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Is there any literature on the prevalance of Plantar Fasciitis occurring as a complication of a achilles tendon rupture. I have a patient who rupture his TA back in October 2008. Initially treated by Plaster for the first three weeks , then moon boot for the next 2 months then heel raises externally on his shoes and Physio. Physio comprised of ultrasound,massage and calf raises. Over the last 6 weeks as his activity increased he has developed plantar facial pain.
He is covered by our accident insurance cover But our provider of this insurance is disputing the claim for plantar fasciitis saying it is a gradual process injury. In my first correspondence to them regarding this I made the comment that "I have seen plantar fasciitis conditions occurring post Achilles tendon ruptures due to the compensatory process within the foot" I mean that due to the lack of ankle dorsiflexion the foot compensates by pronating producing the plantar fasciitis.
This insurance company's medical advisor has been unable to find any literature supporting this. They what me to provided the literature to support this claim.
My comment was made on an understanding of lower limb biomechanic's and observations made in clinical practise.
Therefore, Can anybody provide me with any literature or reference to literature that will help support this claim so I can correlate it and send it on to the insurance company.
Much appreciated

Ian Graham

What you haven't mentioned is...
The plantar fascia, by virtue of the necessary post-surgical protection, entered an artificial period of zero tension for a period of time (at least 3 weeks). Isn't there some law that suggests zero tension = shortening of the structure?


If the presentation is ipsilateral, and there was no past history, you would have a good case I would think. To strengthen your case, maybe some scanning (MRI? US?) might highlight the acute form of plantar fasciitis.

What these insurance company bozos don't realise is that the literature is in its infancy; and only explains less than 25% of clinical cases (no I haven't got any supporting literature).


What I would also raise is a hypothetical example whereby the medical advisor broke his legs in an unfortunate accident. Would we need some literature to connect a subsequent weight-gain and deconditioning?



Ron
Physiotherapist (Masters) & Podiatrist

Hi Ian,

http://www.ejbjs.org/cgi/content/abstract/85/5/872

This is an abstract (one of many I imagine) which concludes that a major risk factor for plantar fascia pathology is reduced ankle joint dorsiflexion - which I'm sure you can prove to the insurance company that your chap had following his TA rupture

Hope this gets the ball rolling

Ian

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My location

Hi Ron and Ian
Thank you for your prompt reply. You have provided some useful information

Ian

Ian:

Since the tensile forces within the plantar fascia and Achilles tendon are directly related to each other (Carlson RE, Fleming LL, Hutton WC: The biomechanical relationship between the tendoachilles, plantar fascia and metatarsophalangeal joint dorsiflexion angle. Foot Ankle Intl., 21:18-25, 2000; Erdimir A, Hamel AJ, Fauth AR, Piazza SJ, Sharkey NA: Dynamic loading of the plantar aponeurosis in walking. JBJS, 86A:546-552, 2004), then you could argue that the same pathological force that caused the Achilles tendon rupture also caused a plantar fascial tear which resulted in the plantar fasciitis.

However, if the patient has lost significant power and has over-lengthened the gastrocnemius-soleus complex due to the Achilles tendon rupture, then often times patients will develop plantar heel pain due to increased ground reaction force on the plantar heel (i.e. calcaneus type gait), not due to increased plantar fascial tension.

I am unclear as to which mechanism is most likely due to the insufficient amount of information you have provided to us regarding this patient's injury and biomechanics.

__________________
Sincerely,

Kevin

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Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
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Voice: (916) 925-8111 Fax: (916) 925-8136
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Ian,

Sidelining slightly from your original point but I've had a similar patient recently and was wondering what has been your treatment since the plantarfascia problems have occured?

I note you mention he has heel raises on the shoes but does he have orthotics as well?

Thanks

Hi

The treatment I provided for him involved: restoring his heel lifts on the bottom of the shoes, I used 10mm heel raise. To date I have used a soft prefabricated orthosis with a small amount of medial rearfoot and arch posting. I put a cavity in the heel as he had a prominent plantar medial tubercle. The soft insole was chosen because he has had alot of atrophy of the fibrofatty pad beneath the calcaneus.( the pictures getting worse isn't it. ) I also started him on both calf strengthening and stretches, with a referral back to the physio to monitor part of the rehab more closely. Once we start settling his pain down and getting some strenght back I will look at getting him into custom made device. I hope that helps.

Cheers
Ian

Thanks Ian

My patient already had orthotics (from another podiatrist) prior to rupturing the achilles - at the moment I've got her strengthening and stretching etc and thinking about what mods to make to her orthoses or whether to just start over again.

She's had a tendon repair op which was delayed significantly due to an ortho specialist telling her it wasn't ruptured and putting her in a cast which didn't do much for her other than restrict her blood flow further and put her at risk of losing her foot.

Since returning back to work (long hours on feet in post shop) she's developed the plantarfasciitis. From what she's told me her rehab following the surgery wasn't much.

Anybody got any info / articles on expected outcomes following tendon repair i.e how much movement there should be, how much she will actually benefit from the stretches etc?

Thanks
Chloe