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Rupture of plantar fascia: Current standard of therapy
G Model FAS 1307 No. of Pages 5
Foot and Ankle Surgery xxx (2019) xxx–xxx
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Review
Rupture of plantar fascia: Current standard of therapy A systematic literature review Florian Debusa,* , Daphne Eschbachb , Steffen Ruchholtzb , Christian Dominik Peterleinb a b
Sportorthopädie Bruchsal, Bruchsal, Germany University of Giessen and Marburg, Department of Orthopeadics and Traumatology, Marburg, Germany
A R T I C L E I N F O
A B S T R A C T
Article history: Received 14 December 2018 Received in revised form 27 April 2019 Accepted 7 May 2019 Available online xxx
Background: The aim of the present systematic literature review is to give an overview of ruptures of the plantar fascia. For this purpose, a detailed description of the patient collective is provided. However, the focus of this analysis is based on the current therapy concepts. Based on the results the authors propose a standardized therapy concept. Material and Methods: A systematic literature review was performed using the PubMed database using the terms: ("rupture plantar fascia" OR "plantar fascia tear" OR "rupture plantar aponeurosis"). All articles published in the PubMed database until 07.11.2018 were included. The articles were evaluated with regard to three research question: (1) Which patients are affected by a rupture of the plantar fascia? (2) Which therapy concept was used to treat rupture of the plantar fascia? And (3) which result was achieved and how was this measured? Results: A total of 78 studies were identified, of which the full text of 17 were analysed. 12 publications were cases reports, 5 studies were retrospective analyses. Data from 124 patients could be included. The average age of patients was 39.6 years. In 63.2% (n = 12) of the studies, patients with a high level of athletic activity or even professional athletes were analyzed. 94.4% of all patients were treated conservatively. The average duration of immobilization in a rigid walker was 2.6 weeks. In the majority of cases, pain-adapted weight-bearing was allowed in the rigid walker. Conclusion: There are few available studies concerning the rupture of plantar fascia. The quality of data is poor. The maximum duration of immobilization of 3 weeks in a rigid walker with pain-adapted weightbearing appears to be the most applied therapy concept. Further studies are needed to evaluate the efficacy of the therapy and to optimize the therapy concept. © 2019 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Rupture plantar fascia Plantar fascia tear Heel pain Treatment Review
Contents 1. 2. 3.
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Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Material and methods . . . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Basic data . . . . . . . . . . . . . . . . . . . . . . . . . . Treatment concepts . . . . . . . . . . . . . . . . . . 3.2. Return to sports and return to full activity 3.3. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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1. Introduction
* Corresponding author at: Sportorthopädie Bruchsal, Stadtgrabenstraße 30A, 76646 Bruchsal. E-mail address: debus.fl[email protected] (F. Debus).
Plantar heel pain is a widespread disorder with which orthopaedists and surgeons are often confronted in daily business. About 15% of all consultations in foot and ankle surgery concern plantar heel pain [1]. The majority of these cases are based on
https://doi.org/10.1016/j.fas.2019.05.006 1268-7731/© 2019 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: F. Debus, et al., Rupture of plantar fascia: Current standard of therapy, Foot Ankle Surg (2019), https://doi.org/ 10.1016/j.fas.2019.05.006
G Model FAS 1307 No. of Pages 5
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plantar fasciitis. The role of plantar fascia in plantar heel pain is increasingly being analysed and understood [2,3]. In comparison, the rupture of the plantar fascia is rather uncommon and is not always considered in differential diagnosis. Ruptures of the plantar fascia can be divided into so-called acute-on-chronic cases and acute ruptures. In acute-on chronic cases, the fascia is ruptured after a history of plantar fasciitis. These cases are also designated as a plantar fascia tear. Many patients reported previous injections of glucocorticosteroids. Approximately 12% of all patients with plantar fasciitis have a plantar fascial tear [4]. In contrast, acute or spontaneous rupture leads to damage of the plantar fascia without previous symptoms. This often affects competitive or amateur athletes. It can be presumed that real number of plantar fasica ruptures is significantly higher, due to a high rate of misdiagnoses. Accordingly, only a few cases of ruptures of the plantar fascia are described in the current literature. There are no consistent therapy concepts and the treatments in the existing case reports differ considerably with regard to the duration and type of immobilization as well as the weight-bearing of the affected extremity [5,6]. The aim of this study is to characterize patients affected and to provide a survey of available treatment options in order to be able to define a therapy recommendation in the future. 