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Evidencia En La Fascitis Plantar

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Evidencia En La Fascitis Plantar

  1. 1. FASCITIS PLANTAR <ul><li>La fascitis plantar afecta al 10% de la población en algún momento de su vida. </li></ul><ul><li>Mas frecuente en mujeres. </li></ul><ul><li>Dolor en talón, de intensidad variable, generalmente aumenta con los primeros pasos de la mañana. </li></ul><ul><li>Se desconoce la importancia del espolón calcáneo en esta patología. </li></ul>
  2. 2. PRONÓSTICO DE LA FASCITIS PLANTAR <ul><li>En más del 80 % de los pacientes los síntomas desaparecen dentro del primer año , sin importar el tratamiento. </li></ul><ul><ul><li>The New England Journal of Medicine. May 20, 2004. Tomo 305,Nº 21 </li></ul></ul><ul><li>Una investigación telefónica de 100 pacientes con tratamiento conservador (media de seguimiento de 47 meses): </li></ul><ul><ul><li>82 curación </li></ul></ul><ul><ul><li>15 continuaron los síntomas, pero sin limitaciones en su actividad laboral. </li></ul></ul><ul><ul><li>3 tuvieron síntomas continuados que limitaron su actividad laboral. </li></ul></ul><ul><ul><li>Foot Ankle Int 1994;15:97-102. </li></ul></ul>
  3. 3. TRATAMIENTOS EN LA FASCITIS PLANTAR <ul><li>Analgésicos </li></ul><ul><li>AINES </li></ul><ul><li>Electroterapia </li></ul><ul><li>Plantillas </li></ul><ul><li>Ortesis de tobillo </li></ul><ul><li>Fisioterapia </li></ul><ul><li>Ondas de choque </li></ul><ul><li>Infiltraciones con corticoides </li></ul><ul><li>Cirugía </li></ul>
  4. 4. ¿Qué prueba diagnóstica pedir en la fascitis plantar? <ul><li>ECA. La gammagrafia osea en tres fases es una prueba objetiva en el diagnostico de la fascitis plantar. </li></ul><ul><ul><li>J Ultrasound Med. 2005 Aug;24(8):1041-8.) </li></ul></ul><ul><li>ECA. La Ecografía y la gammagrafia son igual de efectivas . </li></ul><ul><ul><li>Rheumatology 2001; 40: 1002-8 . </li></ul></ul><ul><li>ECA. La R.N.M., es igual de efectiva que la ecografía . </li></ul><ul><ul><li>J. Ultrasound Med. 2005 Aug;24(8):1041-8 </li></ul></ul>
  5. 5. TRATAMIENTOS EN LA FASCITIS PLANTAR
  6. 6. ESTIRAMIENTOS DE TRICEPS
  7. 7. ¿Son útiles los estiramientos de tríceps en la fascitis plantar? <ul><li>Una revision sistemática Cochrane no encuentra ECAs que comparen estiramientos con no tratamiento en fascitis plantar </li></ul><ul><ul><li>The Cochrane Library, Issue 3, 2004. </li></ul></ul><ul><li>AUSENCIA DE EVIDENCIA </li></ul>
  8. 8. ¿ Son útiles las ortesis para estirar la fascia plantar y el triceps ? <ul><li>Un ECA no encuentra diferencia entre dos grupos de tratamiento después de 3 meses : 1. férulas nocturnas más AINES, y 2. AINES. </li></ul><ul><ul><li>Clin Orthop 1999;368:191–195 . </li></ul></ul><ul><li>Otro ECA compara férulas nocturnas y plantillas sin encontrar diferencias . </li></ul><ul><ul><li>EVIDENCIA CLINICA. 2004 </li></ul></ul><ul><li>R.S.C., 2.003: </li></ul><ul><ul><li>No existen estudios que permitan demostrar su eficacia </li></ul></ul><ul><li>AUSENCIA DE EVIDENCIA . </li></ul>
  9. 9. ¿Es útil la electroterapia en la fascitis plantar? <ul><li>ECA. El laser es igual de efectivo que el placebo . </li></ul><ul><ul><li>Arch Phys Med Rehabil. 1998 Mar;79(3):249-54 </li></ul></ul><ul><li>ECA. Los ultrasonidos son igual de efectivos que el placebo en la fascitis plantar . </li></ul><ul><ul><li>Annales of the Reumatic Diseases 1996. </li></ul></ul><ul><li>ECA. L a iontoforesis con dexametasona al 0.4 % es mejor que el placebo pero debe reservarse solamente cuando son necesarios resultados inmediatos como en los deportistas. </li></ul><ul><ul><li>Am J Sports Med. 1997 May-Jun;25(3):312-6 </li></ul></ul><ul><li>EVIDENCIA INCIERTA </li></ul>
  10. 10. PLANTILLAS
  11. 11. ¿Son útiles las plantillas en la fascitis plantar? <ul><li>ECA con tres grupos: plantillas, soportes de arco interno y férulas nocturnas. No hubo diferencias significativas a los tres meses. </li></ul><ul><ul><li>J Am Podiatr Med Assoc. 2001 Feb;91(2):55-62 </li></ul></ul><ul><li>Una revisión sistemática Cochrane no encontró ECAs que compararan el efecto de las plantillas con placebo o no tratamiento. </li></ul><ul><ul><li>The Cochrane Library, Issue 3, 2004. </li></ul></ul>
