis. The posterior tibial nerve is a nerve that runs along the inside and back portion of the ankle. It branches into several different nerves. Um, some of these nerves go to the muscles in the bottom of the foot, and they can be pinched by the plantar fascia or other connective tissue structures and give you heel pain. Um, some authors say that as may as 30% of the cases that are diagnosed as plantar fasciitis can be caused from this nerve pressure. However, it is my opinion that it's not that high. Um, in addition, these, the damage to these nerves can weaken the muscles to the point that the plantar fascia becomes more exposed to stress. And therefore becomes more, it becomes more common that plantar fasciitis occurs. Yet, the last thing that is important to differentiate and this is really the only reason that I get an x-ray with people with plantar fasciitis, is to look for bone tumors – which are very rare, but um, important to ah determine if one is present if pain persists despite good nonoperative treatment for a period of several months.
Dr. Sechrest: Well, lets talk a little bit about the diagnosis of of heel pain. When you see the patient in your office, how do you normally start out in terms of evaluating that patient?
Dr. Fink: Well, a history is probably the first um thing. It tends to be pretty common that they, that these stories um are a variable length of time of pain, and usually again, this start-up pain that people get when they get up from sleep or when they get up from a standing position. And then I evaluate them, and I think it's pos, that it's important to do a complete physical exam of the foot. Um, and usually they have tenderness and some degree of swelling again in that front portion of the weight bearing heel pad. Usually along the inside, but sometimes also along the outside. And as a foot and ankle specialist, they usually have come in with some degree of treatment. And so I evaluate their x-rays at that point. But, ah, again, the presence of a heel spur is not the important thing. It's really making sure that the bone looks otherwise undamaged. That there aren't any fractures, no arthritis and no tumors present.
Dr. Sechrest: How about any special tests? Do you feel the need to get an MRI scan for example? Or any special lab tests when you see these patients in the office?
Dr. Fink: I use MRI's and other tests only to uh, insure that I've got the right diagnosis right before I consider surgery. Uh, otherwise I don't think MRI has much of a place in the evaluation of these problems unless we're going on to surgery. I use it more or less as a road map um, during uh my surgical approach. Short of that, no, really there aren't really any other diagnostic tests. If, if people have an abnormal physical finding like numbness, or extreme weakness in their uh, in their muscles, I will evaluate that but for the most part I do not do any special tests.
Dr. Sechrest: And what about treatment? When you start out with these patients and first see them in the office, I think you mentioned earlier that that you're going to probably try some different types of conservative treatment uh for the the first several months anyway. What does that consist of?
Dr. Fink: After the initial evaluation, I feel that ah,a strengthening and stretching program is probably key to the treatment of these problems. Again, we've talked about the fact that tendon contractures, especially of the Achilles and hamstrings are very associated with plantar fasciitis, and so I work hard to have my patient start to do this – to stretch out those tendons so that the plantar fascia is loaded just a minimally as possible during the initial recuperation. As the person recupe recuperates more, and they're able to do more, I add strengthening exercises. It's my belief that the intrinsic muscles of the foot are key to preventing plantar fasciitis at the, in the long run. And so I usually start my patients on strengthening exercises that more of less involve suspending their heel off the edge of a step and having them more of less shift their weight from one side of the foot to the other as they bring their foot into full plantar flexion, or come up into a pointed toe position. It's a little hard to explain, after that, arch supports are very helpful. I generally recommend early in the recuperation that people wear a rigid rocker soled shoe. The Skechers shape up or the NBT shoes have become less popular in the market, but they are very helpful for this problem. Especially early on. As the patient improves, I look to get into some more normal shoe wear.
Dr. Sechrest: In terms of physical therapy, is this something that you teach them on your own during your office visit, or do you have the patient work with a physical therapist to actually become skilled at these exercises?
Dr. Fink: I usually begin with the patient on a self help program. Physical therapy for a lot of people can be quite expensive. I've, patients in my office can have co-payments of 45 to up to $100 per physical therapy visit. And so I try to reserve that for only the patients that don't um improve by themselves. And I think that 5 or 10 minutes of instruction and some instructional worksheets are often very helpful for that. Which I keep in my office.
Dr. Sechrest: How about medications? Any specific medications that you recommend for treatment of the pain associated with plantar fasciitis?
Dr. Fink: As far as oral medications are concerned, I believe that the anti-inflammatories are very helpful pain medicine, however, I don't believe, and I have not seen any evidence to say that these anti-inflammatories really do much to cure plantar fasciitis. Uh, but in the initial stages when the pain is quite severe, they can be quite helpful. As far as injectable medication, steroid injections are helpful, but I usually tell my patients that if you look at your outcome six months down the road, I don't think it really matters whether you get a steroid injection or not. But it is helpful if someone has a great deal of pain initiating therapy and uh making them more comfortable over the short period of time.
Dr. Sechrest: Any downsides to those injections? Do you find that some people actually are at high risk of complications or perhaps some untoward effect of the injections?