2. Material and methods The literature search included acute ruptures of the plantar fascia as well as tears of the plantar fascia after a history of plantar fasciitis, so called plantar fasical tears. A systematic literature review was performed by the first author, which included all articles published in the PubMed database up until 07.11.2018. The articles were evaluated with regard to the following research question: Which patients are affected by a rupture of the plantar fascia? Which therapy concept was used to treat rupture of the plantar fascia? Which result was achieved and how was this measured? The following search terms were used: ("rupture plantar fascia" OR "plantar fascia tear" OR "rupture plantar aponeurosis") Only English articles were included in the literature review. After reviewing the all abstracts, the relevant works were read in full text and analysed with regard to the questions posed. 3. Results A total of 78 abstracts could be identified in the literature review. Of these, 59 articles could be excluded on the basis of the abstract or the title. Most of these papers had a focus on plantar fasciitis, one of them was excluded because of language. Biomechanical studies and articles focused on diagnostics and imaging were also excluded. For 2 of the 19 papers no full texts were available, so that the analysis of epidemiology and therapy standards is based upon 17 publications. These were published between 1978 and 2018. The majority of articles were case reports or case series (n = 12). Some retrospective analyses were also published (n = 5). Prospective studies have not yet been published. An overview of the publications included can be found in Table 1. 3.1. Basic data A total of 124 patients with plantar fascial injuries were identified in the included studies. 16.3% (n = 20) of the patients suffered from an acute rupture of the plantar fascia, whereas 69.4% (n = 86) suffered from an acute on chronic tear. The remaining
patients could not be assigned. A total of 61.5% of the patients were male. The average age was 39.6 years. In 63.2% (n = 12) of the studies, patients with a high level of athletic activity or even professional athletes were analyzed. In 10.5% (n = 2) of the studies, patients were classified as low activity patients. In the remaining studies, no statement was made about the patient's activity. 3.2. Treatment concepts Looking at the available studies with regard to the treatment, the therapy concept for a total of 36 patients could be reconstructed. 5.6% (n = 2) had an operation with open surgical revision of the plantar fascia and resection of the scarfs and release of the fascia. However, 94.4% (n = 34), most of the patients was treated conservatively. With regard to the single studies, the information regarding the therapy concept differs a lot. Sufficient data to understand and reproduce the therapy with regard to immobilization, use of cast or walker, the duration and allowed weight-bearing were provided by 35.3% (n = 6) of all studies. 41.2% (n = 7) of the studies provided partial information. The remaining 23.1% (n = 4) of the publications did not deal with therapy in detail. 5 of the 6 studies included information of the therapy concept. The patients were immobilized in a cast or walker for a period between 1 and 6 weeks. The average time of immobilization was 2.6 weeks. In 4 of 6 therapy concepts, pain-adapted weight-bearing of the affected extremity was allowed. One study used a combined therapy concept of partial weight-bearing followed by painadapted weight-bearing. 3.3. Return to sports and return to full activity Trying to report the outcome of the affected patients non of the studies used a clinical scale. Sometimes imaging was used but this was not reported constantly. Regarding the amount of time before returning to the previous level of sporting performance, there was a large span. The period varied between 3 and 64 weeks. On average, the patients were performing at their former level of activity after 14.7 weeks. Most patients were pain-free in their activities of daily life much earlier. 4. Discussion For the first time, this work offers a systematic review of the current literature regarding the treatment of the rupture of the plantar fascia. Plantar heel pain and thus a plantar fascia problem are a frequent reason for consultations with regards to foot and ankle surgery. It is often the mechanical strain which leads to pathological conditions, Foot malpositions can also lead to an altered biomechanics of the entire foot [2]. Especially amateur athletes with a high activity level and competitive athletes are often affected by a disease of the plantar fascia [7–11]. In many cases, patients were not able to participate in sporting activities for a long period of time. This effect is supported by our analysis of the basic data. With an average age of 39.6 years, young and active people are particularly affected. Return to the former level of activity takes more than three months. Our literature review was able to show that the quality of data is very poor. Only a few studies have been published. The majority of these papers are case reports or small case series. Currently only five retrospective studies are available. We were not able to identify any prospective studies. This certainly leads to a great uncertainty in the treatment of the affected patients. It is important to distinguish an acute rupture from an acute-on-chronic tear in the clinical treatment of patients [12–16]. This is usually possible without any problems. Patients with an acute-on-chronic tear often report a long history of pain. Often they have received corticosteroid injections. Lee et al.
