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Thank you for joining our CM E presentation today. I'm Doctor David Benoy E VP of Clinical Value Based Care for health care Outcomes Performance company, also known as HCO. Our topic for today is initial management of plantar fasciitis. Uh Before we get started on the topic of the day, uh as we do for all CM events, I wanna assure the audience that I have no financial or nonfinancial relationships to disclose as it relates to this topic and subsequent presentation. This may be a review for those of you who have attended our other CM E uh talks in the series. Uh But for the series, our, our objective is to improve the continuum of care and outcomes for musculoskeletal patients by defining the role of primary care providers in musculoskeletal value based care. Uh We also aim to provide diagnostic and management pearls to pcps and other providers uh referring to PMS K specialists so that providers who manage the initial presentation of many common M SK issues can uh better more accurately, diagnosed and treat these conditions. In addition, we aim to help providers identify red flags and other clinical factors in necessitating urgent imaging or specialist referral at the end of today's session. Uh We hope the audience will be able to diagnose plantar fasciitis. Initiate non surgical treatment for patients with plantar fasciitis symptoms and determine which patients would be uh most likely to benefit from therapy, diagnostic imaging and specialist referrals. In order to achieve these objectives, we will briefly review the HCO specialty care network tip sheet. Uh Then we'll do a brief run through multiple important topics in the initial management of plantar fasciitis starting with uh background. Uh then moving to evaluation of the foot for plantar fascia, um and plantar fasciitis issues. And then moving on to tips for conservative treatment testing. And finally, we'll touch on when a special referral may be uh clinically warranted hop O and hop O Specialty Care Network also abbreviated as HSC N. Um Believe that this is an important um uh topic to distribute to our referral network including PCPs and all upstream uh providers. As a way of context. This HSEN uh the HSEN network comprises more than 230 orthopedic surgeons and muscle Kear providers across Arizona who have joined forces to follow standardized evidence based clinical pathways. Never before um have a network of skeletal specialists uh across the state come together to align around best practice uh delivery and education. Our network is a first of its kind in co in the country and is already managing and improving outcomes for United Healthcare uh Medicare advantage patients across Arizona and we anticipate adding additional patient populations in the near future. HCO specialty care network is a clinically integrated network which is a type of value based uh care program. And by definition, value based care programs incentivize health care providers to provide improved quality of care while reducing unnecessary cost of note, HSEN was recently recognized by a top national accreditation organization U A uh for its commitment, commitment to clinical integration and high quality care. HSEN is actually the first specialty network in the country to be awarded um uh accreditation as a high quality clinically integrated network. HSEN also collaborates with other providers including yourselves uh who encounter M SK conditions with a goal of improving patient outcomes and experience. As you're well aware, a lot of the initial management of M SK care occurs not at the specialist level um but upstream um uh particularly at PCP uh clinic visits in saying that it's clear that a population health program relies on PCPs to help reduce unnecessary M SK cost. Uh As PCPs are the most common gatekeeper for M SK care before we dive in the topic uh of the day. It's also important to mention that information is shared that the information that's shared in this talk is evidence based a consensus driven with the recommended practice designed to be implemented for uh patients with M SK conditions, but should be said, but that should be said for all clinical programs. Clinical discussion should be used with these guidelines for patients. Um especially if there are concomitant clinical factors or comorbid conditions that may alter the clinically appropriate treatment path. As we do in uh all uh talks in this series. Let's start with a review of the HSEN tip sheet. Um We'll send out this tip sheet to all of you. Uh But again, if you don't have a copy of this and like it for your uh office, um please send us an email. We'd be happy to get it over to you. Uh You can email us at HSEN at HCO dot com. Uh This tip sheet is uh obviously more specific to Medicare and