Dr. Fink: Uh, as you know, Randale, uh, it, no um, no medication is without complications, and steroid injections are no exception. Probably the most serious is uh, the complication of plantar fascia rupture. Which some people um, have said can occur up to ten percent of the time. But, uh, in my practice, now practicing over 12 years, I've only seen steroid induced plantar fascia rupture perhaps two or three times in my entire career. And I look for it pretty closely, and I follow my patients up frequently. Um, beyond that, some people will get a lot of injection-site pain immediately after the opera, immediately after the procedure. Uh, perhaps a quarter of them, about 10% of people will have pain that lasts up to a day or two. But, in general, they have fairly few complications. The only other ones that I can think of is that some people will have facial flushing after a steroid injection.
Dr. Sechrest: What makes you give up on conservative therapy and start talking to patients about the potential of some type of surgical intervention. How long do you normally continue conservative care or conservative therapy and what sort of tips you off that maybe this patient is not going to respond to conservative therapy.
Dr. Fink: Um, well, certainly the guidelines that the, um American Academy of Orthopaedic Surgeons have put down have suggested that you do conservative therapy for 4-6 months. In my own practice, I believe that at least 2 months is advisable. And then it really is a matter of whether my patient is improving. If uh, if I see a trend towards them getting better and better, I really stay away from surgery. Because I think that there are some downsides to surgery which are unfortunately hard to treat , so I really avoid it whenever possible.
Dr. Sechrest: What type of surgical procedures, once you get to that point, are you using now for the treatment of plantar fasciitis?
Dr. Fink: Well, I think I'll start with discussing the things that are beyond, that are more of less experimental at this point. Um, one of the things that is certainly out in the lay literature and had been looked at pretty closely by some investigators, it the use of platelet-rich plasma, which is a type of tissue product that is derived from blood. Basically what you do is you take blood, you spin it down in a centrifuge, and you separate the blood into it's component, components. The red blood cells, the plasma and what's called the platelet-rich plasma, which is the area that contains mainly platelets, but other things as well. Um, some practitioners have begun to inject this into people into the plantar fascii – plantar fascia, and there have been some reports that it has been helpful. I would have to say most of these reports have come from one investigator. And um, as of yet, I don't thi, I think that the jury is still out on whether platelet-rich plasma is going to be a good or a bad thing for it. On the one hand, it does contain these growth factors which are supposed to help with healing. On the other hand, these growth factors, when you inject platelet-rich plasma, you're really injecting a mixed bag or growth factors.
And all these growth factors do different things. The platelet-rich plasma that they inject it's very variable from one person to another what the con, what is in these uh, what is in these uh, in the stuff that you're injecting. And so, with all these variables, it's not something that I uh recommend. Um, there is, there are some investigators that have looked at injecting botulism toxin. The same thing that they use for cosmetic procedures into the plantar fascia. And it has shown some good results. And this is something that I have begun to use in my practice in patients that do not fare well with other more conservative treatment. After that, uh, surgical treatment involved generally cutting a piece of the plantar fascia. This is usually done through an open incision, or what's called endoscopically, meaning using a fiber optic camera to look at the plantar fascia as it's being cut. The goal is to cut 25 – 50% of the plantar fascia. Again, as I've said, the plantar fascia is a very important structure and removing all of it can cause some some very bad consequences. So, this is usually a procedure that takes 10 minutes of so. And the results are fairly good. About 70% of people will do well enough to be glad that they had the procedure. About 25% um, will really have not enough improvement, or no improvement at all. And then there is there is this other 5% that may actually get worse. And my suspicion is that perhaps in that 5% there are people that have had their plantar fascia over-cut or not cut enough. It really is kind of a judgment call, unfortunately.
Dr. Sechrest: And, any other complications that you worry about, I mean other than the typical possibility of infections, possibility of anesthesia complications? Anything else that surgery on the plantar fascia um can lead to that patients need to understand?
Dr. Fink: Well, probably the most common, especially in the open plantar fasciotomy is numbness on the heel. There is a nerve called the medial branch, the medial calcaneal branch of the posterior tibial nerve that runs very close to where the incision generally is. And if it is hid, then there will be a noticeable patch of numbness. Occasionally damage to this nerve can cause really fairly significant pain that will, that is quite a severe complication. I've also seen people develop a Reflex Sympathetic Dystrophy, which is uh, an extreme hypersensitivity of the heel after this operation. And it's unfortunately partially treatable, but a lot of times people continue to have significant heel pain after that procedure. Following that, uh, other complication, are related to the release of the plantar fascia like we talked about. If you look at scientific studies that have looked at people's feet after plantar fasciotomy, there is always a measurable lowering of their arch. Ah, whether this is going to lead to a fallen arch with time, no one knows. Sometimes the change in the shape of the foot and the bio-mechanics can lead to other joint pain. Some people have developed stress fractures, they've developed um, ah pains to the outside of their foot – something called lateral column syndrome. In addition, it would not surprise me if uh, if we had a set of plantar fasciotomy patients and looked at them over a period of 20 or 30 years, it would not surprise me if their incidence of developing arthritis in the middle of the foot was not increased. But, unfortunately, we have not had a study that looks at this yet.
Dr. Sechrest: In terms of after surgery, how long does it take a patient to get over this operation and essentially be done with this and back to what you would consider a stable normal condition after a surgical release of the plantar fascia?