Please cite this article in press as: F. Debus, et al., Rupture of plantar fascia: Current standard of therapy, Foot Ankle Surg (2019), https://doi.org/ 10.1016/j.fas.2019.05.006
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Author and Year
Level of evidence
Topic
Servey et al., 2018 [20]
Case report [V]
Acute rupture
Öztürk et al., 2017 [23] Gitto et al. [12] Pascoe et al., 2016 [22]
Case report [V] Case report [V] Case report [V]
Acute on chronic tear Acute rupture Acute rupture
Suzue et al., 2014 [11]
Case report [V]
Acute on chronic tear
Louwers et al., 2010 [14]
Case report [V]
Acute rupture
Lun et al., 1999 [15] Rolf et al., 1997 [16]
Case report [[V] Case series [IV] Two cases
Acute rupture Acute rupture Acute on chronic tear
Available information about therapy 2 weeks controlled ankle movement (CAM) walker boot with full weight-bearing, followed by a commercial ankle brace. Single injection of platelet rich plasma (PRP). Send to physiotherapist. Joint immobilization, stretching, after that pain free weight-bearing exercises. Partial weight-bearing and using crutches for 2 weeks, after that full weight-bearing using rocker bottom shoes. PRP 4 and 8 weeks after injury. Aircast boot for 3 weeks, followed by stretching and exercises. Taping, partial weight-bearing and using of night splint. Shoes with arch supports and physiotherapy.
Results Return to full activity after 5 weeks.
Pain on VAS was reduced from 10 to 2. No information. Return to soccer after 16 months. Pain free in daily activity after 2 months. Return to sports after 3 months. Return to soccer after 5 months. Return to full activities after 5 weeks. Pain free after 3 weeks. Return to football after 5 weeks. Pain free after 6 months. Pain free after 22 months.
Kruse et al., 1995 [21]
Case report [V]
Acute rupture
Ahstrom et al., 1988 [13] Herrick et al., 1983 [8]
Case series [IV] Case report [V]
Acute on chronic tear Acute rupture
2 weeks below knee cast, after that shoe arch support and physiotherapy, crutches with pain-adapted weight-bearing. After 6 months operation with insertion of medial plantar fascia. Initial elastic wrap, after that fibreglass cast and crutches for 5 days with full weight-bearing. Lessened activity Compression bandage and weight-bearing as tolerable.
Leach et al., 1978 [9]
Case series [IV] Two cases
Acute rupture
Felt pad beneath the arch without sports.
Acute rupture
Felt pad beneath the arch without sports, followed by surgery.
No information.
Conclusion Only corticosteroid injection as independent risk factor. Age, gender, body mass index (BMI) and pain are no risk factors. Common injury in elite athletes.
Author and Year Lee et al., 2014 [4]
Level of evidence Retrospective comparative study [III]
Topic Acute on chronic tear
Results MRI in 286 patients with plantar fasciitis. 35 with and 251 without acute on chronic tear.
Elias et al., 2013 [7]
Retrospective analyses [III]
Kim et al., 2012 [17]
Retrospective analyses [III]
Acute rupture and acute on chronic tear Acute on chronic tear
Saxena et al., 2004 [10]
Retrospective analyses [III]
Acute rupture and acute on chronic tear
Sellman et al., 1994 [18]
Retrospective analyses [III]
Acute on chronic tear
10 acute ruptures and 2 acute on chronic tears in all professional sportsmen at the Olympics 2012. Only 4 of 120 patients had a chronic tear in MRI after corticosteroid injection. Average BMI of these patients was 38,6. 18 athletes were treated with 2 to 3 weeks below knee or high-top boot with non-weight-bearing followed by additional 2 to 3 weeks of weight-bearing in the boot. 37 of 37 patients with acute on chronic tear had former corticosteroid injections in MRI.
Return to running after 13 days. Return to basketball after 21 days. All patients pain free after 3 to 4 weeks. Return to normal walking after one week. Return to tennis after 3 weeks. Pain free after 2 weeks.
F. Debus et al. / Foot and Ankle Surgery xxx (2019) xxx–xxx
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Table 1 Included studies.
Corticosteroid injections appear to be no risk factor.
Return to activity after 2 to 26 weeks. No further complications. Corticosteroid injections as risk factor for acute on chronic tear.
