PLANTAR FASCITIS

PRESENTER : ANKUR MITTAL

INTRODUCTION

The foot is really unique to human being. The structure of the foot allows the foot to sustain large weight bearing stresses under a variety of surfaces and activities that maximize stability and mobility.

Arches of the foot help in fast walking, running, jumping, weight bearing

and in providing upright posture.

Arches are supported by intrinsic and extrinsic muscles of the sole in addition to ligaments, aponeurosis and shape of the bones.

The frequency of ankle or foot problems can be traced readily by the complex structure of the foot and their participation in all weight bearing activities.

Structural abnormalities can lead to altered movements between joints & contribute to excessive stresses on tissues of the foot and ankle that result in injury

The foot has to suffer from many disorders because of tight shoes or high heels which we wear for various reasons and also over using the foot may cause microtears and inflammation.

Plantar fascia acts like a shock-absorbing bowstring, supporting the arch in foot. But if any tension on that bowstring becomes too great, it can create small tears in the fascia; repetitive stretching & tearing can cause the fascia to become irritated or inflamed leading to plantar fasciitis.

Plantar fascitis is also known as a “heel speer”.Poor foot alignment, muscular control and flexibility are frequent causes of

plantar fasciitis.

DEFINITION

‘‘Plantar fascitis is a painful condition caused by inflammation of the plantar fascia. The pain is usually felt on the bottom of the foot near the heel and is worst when getting out of bed in the morning or after sitting for a long time. It is caused by too much pressure or trauma to the bottom of the foot resulting from wearing old "dead" shoes or weight gain. Recovery takes several weeks, aided by icing and taping of the foot and anti-inflammatory medication.’’

RELEVANT ANATOMY

The os calcis is elveated anteriorly so that during heel strike, the posterior tubercle contacts the ground 1st and transmits full body weight.

This make the calcaneum vulnerable to trauma or micro trauma

The heel fat pad has many fat globules enclosed by multiple fibroelastic septa

These septa act like hydraulic chamber to bear weight evenlly across the os calsis during locomotion

And after 40 years this fat pad begin to atrophy and degenerate

The plantar aponeurosis is an inelastic facia that arises from the os calcis and is composed of three segments

Anteriomedial tuberosity

Covers undersurface of abductor haluucis

Windlass mechanism of the plantar fascia as the toes are dorsiflexed.

The plantar fascia, which originates from the anteriomedial plantar aspect of the calcaneal tuberosity and inserts through several slips into the plantar plates of the metatarsophalangeal joints, the flexor tendon sheaths, and the bases of the proximal phalanges of the digits, is under constant traction as it is pulled distally around the drum of the windlass (metatarsal heads). This tightening elevates the longitudinal arch, inverts the hind foot and externally rotates the leg. This mechanism is passive and depends entirely on bony and ligamentous instabilty.

This mechanism whereby the arch is raised and supported with dorsiflexion of toes providing more flexibilty and rigidity to the foot..

•Excessive foot pronation: Excessive pronation or inward rolling of the foot also inhibits efficient use of the windlass mechanism. This decreases shock absorption through the plantar fascia which in turn increases the tension on the plantar fascia.

•Tight calf muscles: Having tight calf muscles can cause excessive foot pronation contributing to excessive foot mobility which increases the level of stresses on the plantar fascia.

•High arched foot: A high arched foot lacks the normal joint mobility which reduces the foot’s ability to absorb shock from the ground, thereby increasing the stresses on the plantar fascia.

•Ill-fitting or worn out shoes: Wearing ill-fitting or worn out shoes may change the foot biomechanics, causing undue strain on the plantar fascia.

•Excessive walking and running on hard surfaces: This increases the shock transmitted to the plantar fascia, increasing the strain on the plantar fascia.•Overweight: Being overweight increases the level of stresses applied to the fascia due to the added body weight on the foot, increasing the strain on the plantar fasci

Another finding that supports this theory is that the most dense, unyielding section of the plantar aponeurosis originates from the location on the tuberosity of the calcaneus where the most common point of local tenderness is found during physical examination. It is not far-fetched to compare this to tennis elbow. In fact, Woolnough called this entity “tennis heel

Aging and repeated trauma, repetitive traction and aging could produce microscopic tears and cystic degeneration in the origin of the plantar fascia and the flexor digitorum brevis immediately beneath the plantar fascia. Furthermore, it is noted that the location of the familiar traction spur on the anteromedial, plantar aspect of the calcaneal tuberosity coincides with the origin of the flexor digitorum brevis.