Dr. Fink: Yeah, and unfortunately that is very variable. Some people seem to get over this in a couple weeks, I've seen people at two weeks follow-up that were noticeably different, or noticeably better. However, I've also seen people at 4-6 months follow-up that were still improving. Um, I would, I usually counsel my patients before doing this to expect six months at least before they have reached what we call maddux, maximum medical improvement. Or that point at which the recovery has really plateaued. And once again I would say 20-30% of people that undergo plantar fasciotomy will not feel that they have benefited from the procedure.
Dr. Sechrest: And just in terms of the percentage of people that you see that require surgery, out of all the people that come to you with plantar fasciitis, how, what percentage do you think end up needing an operation?
Dr. Fink: I would say that plantar fasciitis makes up about 30% of my patient um, load. Thirty per cent of the people that come in to see me, it's plan, have come in because of plantar fasciitis. And I operate on perhaps one a month. So, of the people that I see with plantar fasciitis, certainly less than 10% of them go on to uh, an operation.
Dr. Sechrest:: And you feel that most of these people have benefited, and actually get to a tolerable situation with conservative therapy?
Dr. Fink: Uh, my results have been pretty much in line with what other people have quoted – in that 85%, 85-90% of my patients either completely recover or recover to the point where they don't desire surgical treatment, in my experience.
Dr. Sechrest: So, the take home message I think, for patients, is that most of these people, the vast majority of people with plantar fasciitis are not going to need an operation, really ever, and are probably going to get to the point to where they're are either free of pain altogether or at least it's very tolerable.
Dr. Fink: Like other forms of connective tissue irritation that don't involve complete disruption of a structure, plantar fasciitis is primarily nonoperative.
Dr. Sechrest: One last question before we sort of close this discussion, and that is several years ago, people were using the same technology that's used on kidney stone, where they were using sound waves to try and treat things like plantar fasciitis and to some degree tennis elbow as well. Are we still using that technique to treat plantar fasciitis?
Dr. Fink: That's interesting. The procedure that you were talking about was called extracaporeal shock-wave treatment, or ESWT. A company that made that also called it the lithotripser, or the procedure lithotripsy. And it was FDA certified in about 2002 I believe. And I had used it with fairly good results. I think that it was a good portion, a good tool to use that did not involve cutting, but still required anesthesia. And basically what this machine would do is that it would um, uh take these ultrasonic pulses and more of less beat the heel and stimulate healing. Um, and it did work uh fairly well. Unfortunately these machines are not widely available. Um, there was a study that was, uh, that unfortunately was almost like the uh, putting the nail in the coffin, in the Journal of the American Medical Association, that um, looked at um lipotripsy in the heel and said that it didn't ah, work. However, there were some difficulties with the study in the type of lipo, the type of machine that they used was perhaps not the best one for treatment of heel problem. So, there are still studies that are coming out that said that this is an effective method of treatment, but unfortunately um, insurance doesn't cover it. It's been out for 10 years, and really hasn't caught on, and therefore it's not widely available.
Dr. Sechrest: What do you think the future holds for plantar fasciitis? Do you think that we're going to move towards treatments like the platelet, the platelet-rich plasma type treatments that try to stimulate healing without any type of surgical intervention?
Dr. Fink: I think that plantar fasciitis would be a great disease for treatment using biological processes like platelet-rich plasma, unfortunately we just don't know what combinations of growth factors are going to be effective for this. And I would have to say that at some point, my guess is that we're not going to hear as much about platelet-rich plasma and perhaps find the growth factor that will work for this instead of using this Hodge-podge of growth factors that may or may not contain substances that we really need to procure this. But I think that 10-10 years down the road that we're going to look at an injectable treatment that is going to do fairly well for this problem.
Dr. Sechrest: Well, I think that is good news for everybody that has either done plantar fascia surgery, or has undergone plantar fascia surgery because as you pointed out, it's one of those operations that you know it's not reaching that 90% success rate that that as surgeons we like to see. And clearly if you're a patient, you want to see a 90% success rate. So I definitely hope that some type of treatment comes along and look forward to hearing more about that. So as we close, I want to thanks you for a very comprehensive, thorough discussion of plantar fasciitis. And is there anything else that you think patients ought to know that are suffering from this disease that we have not talked about up to this point?
Dr. Fink: When you are approaching plantar fasciitis, I think that it's important that if you're getting to the point where it's becoming a significant problem, that you go to a physician that is ah, that is well-versed in all the treatments and all the methods of attacking plantar fasciitis because no one treatment right now works for everyone. And I think it's also important that you have a physician that is patient enough to help you through this uh and look towards uh several kind of creative ways of taking care of this. And really avoids using surgery when all else possible. There certainly are people that end up requiring surgery, but they're the vast minority of patient. And for the most part, it's always worthwhile to insure that you've completely investigated all avenues of treatment before you resort to that.
Dr. Sechrest: Well, I think that is excellent advice for everybody. I want to thank you again for joining us today, I look forward to further discussions in the future. Thanks a lot.
Dr. Fink: Thank you very much.