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were able to show that 12% of all patients with plantar fasciitis also have a plantar fascial tear [4]. The literature provides different conclusions regarding the role of corticosteroid injections. While Sellman et al. were able to detect plantar fascial tears after corticosteroid injection in 100% of cases in the MRI, Kim et al. reported steroid injections only in 3.3% of cases [17,18]. Kim et al. were able to identify a high body-mass-index as a risk factor for plantar fascia tear. Younger athletes are often affected by an acute rupture. Therefore, this type of injury must be taken into consideration in the case of a typical history and the clinical examination. History and clinical examination are important criteria to distinguish between acute and chronic rupture. While acute ruptures are often accompanied by a typical "pop-sound" and a plantar hematoma, these signs are missing in acute-on-chronic ruptures. Another clinical sign is the limited tiptoe position. Ultrasound or magnetic resonance imaging (MRI) are the most important tools for further diagnosis. An ultrasound examination can confirm the diagnosis. MRI reliably detects the lesion [19]. Typical MRI findings for the different types of ruptures are shown in Figs. 1 and 2. As already mentioned, in most of studies the therapy concept cannot be sufficiently reproduced. Since there is currently no guideline or other recommendation for the treatment of the rupture of the plantar fascia, large differences in the treatment strategy are not surprising. Most patients were managed conservative. Surgery was performed only in a few cases. Most authors report the use of a rigid walker for immobilization [20]. This was worn by the patients for from 1 to 6 weeks [10,21]. A maximum duration of 3 weeks seems to be sufficient with regard to the expected time in which pain alleviation is achieved. The period of immobilization should be as short as possible, especially regarding the need to perform thrombosis prophylaxis with all known risks. There are also great differences in the individual therapy concepts with regard to the permitted weight-bearing. These range from non-weight-bearing to pain-adapted or fullweight-bearing [11,22]. As there are no relevant differences in the results regarding return to sports, the most convenient solution can be chosen with regard to the practicability for the patient. Physiotherapy seems to have been used in many cases and has an important role to play in the treatment. Newer procedures such as the injection of platelet-rich plasma (PRP) or shockwave are described in two case reports [11,23]. PRP and shockwave therapy are of increasing interest in the treatment of plantar fasciitis, however the role of those concepts in the treatment of a plantar fascia tear is not defined [24–27]. To summarise all the available publications, the authors consider the following therapy concept to be useful:
Fig. 2. Acute-on-chronic rupture of the proximal part of plantar fascia in MRI.
Immobilization of the affected foot in the rigid walker for 2 weeks. Maximum extension of immobilization to a total of 3 weeks if pain does not allow walking in normal shoes after 2 weeks. Pain-adapted weight-bearing should be allowed in the rigid walker. Thrombosis prophylaxis according to current guidelines. Complementary therapies such as NSAID, physiotherapy with a focus on eccentric training. Physiotherapy is recommended in 10 studies. Immobilization for 2–3 weeks is supported by 7 studies. The proposed therapy concept should be analysed for its suitability in everyday clinical practice. Prospective studies would of course be desirable, but would be difficult due to the small number of cases Conflict of interest We confirm that this manuscript has not been published elsewhere and is not under consideration by any other journal. All of the authors agree with submission to Foot and Ankle Surgery. We have no conflict of interest to declare. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References
Fig. 1. Acute rupture of the distal part of plantar fascia in MRI.
[1] Irving DB, Cook JL, Menz HB. Factors associated with chronic plantar heel pain: a systematic review. J Sci Med Sport 2006;9(11). [2] Guo J, Liu X, Ding X, Wang L, Fan Y. Biomechanical and mechanical behavior of the plantar fascia in macro and micro structures. J Biomech 2018;76(160). [3] Guo JC, Wang LZ, Mo ZJ, Chen W, Fan YB. Biomechanical analysis of suture locations of the distal plantar fascia in partial foot. Int Orthop 2015;39(2373). [4] Lee HS, Choi YR, Kim SW, Lee JY, Seo JH, Jeong JJ. Risk factors affecting chronic rupture of the plantar fascia. Foot Ankle Int 2014;35(258). [5] Kaufmann J, Strasser R, Peepschläger B, Erhardt J. Ruptur der plantaren Faszie. Schweiz Med Forum 2017;17(818). [6] Walther M. Fersenschmerz: Einriss der plantaren Platte. Orthopädie Aktuell 2016;8(1). [7] Elias DA, Carne A, Bethapudi S, Engebretsen L, Budgett R, O’Connor P. Imaging of plantar fascia and Achilles injuries undertaken at the London Olympics. Skeletal Radiol 2012;42(1645).
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F. Debus et al. / Foot and Ankle Surgery xxx (2019) xxx–xxx [8] Herrick RT, Herrick S. Rupture of the plantar fascia in a middle-aged tennis player. A case report. Am J Sports Med 1983;11(95). [9] Leach R, Jones R, Silva T. Rupture of the plantar fascia in athletes. J Bone Joint Surg Am 1978;60(537). [10] Saxena A, Fullem B. Plantar fascia ruptures in athletes. Am J Sports Med 2004;32(662). [11] Suzue N, Iwame T, Kato K, Takao S, Tateishi T, Takeda Y, Hamada D, Goto T, Takata Y, Matsuura T, Sairyo K. Plantar fascia rupture in a professional soccer player. J Med Invest 2014;61(413). [12] Gitto S, Draghi F. Spontaneous distal rupture of the plantar fascia. J Clin Ultrasound 2018;46(419). [13] Ahstrom Jr. JP. Spontaneous rupture of the plantar fascia. Am J Sports Med 1988;16(306). [14] Louwers MJ, Sabb B, Pangilinan PH. Ultrasound evaluation of a spontaneous plantar fascia rupture. Am J Phys Med Rehabil 2010;89(941). [15] Lun V, Meeuwisse W, Vellet D. Spontaneous rupture of plantar fascia. Clin J Sport Med 1999;9(48). [16] Rolf C, Guntner P, Ericsater J, Turan I. Plantar fascia rupture: diagnosis and treatment. J Foot Ankle Surg 1997;36(112). [17] Kim C, Cashdollar MR, Mendicino RW, Catanzariti AR, Fuge L. Incidence of plantar fascia ruptures following corticosteroid injection. Foot Ankle Spec 2010;3(335). [18] Sellman JR. Plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int 1994;15(376).