Medicare advantage population, a slightly older population. But many of the tips here are also relevant to a younger population as well. Uh Today, we're focusing on foot pain due to plantar fasciitis. Um If you look at the um uh all the rows here, it's on the bottom, a row of this tip sheet. Um We'll go through each column in a little bit more detail during this talk, but it's a good way to see the overall suggestions um of the specialists for initial management uh of these conditions including plantar fasciitis uh as you see on the tip sheet, um or plantar fasciitis initial management comprised of conservative care, which may include activity modification and DM E but does not include a formal outpatient physical therapy or advanced imaging as you can see here with the red icons. Uh As a review, the plantar fascia is a thick connective tissue band on the plantar or bottom side of the foot. Um that stretches from the heels um to um to the toes. Uh symptoms of plantar fasciitis typically present with um uh gradually um and the pain could be stabbing or achy in quality. The heel pain is most intense in the morning uh prior to or with the first few steps of the day and it can be exquisitely uh painful. Uh Then despite uh getting slightly better after those first few steps, uh with prolonged weight bearing or sometimes with inactivity that pain um can return and can be quite intense throughout the day. Uh In addition to heel pain, uh patients could also have pain in the arch of the foot, uh or up through the achilles tendon. Um and there may be associated swelling and stiffness in the foot as well. Uh The symptoms are often um uh confused with pain from a stress fracture or they may be concerned for a stress fracture. The pain from a stress fracture doesn't usually go away after the first two steps a day. It actually gets worse, the more weight bearing, um you would have on that, on that fracture. So it's a good way to separate those uh two. Although plantar fasciitis is much more common in plantar fasciitis and also a different patient population. You would wanna consider for a stress fracture on exam. Some patients uh have findings of a high arch and a limited dorsiflexion um that may predispose them uh to plantar fasciitis. Uh plantar fascia is um is inflammation of the plantar fascia that they connect to tissue band. Um on the plantar side of the foot, it's one of the most common cause of heel pain. It accounts for over uh 1 million medical visits per year. Um Men are more effective than women but women get plantar fasciitis and significant numbers uh as well. Uh The most common age range is 40 to 60 year olds. Um but it frequently occurs uh ear both earlier and later in life. Uh, excision also affects those who undergo repetitive microtrauma uh to the plantar fascia. In addition to the history of heel pain, that's consistent with plantar fasciitis. There are certain examination techniques that can be useful uh to uh diagnose this condition. Uh uh and, and one of the main ones, just palpation of the plantar fascia. Um patients with plantar fasciitis, which really have pain with palpation on the medial region, um uh where they heal um uh where the heel ends, uh on the bottom of the foot. It also could be on the lateral side, not uh not the medial side for some, for some patients. Uh The pain can become worse with moving the ankle. Um uh a skyward dorsiflex in the ankle and less painful as the ankles move downward or plantar flex, initial treatment for patients with symptoms of plantar uh fasciitis um can include ice and anti-inflammatories. Um And I should add here. Actually, stretching of the plantar fascia is one of the initial treatments as well. In order to stretch the plantar fascia, the, the patient use like a, a 2 L um uh bottle uh of soda or, or a can to roll their foot over. Actually, a tennis ball works pretty well as, uh, as well. Um, using a canner bottle is also a good way of icing the foot if that canner bottle could be put in the freezer. Uh, there are also dorsal splints, um, that a patient could wear at night, um, or during the day when the patient's, um, uh, inactive for prolonged periods, uh, during the day, um, like working a computer or watching television. Um, and by the way, it's a good time, uh, when they're not wearing a splint to do stretching of the plantar fascia over that, um, bottle or can as well. Um, and it's important to know that dorsal splints, uh, used for plantar fasciitis can, uh, fit, usually be found in a drugstore. These are, uh, pretty common, uh, splints, uh, that you can find, um, in your, uh, in your local drugstores and it usually actually a little bit cheaper, uh, than if you prescribe, um, uh, the splint to a patient, uh, due to copays and coinsurance uh There are also heel inserts uh that are