  12. 12. ¿Son útiles las plantillas en la fascitis plantar? <ul><li>Una revisión sistemática encontró evidencia limitada y contradictoria sobre los efectos de las almohadillas calcáneas y taloneras versus otras modalidades de tratamiento. </li></ul><ul><ul><li>EVIDENCIA CLINICA. 2002 </li></ul></ul><ul><li>Un ECA comparando las plantillas magnéticas con las normales sin encontrar diferencia. </li></ul><ul><ul><li>JAMA. 2003 Sep 17;290(11):1474- </li></ul></ul><ul><li>EVIDENCIA INCIERTA </li></ul>
  13. 13. A FAVOR DE LAS ONDAS DE CHOQUE <ul><li>Un ECA de alta calidad. Tres tratamientos de 1000 impulsos con ondas de choque de baja energía parecen ser efectivas en las fascitis plantar crónica mientras que tres aplicaciones de 10 impulsos no mejoraron los síntomas. </li></ul><ul><ul><li>J Bone Joint Surg Am. 2002 Mar;84-A(3):335-41. </li></ul></ul><ul><li>Un ECA de baja calidad. Tres sesiones de tratamiento con ondas de choque de baja intensidad con 2100 impulsos, es un método seguro y eficaz </li></ul><ul><ul><li>Am J Sports Med. 2003 Mar-Apr;31(2):268-75 </li></ul></ul><ul><li>ECA de alta calidad. La aplicación de ondas de choque de alta energía en el talón es un método seguro y efectivo para tratar la fascitis plantar con un efecto duradero mayor de un año </li></ul><ul><ul><li>J Bone Joint Surg Am. 2004 Oct;86-A(10):2216 </li></ul></ul>
  14. 14. EN CONTRA DE LAS ONDAS DE CHOQUE <ul><li>Dos ECAs de baja calidad, que encontraron una reducción no significativa en el dolor con el tratamiento con ondas de choque extracorpóreas versus un tratamiento simulado después de 3 meses y 2 meses respectivamente. </li></ul><ul><ul><li>Rheumatology 2000;39(suppl 123):230. </li></ul></ul><ul><ul><li>Clin Orthop Related Res 2001;1:47 </li></ul></ul><ul><li>Un ECA de alta calidad. No encuentran evidencia que muestre los beneficios de las ondas de choque guiadas con ultrasonidos sobre el placebo a las 6 y 12 semanas después del tratamiento. </li></ul><ul><ul><li>JAMA. 2002. Sep 18;288(11):1364- </li></ul></ul><ul><li>Un ECA de alta calidad . Las ondas de choque no son efectivas en el tratamiento de la fascitis plantar crónica. </li></ul><ul><ul><li>BMJ    2003;327:75  </li></ul></ul>
  15. 15. EN CONTRA DE LAS ONDAS DE CHOQUE <ul><li>R.S.C., 2003: </li></ul><ul><ul><li>La terapia con ondas de choque no ha podido demostrar su eficacia hasta este momento. </li></ul></ul><ul><li>Institute for Clinical Systems Improvement (ICSI), 2004. </li></ul><ul><ul><li>Una revisión sistemática. No se pueden establecer conclusiones sobre la eficacia de las ondas de choque en la fascitis plantar. </li></ul></ul><ul><li>CLINICAL EVIDENCE. Agosto 2004 . Insuficiente evidencia para establecer la eficacia de las ondas de choque </li></ul>
  16. 16. ONDAS DE CHOQUE EN LA FASCITIS PLANTAR ¿EVIDENCIA INCIERTA?
  17. 17. ¿ Son útiles las infiltraciones con corticoides en las fascitis plantar? <ul><li>Una R.S.C. encontró una evidencia limitada sobre la efectividad de la terapia local con corticosteroides. Parece que solo son útiles a corto plazo </li></ul><ul><ul><li>Biblioteca Cochrane Plus , 2005 Número 4 </li></ul></ul><ul><li>Un pequeño ECA no encontró diferencias significativas en el dolor con triamcinolona más inyección de lidocaína versus una almohadilla para el talón después de 24 semanas. </li></ul><ul><ul><li>Rheumatology 1999;38:974-977. </li></ul></ul><ul><li>Estudios observacionales han encontrado una tasa alta de ruptura de la fascia plantar y otras complicaciones asociadas con las infiltraciones con corticoides. </li></ul><ul><ul><li>Foot Ankle Int 1994;15:376–381 </li></ul></ul><ul><ul><li>Foot Ankle Int 1998;19:91–97. ( 30 % infiltaciones Ruptura fascia ) </li></ul></ul><ul><li>SI, EVIDENCIA LIMITADA </li></ul>
  18. 18. ¿ Es útil la cirugía en la fascitis plantar ? <ul><li>Una R.S.C. no ha encontrado ningún ECA sobre cirugía en la fascitis plantar </li></ul><ul><ul><li>The Cochrane Library, Issue 3, 2004. </li></ul></ul><ul><li>EVIDENCIA INCIERTA </li></ul>
  19. 19. MI PROPUESTA PARA EL TRATAMIENTO DE LA FASCITIS PLANTAR <ul><li>Reposo relativo. No AINES de forma rutinaria </li></ul><ul><li>Plantillas semirrigidas con sostén de arcos y almohadillado de talón </li></ul><ul><li>Estiramientos de fascia y tríceps </li></ul><ul><li>Iontoforesis con dexametasona al 0.4 % </li></ul><ul><li>Inmovilización con ortesis </li></ul><ul><li>Cirugía </li></ul><ul><ul><ul><li>! Cuidado con las fibromialgias ! </li></ul></ul></ul>

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