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[19] Bicer M, Hocaoglu E, Aksoy S, Inci E, Aktas I. Assessment of the Efficacy of Extracorporeal Shockwave Therapy for Plantar Fasciitis with Magnetic Resonance Imaging Findings. J Am Podiatr Med Assoc 2018;108(100). [20] Servey JT, Jonas C. Plantar Fascia Rupture: Ultrasound to Facilitate Recognition. J Am Board Fam Med 2018;31(282). [21] Kruse RJ, McCoy RL, Erickson T. Diagnosing Plantar Fascia Rupture. Phys Sportsmed 1995;23(65). [22] Pascoe SC, Mazzola TJ. Acute Medial Plantar Fascia Tear. J Orthop Sports Phys Ther 2016;46(495). [23] Ozturk GT, Ulasli AM. Ultrasound-Guided Platelet-Rich Plasma Injection in a Patient with a Plantar Fascia Tear. J Am Podiatr Med Assoc 2017;107(565). [24] Franceschi F, Papalia R, Franceschetti E, Paciotti M, Maffulli N, Denaro V. Platelet-rich plasma injections for chronic plantar fasciopathy: a systematic review. Br Med Bull 2014;112(83). [25] Hsiao MY, Hung CY, Chang KV, Chien KL, Tu YK, Wang TG. Comparative effectiveness of autologous blood-derived products, shock-wave therapy and corticosteroids for treatment of plantar fasciitis: a network meta-analysis. Rheumatology (Oxford) 1735;54:2015. [26] Singh P, Madanipour S, Bhamra JS, Gill I. A systematic review and metaanalysis of platelet-rich plasma versus corticosteroid injections for plantar fasciopathy. Int Orthop 2017;41(1169). [27] Wilson JJ, Lee KS, Miller AT, Wang S. Platelet-rich plasma for the treatment of chronic plantar fasciopathy in adults: a case series. Foot Ankle Spec 2014;7(61).
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Foot and Ankle Surgery xxx (2019) xxx–xxx
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Review
Rupture of plantar fascia: Current standard of therapy A systematic literature review Florian Debusa,* , Daphne Eschbachb , Steffen Ruchholtzb , Christian Dominik Peterleinb a b
Sportorthopädie Bruchsal, Bruchsal, Germany University of Giessen and Marburg, Department of Orthopeadics and Traumatology, Marburg, Germany
A R T I C L E I N F O
A B S T R A C T
Article history: Received 14 December 2018 Received in revised form 27 April 2019 Accepted 7 May 2019 Available online xxx
Background: The aim of the present systematic literature review is to give an overview of ruptures of the plantar fascia. For this purpose, a detailed description of the patient collective is provided. However, the focus of this analysis is based on the current therapy concepts. Based on the results the authors propose a standardized therapy concept. Material and Methods: A systematic literature review was performed using the PubMed database using the terms: ("rupture plantar fascia" OR "plantar fascia tear" OR "rupture plantar aponeurosis"). All articles published in the PubMed database until 07.11.2018 were included. The articles were evaluated with regard to three research question: (1) Which patients are affected by a rupture of the plantar fascia? (2) Which therapy concept was used to treat rupture of the plantar fascia? And (3) which result was achieved and how was this measured? Results: A total of 78 studies were identified, of which the full text of 17 were analysed. 12 publications were cases reports, 5 studies were retrospective analyses. Data from 124 patients could be included. The average age of patients was 39.6 years. In 63.2% (n = 12) of the studies, patients with a high level of athletic activity or even professional athletes were analyzed. 94.4% of all patients were treated conservatively. The average duration of immobilization in a rigid walker was 2.6 weeks. In the majority of cases, pain-adapted weight-bearing was allowed in the rigid walker. Conclusion: There are few available studies concerning the rupture of plantar fascia. The quality of data is poor. The maximum duration of immobilization of 3 weeks in a rigid walker with pain-adapted weightbearing appears to be the most applied therapy concept. Further studies are needed to evaluate the efficacy of the therapy and to optimize the therapy concept. © 2019 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Rupture plantar fascia Plantar fascia tear Heel pain Treatment Review
Contents 1. 2. 3.