Enterapment of nerve to abductor digiti mini can occur between abductor hallucis and the medial margin of medial head of quadratus plantae muscle

•Structurally there are three arches (transverse, longitudinal, lateral) that provide support, stability and aid in locomotion.

•The three- arch system contains an elaborate support system of ligaments, tendons and muscles

•There is only one plantar arch in the sole.

•All the intrinsic muscles of the sole only are supplied by either of the two plantar nerves.

•The extrinsic muscles of the sole are supplied by the nerve of the respective compartment.

•The tendons and muscles of the sole maintain the arches of the foot.

•Superficial fascia of the sole is fibrous and dense.

•Fibrous bands bind the skin to the deep fascia or plantar aponeurosis and divide the subcutaneous fat in to small tight compartment which serves as water-cushions and reinforce the spring-effect of the arches of the foot during walking, running and jumping

•The largest bone in the foot is the calcaneus. The most common site of injury in the plantar fascia is at the attachment point of the plantar fascia on the medial tubercle of the calcaneus

• Muscles of the foot are arranged in four layers with neuro vascular bundles between first and second layers and then between third and fourth layers.

MUSCLES OF SOLE OF THE FOOTMuscles of first layer of the sole•Flexor digitorum brevis•Abductor hallucis•Abductor digiti minimi

Muscles of second layer of the sole•Flexor digitorum longus•Flexor digitorum accessories•Lumbricals•Flexor hallucis longus

Muscles of third layer of the sole•Flexor hallucis brevis•Adductor hallucis•Flexor digiti minimi brevis

Muscles of fourth layer of the sole•Interosseus•Three plantar and four dorsal interosseus

These are small muscles placed between the metatarsal bone.

Plantar facitis occurs when these tissues are inflammed and irritated. Two muscles the quadratus plantae &the flexor digitorum brevis contribute to the problem.

AETIOLOGY 

•Excessive pronation of the foot.•Poor arch support in the shoe•Flat foot•Prolonged standing•Fat pad atrophy•Tight triceps surae•Repetitive strength imbalances•Stress,tension and pulling on the plantar fascia•Over use may cause microtears and inflammation•Weak peroneii•Congenital problems such as Pescavus and Pesplanus•Obesity •Reiters disease,Ankylosing spondylitis,Diffuse idiopathic skeletal hyperostosis•Some of the causes of plantar fasciitis may include: - Excessive running or even walking uphill -Lack of stretching prior to exercise -Wearing flexible, soft shoes that don't protect your feet -Injuries to the planter fascia.

In patients with idiopathic heel pain, the differential diagnosis should include rheumatoid arthritis, ankylosing spondylitis, Reiter syndrome, and osteoarthritis.

In addition, especially in patients with diabetes, deep soft-tissue abscess should be considered.

In men younger than 40 years with bilateral painful heels, ankylosing spondylitis and Reiter syndrome should be ruled out.

Women with bilateral symptoms should be evaluated for rheumatoid arthritis.

RISK FACTORS

AGE: Plantar fascitis is most common between the ages of 40 and 60.

SEX: Women are more likely to develop plantar fasciitis when compared to men.

CERTAIN TYPES OF EXERCISE: Activities that place a lot of stress on heel and tissue-such as long distance running, ballet dancing and aerobics can contribute to an earlier onset of plantar fascitis.

FAULTY FOOT MECHANICS: Being flat-footed, having a high arch or even having an abnormal pattern of walking can adversely affect the weight distribution when standing, adding stress on the plantar fascia.OBESITY: Excess weight put extra stress on your plantar fascia.

OCCUPATION: People with occupations that require a lot of walking or standing on hard surfaces such as factory workers, teachers and waitresses can damage their plantar fascia.

IMPROPER SHOES: Shoes that are thin soled, loose, lacking arch support or the ability to absorb shock cannot protect the feet. If we wear high heels regularly, the Achilles tendon which is attached to the heel can contract and shorten, causing strain, on the tissue around the heel.

PATHOLOGY

The plantar fascitis injury sequence:

•Repetitive impact on feet for long time causes flexor muscles/tendons to become short and tight.