available over the counter. Um This is uh exactly what they sound like they're inserts that patients could put in their shoes to reduce tension uh on the plantar fascia, but no treatment for plantar fascia. Uh fasciitis is complete without uh recommending that the patient wear appropriate footwear. Uh First and foremost, the patient should um uh should avoid uh being barefoot um throughout the day, especially when the pain um uh is intense or when they're gone, uh undergoing um active plantar uh fasciitis symptoms, especially that when walking on hard surfaces, like wood floors or tile or travertine. Uh this can make the condition uh worse or uh take longer for the patients to uh improve. Um It's just for the patient to wear shoes with thick soles and extra cushion to uh reduce pain of plantar fascia with standing and walking. And uh I she mentioned that for most patients to remind them to get um new sneakers uh or new shoes of their soles have worn out. Um This is true for work shoes also actually not just sneakers. Uh for runners, uh this means changing shoes every 300 to 500 miles. Um But even for those of us who don't run and and don't calculate the mileage per day. And that means in instead of maybe for runners changing uh sneakers every 3 to 4 months, uh for the rest of us changing it every 6 to 9 months. Um is um uh it's probably an appropriate uh time range. Um but it's depending on the activity level and how much you use the shoes uh for walking and other exercise. Excuse me. In addition to improving footwear choices, uh activity modification may be useful. This is a stress especially true for runners or anyone who's engaging in high impact activities because this activity can cause microtrauma to the plantar fascia. And probably the most importantly, but not mention the slide is patients uh plantar fasciitis can be stubborn in its resolution. Uh But if the patient sticks with the treatment plan, including stretching, activity modification and improving footwear, uh most people do get better over time with regard to diagnostic testing. Uh x-rays of the foot are not indicated as first line management. Uh Sometimes you may um if you do have an x-ray see a heel spur, but this finding may um be a cause of pain related to or unrelated to the plantar fasciitis, but generally doesn't um impact uh initial management. So it's not necessary to get an X ray and even if you do a heel spur may not tell you too much. Um Also, it may come to no surprise uh that MRI Ct scans and ultrasounds and blood work have limited um uh use unless uh uh uh unless uh the patient has other concomitant uh issues or muscle skele issues or other issues. Um And any one of those including MRI should to scan ultrasound and blood work should be ordered by a specialist. Uh If it gets to that point as it relates to therapy, uh physical therapy is not indicated for initial management of uh plantar fasciitis. Um You may consider a home exercise program for, for uh your patients um for symptoms of plantar fascial pain. A lot of what the home exercise program would be. The, the, um, uh, the concepts that I described already, which is a lot of strengthening, a lot of stretching of the plantar fascia and eventually getting to light stretching of the foot and ankle. Uh, these are, there are many publicly available websites and fine exercise would be a good start for your patients, including the aaos website. So when you have a patient that's gone through an initial course of treatment, uh, when should you refer, um, a patient to a foot and ankle specialist? If patients don't improve with the conservative measures in 6 to 12 weeks, then a patient may benefit from a referral to a foot and ankle specialist for further evaluation. Um, but just so, you know, surgery is, uh, typically not necessary for patients experiencing plantar fasciitis. That surgery is quite rare actually. And as we do in all talks of this series, I'd like to end the, um, uh, this, uh, uh, quick talk today with, uh, some take home points, um, conservative treatment prior to specialist referral and diagnostic imaging is typically uh the most appropriate uh initial treatment and that conservative trials should last 6 to 12 weeks of minimum to avoid unnecessary referrals and testing. Uh physical therapy, it's only limited to refractory cases. A as a matter of fact, probably um having the specialist order therapy if it gets to that point would be uh the recommended course. Um CT S and ultrasounds are not indicated. MRI S are typically not indicated. Um But when they are uh indicated, they should be ordered by a specialist after a referral. Thank you for uh joining us today for this presentation and we hope you enjoyed the talk and hope uh you join us again as we explore other topics in M SK care. Have a great day.