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Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Material and methods . . . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Basic data . . . . . . . . . . . . . . . . . . . . . . . . . . Treatment concepts . . . . . . . . . . . . . . . . . . 3.2. Return to sports and return to full activity 3.3. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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1. Introduction
* Corresponding author at: Sportorthopädie Bruchsal, Stadtgrabenstraße 30A, 76646 Bruchsal. E-mail address: debus.fl[email protected] (F. Debus).
Plantar heel pain is a widespread disorder with which orthopaedists and surgeons are often confronted in daily business. About 15% of all consultations in foot and ankle surgery concern plantar heel pain [1]. The majority of these cases are based on
https://doi.org/10.1016/j.fas.2019.05.006 1268-7731/© 2019 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: F. Debus, et al., Rupture of plantar fascia: Current standard of therapy, Foot Ankle Surg (2019), https://doi.org/ 10.1016/j.fas.2019.05.006
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plantar fasciitis. The role of plantar fascia in plantar heel pain is increasingly being analysed and understood [2,3]. In comparison, the rupture of the plantar fascia is rather uncommon and is not always considered in differential diagnosis. Ruptures of the plantar fascia can be divided into so-called acute-on-chronic cases and acute ruptures. In acute-on chronic cases, the fascia is ruptured after a history of plantar fasciitis. These cases are also designated as a plantar fascia tear. Many patients reported previous injections of glucocorticosteroids. Approximately 12% of all patients with plantar fasciitis have a plantar fascial tear [4]. In contrast, acute or spontaneous rupture leads to damage of the plantar fascia without previous symptoms. This often affects competitive or amateur athletes. It can be presumed that real number of plantar fasica ruptures is significantly higher, due to a high rate of misdiagnoses. Accordingly, only a few cases of ruptures of the plantar fascia are described in the current literature. There are no consistent therapy concepts and the treatments in the existing case reports differ considerably with regard to the duration and type of immobilization as well as the weight-bearing of the affected extremity [5,6]. The aim of this study is to characterize patients affected and to provide a survey of available treatment options in order to be able to define a therapy recommendation in the future. 2. Material and methods The literature search included acute ruptures of the plantar fascia as well as tears of the plantar fascia after a history of plantar fasciitis, so called plantar fasical tears. A systematic literature review was performed by the first author, which included all articles published in the PubMed database up until 07.11.2018. The articles were evaluated with regard to the following research question: Which patients are affected by a rupture of the plantar fascia? Which therapy concept was used to treat rupture of the plantar fascia? Which result was achieved and how was this measured? The following search terms were used: ("rupture plantar fascia" OR "plantar fascia tear" OR "rupture plantar aponeurosis") Only English articles were included in the literature review. After reviewing the all abstracts, the relevant works were read in full text and analysed with regard to the questions posed. 3. Results A total of 78 abstracts could be identified in the literature review. Of these, 59 articles could be excluded on the basis of the abstract or the title. Most of these papers had a focus on plantar fasciitis, one of them was excluded because of language. Biomechanical studies and articles focused on diagnostics and imaging were also excluded. For 2 of the 19 papers no full texts were available, so that the analysis of epidemiology and therapy standards is based upon 17 publications. These were published between 1978 and 2018. The majority of articles were case reports or case series (n = 12). Some retrospective analyses were also published (n = 5). Prospective studies have not yet been published. An overview of the publications included can be found in Table 1. 3.1. Basic data A total of 124 patients with plantar fascial injuries were identified in the included studies. 16.3% (n = 20) of the patients suffered from an acute rupture of the plantar fascia, whereas 69.4% (n = 86) suffered from an acute on chronic tear. The remaining
patients could not be assigned. A total of 61.5% of the patients were male. The average age was 39.6 years. In 63.2% (n = 12) of the studies, patients with a high level of athletic activity or even professional athletes were analyzed. In 10.5% (n = 2) of the studies, patients were classified as low activity patients. In the remaining studies, no statement was made about the patient's activity. 3.2. Treatment concepts Looking at the available studies with regard to the treatment, the therapy concept for a total of 36 patients could be reconstructed. 5.6% (n = 2) had an operation with open surgical revision of the plantar fascia and resection of the scarfs and release of the fascia. However, 94.4% (n = 34), most of the patients was treated conservatively. With regard to the single studies, the information regarding the therapy concept differs a lot. Sufficient data to understand and reproduce the therapy with regard to immobilization, use of cast or walker, the duration and allowed weight-bearing were provided by 35.3% (n = 6) of all studies. 