How Does Equinus Affect Plantar Fasciitis Treatment?

A recent study in PM&R investigated whether initial clinical findings such as equinus could forecast how patients would respond to conservative treatment for plantar fasciitis.

The study focused on 77 patients with non-chronic plantar fasciitis, 69 of whom completed the study through to a three-month follow-up. Researchers excluded patients who had a heel injection in the prior six months or were wearing custom foot orthoses. The authors concluded that patients with severe ankle equinus were nearly four times more likely to have a favorable response to home Achilles tendon stretching and supportive therapy. Researchers recommended that the earlier use of more advanced therapies may be most appropriate in plantar fasciitis patients without severe ankle equinus, noting that patients with less severe equinus and less severe pain did worse with conservative care.

Study coauthor James Wrobel, DPM, notes the study found that all groups initially improved in morning pain after treatment using standardized athletic shoes, longitudinal metatarsal (L&M) padding, stretching and ice.

“We believe we were the first group to describe the benefits of a removable L&M pad that can also help until they receive their custom or prefabricated foot orthoses,” he notes.        

Dr. Wrobel, a faculty member of the University of Michigan Medical School, believes patients with biconvexity of the plantar fascia might benefit from other modalities such as anti-inflammatories, physical therapy modalities, night splints and injections.

Patrick DeHeer, DPM, FACFAS, has found patients with severe equinus respond well to stretching and supportive therapy.

“A comprehensive treatment plan is critical and this includes both of these elements combined with reduction in inflammation for the initial stage of treatment in plantar fasciitis patients,” says Dr. DeHeer, who is in private practice in Indiana.

Dr. DeHeer agrees with the study that plantar fasciitis patients without equinus are less responsive to conservative therapies. He has abandoned plantar fascia releases for non-responsive plantar fasciitis in favor of gastrocnemius recessions and cites very good results.

Craig Clifford, DPM, has found most patients with non-chronic plantar fasciitis seem to do well with stretches and supportive therapy, regardless of the presence of equinus.

“Equinus is not something that ‘suddenly occurs’ and begins to create pathology,” says Dr. Clifford, a Research Director at the Franciscan Foot and Ankle Institute in Federal Way, Wash. “Its presence likely lowers the threshold for pathology so focusing on stretching exercises is important but it is only one piece of the puzzle.”

In his practice, Dr. Clifford prescribes patients with acute plantar fasciitis a rehabilitation regimen including icing, stretching, deep tissue massage, balance exercises, high-load strength training and OTC insoles, a regimen he uses routinely regardless of the presence or absence of equinus.

When equinus is present in plantar fasciitis patients, one must treat equinus concurrently and as part of a global treatment plan, emphasizes Dr. DeHeer. He uses bracing therapy for one hour per day to treat the equinus and instructs the patient that it takes eight to 12 weeks to get fully stretched out. He also stresses attention to shoe drop for daily shoes and exercise shoe gear. Dr. DeHeer says a shoe with a high drop is fighting the equinus treatment and changing to shoes with a midrange drop (4 to 8 mm) can be a good starting point.

Dr. Wrobel says a longitudinal metatarsal pad can be beneficial until patients receive custom or prefabricated foot orthoses. He adds that both custom and prefabricated foot orthoses groups improved in morning and evening pain after three months.

“I believe this gives credence to the notion that orthopedic house shoes can help as patients were instructed to use their ‘properly fit’ standardized athletic shoes as house shoes,” notes Dr. Wrobel.

Does Treating Coexisting Tinea Pedis Enhance The Efficacy Of A New Topical For Onychomycosis?

By Brian McCurdy, Managing Editor

Patients using a new topical agent for onychomycosis may expect more successful results if they receive treatment for coexisting tinea pedis, according to a new study in the Journal of the American Podiatric Medical Association.

The randomized study focused on 1,655 patients, who received efinaconazole (Jublia, Valeant Pharmaceuticals) or a vehicle control. The study’s primary end point was complete cure rate at week 52, defined as 0 percent clinical involvement of the target toenail and negative KOH examination and fungal cultures. In the study, 352 patients with onychomycosis (21.3 percent) had coexisting interdigital tinea pedis with 215 (61.1 percent) receiving topical antifungal agents for their tinea pedis in addition to their randomized onychomycosis treatment. At week 52, researchers note efinaconazole complete cure rates of 29.4 percent in patients with onychomycosis and treated coexisting tinea pedis in comparison with 16.1 percent cure rates when coexisting tinea pedis went untreated.

“It makes perfect sense that there would be increased efficacy when coexisting tinea pedis was treated. These infections are inexorably linked,” says Warren Joseph, DPM.  

The same organism generally causes both onychomycosis and tinea pedis, which occur concomitantly, concurs study lead author Bryan Markinson, DPM. As with any other skin infections, including bacterial infections, he says one must eradicate multiple foci as they easily spread to other skin areas by simple contact with hands, washcloths, towels, etc. Dermatophyte infection is no exception, notes Dr. Markinson, an Associate Professor and the Chief of Podiatric Medicine and Surgery in the Leni and Peter W. May Department of Orthopedic Surgery at the Icahn School of Medicine at Mount Sinai.

As Dr. Joseph notes, the proposed natural history of onychomycosis is that it starts as tinea pedis and then migrates under the distal edge of the nail to infect the nail bed startum corneum. Dr. Markinson agrees, saying, “Migration of organisms from the skin underneath the nail plate can only serve to hinder response to applied topical nail treatments.”

Accordingly, one can assume that any patient with onychomycosis also has or has had tinea pedis, according to Dr. Joseph, who notes that physicians can’t treat one infection without the other. Dr. Joseph says if one uses a topical to treat the tinea but not the onychomycosis, then the nail can re-infect the skin, and vice versa.

Among the effective agents to treat tinea pedis are prescription agents such as luliconazole (Luzu, Valeant Pharmaceuticals) and naftifine (Naftin, Merz Pharmaceuticals) and OTC topicals such as terbinafine and many azoles, according to Dr. Joseph, a Fellow of the Infectious Diseases Society of America. He notes no clear evidence that one drug would be more effective than another. For refractory and severe cases of tinea pedis, he says short courses of an oral, such as terbinafine, although off-label, can be very effective.

Future studies should focus on prevention of reinfection of the nails with continued use of the topical agent, asserts Dr. Markinson. He says the profession must know if the topical helps and what minimum/least frequent dosing is effective. Dr. Joseph agrees that a study on preventing reinfection is “sorely needed,” saying this might entail combinations of tinea pedis and onychomycosis treatments.