41.2% (n = 7) of the studies provided partial information. The remaining 23.1% (n = 4) of the publications did not deal with therapy in detail. 5 of the 6 studies included information of the therapy concept. The patients were immobilized in a cast or walker for a period between 1 and 6 weeks. The average time of immobilization was 2.6 weeks. In 4 of 6 therapy concepts, pain-adapted weight-bearing of the affected extremity was allowed. One study used a combined therapy concept of partial weight-bearing followed by painadapted weight-bearing. 3.3. Return to sports and return to full activity Trying to report the outcome of the affected patients non of the studies used a clinical scale. Sometimes imaging was used but this was not reported constantly. Regarding the amount of time before returning to the previous level of sporting performance, there was a large span. The period varied between 3 and 64 weeks. On average, the patients were performing at their former level of activity after 14.7 weeks. Most patients were pain-free in their activities of daily life much earlier. 4. Discussion For the first time, this work offers a systematic review of the current literature regarding the treatment of the rupture of the plantar fascia. Plantar heel pain and thus a plantar fascia problem are a frequent reason for consultations with regards to foot and ankle surgery. It is often the mechanical strain which leads to pathological conditions, Foot malpositions can also lead to an altered biomechanics of the entire foot [2]. Especially amateur athletes with a high activity level and competitive athletes are often affected by a disease of the plantar fascia [7–11]. In many cases, patients were not able to participate in sporting activities for a long period of time. This effect is supported by our analysis of the basic data. With an average age of 39.6 years, young and active people are particularly affected. Return to the former level of activity takes more than three months. Our literature review was able to show that the quality of data is very poor. Only a few studies have been published. The majority of these papers are case reports or small case series. Currently only five retrospective studies are available. We were not able to identify any prospective studies. This certainly leads to a great uncertainty in the treatment of the affected patients. It is important to distinguish an acute rupture from an acute-on-chronic tear in the clinical treatment of patients [12–16]. This is usually possible without any problems. Patients with an acute-on-chronic tear often report a long history of pain. Often they have received corticosteroid injections. Lee et al.
Please cite this article in press as: F. Debus, et al., Rupture of plantar fascia: Current standard of therapy, Foot Ankle Surg (2019), https://doi.org/ 10.1016/j.fas.2019.05.006
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Author and Year
Level of evidence
Topic
Servey et al., 2018 [20]
Case report [V]
Acute rupture
Öztürk et al., 2017 [23] Gitto et al. [12] Pascoe et al., 2016 [22]
Case report [V] Case report [V] Case report [V]
Acute on chronic tear Acute rupture Acute rupture
Suzue et al., 2014 [11]
Case report [V]
Acute on chronic tear
Louwers et al., 2010 [14]
Case report [V]
Acute rupture
Lun et al., 1999 [15] Rolf et al., 1997 [16]
Case report [[V] Case series [IV] Two cases
Acute rupture Acute rupture Acute on chronic tear
Available information about therapy 2 weeks controlled ankle movement (CAM) walker boot with full weight-bearing, followed by a commercial ankle brace. Single injection of platelet rich plasma (PRP). Send to physiotherapist. Joint immobilization, stretching, after that pain free weight-bearing exercises. Partial weight-bearing and using crutches for 2 weeks, after that full weight-bearing using rocker bottom shoes. PRP 4 and 8 weeks after injury. Aircast boot for 3 weeks, followed by stretching and exercises. Taping, partial weight-bearing and using of night splint. Shoes with arch supports and physiotherapy.
Results Return to full activity after 5 weeks.
Pain on VAS was reduced from 10 to 2. No information. Return to soccer after 16 months. Pain free in daily activity after 2 months. Return to sports after 3 months. Return to soccer after 5 months. Return to full activities after 5 weeks. Pain free after 3 weeks. Return to football after 5 weeks. Pain free after 6 months. Pain free after 22 months.
Kruse et al., 1995 [21]
Case report [V]
Acute rupture
Ahstrom et al., 1988 [13] Herrick et al., 1983 [8]
Case series [IV] Case report [V]
Acute on chronic tear Acute rupture
2 weeks below knee cast, after that shoe arch support and physiotherapy, crutches with pain-adapted weight-bearing. After 6 months operation with insertion of medial plantar fascia. Initial elastic wrap, after that fibreglass cast and crutches for 5 days with full weight-bearing. Lessened activity Compression bandage and weight-bearing as tolerable.
Leach et al., 1978 [9]
Case series [IV] Two cases
Acute rupture
Felt pad beneath the arch without sports.
Acute rupture
Felt pad beneath the arch without sports, followed by surgery.
No information.
Conclusion Only corticosteroid injection as independent risk factor. Age, gender, body mass index (BMI) and pain are no risk factors. Common injury in elite athletes.
Author and Year Lee et al., 2014 [4]
Level of evidence Retrospective comparative study [III]
Topic Acute on chronic tear
Results MRI in 286 patients with plantar fasciitis. 35 with and 251 without acute on chronic tear.
Elias et al., 2013 [7]
Retrospective analyses [III]
Kim et al., 2012 [17]
Retrospective analyses [III]
Acute rupture and acute on chronic tear Acute on chronic tear
Saxena et al., 2004 [10]
Retrospective analyses [III]
Acute rupture and acute on chronic tear
Sellman et al., 1994 [18]
Retrospective analyses [III]
Acute on chronic tear
10 acute ruptures and 2 acute on chronic tears in all professional sportsmen at the Olympics 2012. Only 4 of 120 patients had a chronic tear in MRI after corticosteroid injection. Average BMI of these patients was 38,6. 18 athletes were treated with 2 to 3 weeks below knee or high-top boot with non-weight-bearing followed by additional 2 to 3 weeks of weight-bearing in the boot. 37 of 37 patients with acute on chronic tear had former corticosteroid injections in MRI.
Return to running after 13 days. Return to basketball after 21 days. All patients pain free after 3 to 4 weeks. Return to normal walking after one week. Return to tennis after 3 weeks. Pain free after 2 weeks.
F. Debus et al. / Foot and Ankle Surgery xxx (2019) xxx–xxx
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Table 1 Included studies.
Corticosteroid injections appear to be no risk factor.
Return to activity after 2 to 26 weeks. No further complications. Corticosteroid injections as risk factor for acute on chronic tear.
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were able to show that 12% of all patients with plantar fasciitis also have a plantar fascial tear [4]. The literature provides different conclusions regarding the role of corticosteroid injections. While Sellman et al. were able to detect plantar fascial tears after corticosteroid injection in 100% of cases in the MRI, Kim et al. reported steroid injections only in 3.3% of cases [17,18]. Kim et al. were able to identify a high body-mass-index as a risk factor for plantar fascia tear. Younger athletes are often affected by an acute rupture. Therefore, this type of injury must be taken into consideration in the case of a typical history and the clinical examination. History and clinical examination are important criteria to distinguish between acute and chronic rupture. While acute ruptures are often accompanied by a typical "pop-sound" and a plantar hematoma, these signs are missing in acute-on-chronic ruptures. Another clinical sign is the limited tiptoe position. Ultrasound or magnetic resonance imaging (MRI) are the most important tools for further diagnosis. An ultrasound examination can confirm the diagnosis. MRI reliably detects the lesion [19]. Typical MRI findings for the different types of ruptures are shown in Figs. 1 and 2. As already mentioned, in most of studies the therapy concept cannot be sufficiently reproduced. Since there is currently no guideline or other recommendation for the treatment of the rupture of the plantar fascia, large differences in the treatment strategy are not surprising. Most patients were managed conservative. Surgery was performed only in a few cases. Most authors report the use of a rigid walker for immobilization [20]. This was worn by the patients for from 1 to 6 weeks [10,21]. A maximum duration of 3 weeks seems to be sufficient with regard to the expected time in which pain alleviation is achieved. The period of immobilization should be as short as possible, especially regarding the need to perform thrombosis prophylaxis with all known risks. There are also great differences in the individual therapy concepts with regard to the permitted weight-bearing. These range from non-weight-bearing to pain-adapted or fullweight-bearing [11,22]. As there are no relevant differences in the results regarding return to sports, the most convenient solution can be chosen with regard to the practicability for the patient. Physiotherapy seems to have been used in many cases and has an important role to play in the treatment. Newer procedures such as the injection of platelet-rich plasma (PRP) or shockwave are described in two case reports [11,23]. PRP and shockwave therapy are of increasing interest in the treatment of plantar fasciitis, however the role of those concepts in the treatment of a plantar fascia tear is not defined [24–27]. To summarise all the available publications, the authors consider the following therapy concept to be useful:
Fig. 2. Acute-on-chronic rupture of the proximal part of plantar fascia in MRI.
Immobilization of the affected foot in the rigid walker for 2 weeks. Maximum extension of immobilization to a total of 3 weeks if pain does not allow walking in normal shoes after 2 weeks. Pain-adapted weight-bearing should be allowed in the rigid walker. Thrombosis prophylaxis according to current guidelines. Complementary therapies such as NSAID, physiotherapy with a focus on eccentric training. Physiotherapy is recommended in 10 studies. Immobilization for 2–3 weeks is supported by 7 studies. The proposed therapy concept should be analysed for its suitability in everyday clinical practice. Prospective studies would of course be desirable, but would be difficult due to the small number of cases Conflict of interest We confirm that this manuscript has not been published elsewhere and is not under consideration by any other journal. All of the authors agree with submission to Foot and Ankle Surgery. We have no conflict of interest to declare. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References
Fig. 1. Acute rupture of the distal part of plantar fascia in MRI.
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