•An impact on short, tight muscles/tendons causes micro tearing at the point where tendons attach to heel and toe bones.

•Micro tearing at the point of attachment causes progressive scarring of tissue, inflammation and pain.

•Over a period of time heel spurs and arthritis may develop.

•Magnetic resonance imaging (MRI) studies of patients with heel pain often reveal abnormalities of only the central or intermediate portion of the fascia.

•Fasciitis is actually not an accurate description for the condition. Microscopic studies of the plantar fascia in patients with heel pain usually reveal disorganization of the collagen fibers, an increase in the number of fibroblasts, and a mucoid ground substance with minimal inflammation of the fascia.

•Both MRI and ultrasound confirm thickening of the fascia in symptomatic patients. The plantar fascia is 2-4 mm in asymptomatic patients, while it is 6- 10mm thick in patients experiencing heel pain. 

•Consequently, "heel pain syndrome" has been suggested as a more appropriate term than plantar fasciitis because there is no evidence of inflammation.

•Micro tears of the collagen fibers are thought to be the cause of the microscopic changes.

• It seems that heel impact does not cause the pathologic changes in patients with heel pain syndromes.

• Specifically, gait studies performed on patients with heel pain demonstrate no difference in the force of the heel strike in affected and unaffected heels.  

•X-rays of patients with heel pain sometimes reveal a calcification of the plantar aponeurosis at the origin on the calcaneus, commonly referred to as a heel spur.

• The heel spur represents a marker for chronic heel pain but is not the cause of the pain.

• In fact, foot x-rays of patients often reveal spurs in patients who are asymptomatic. 

•In addition, the presence or absence of a spur does not change the response to therapy.

CLINICAL FEATURES•Pain at the base of the heel

.Pain is most severe in the mornings on getting out of bed, and in the beginning of a run

•Pain and tenderness at the bottom of the foot

•Pain is burning, often sharp, and can be severe

•Moving after any inactivity, such as sitting in a car or at a desk

•Post static dyskinesia

•Plantar fasciitis is sometimes also associated with warmth and swelling of the bottom of the foot.

DIFFERENTIAL DIAGNOSIS OF HEEL PAIN

CONDITION CHARATERISTICS

NEUROGENIC

Abductor digiti mini nerve entrapment Burning heel pain

Lumbar spine disorders Pain radiating down to the leg.heel and abnormal reflexes

Neuropathies common in patients who abuse alchohol and in patients with diabetes Diffuse foot pain and night pain

Tarsal tunnel syndrome Pain, burning sensation and paraesthesisa on sole of foot

SOFT TISSUE

Achilllis tendonitis Pain in retrocalcaneal area

Fat pad atrophy pain in area of atrophic heel pad

Heel contusion History of trauma

Plantar fascia rupture intense tearing sensation on the bottom of foot

Posterior tibial tendonitis pain on the inside of foot and ankle

Retrocalcaneal bursitis pain in retrocalcaneal area

Skeletal

Calcaneal epiphysitis (Sever’s disease) Heel pain in adolescents

Calcaneal stress fracture Calcaneal swelling, warmth, and tenderness

Infections Osteomyelitis

Systemic symptoms (e.g., fever, night pain)

Inflammatory arthropathies More likely with bilateral plantar fasciitis

Multiple joints affected

Subtalar arthritis Heel pain is supracalcane

MiscellaneousMetabolic disorders

Osteomalacia Diffuse skeletal pain, muscle weakness

Paget’s disease Bowed tibias, kyphosis, headaches

Sickle cell disease Acute episodes of pain involving long bones, pelvis, sternum, ribs

Dactylitis in young children

Tumors (rare) Deep bone pain, night pain, constitutional symptoms

Vascular insufficiency Pain in muscle groups that is reproducible with exertion, abnormal vascular examination

Haglunds Deformity

• Triad of thickening of the distalAchilles tendon, retro-Achillesbursitis, and retrocalcaneal bursitis• “Pump bumps” - stiff heel countercompresses posterior soft tissuesagainst the posterosuperiorcalcaneus• Calcaneal tuberosity may focallyenlarge in response to chronicirritation• Leads to cycle of injury, response toinjury and re-injury

Indications for imaging of the PA

Assessment of its anatomic integrity is important in athletes engaged in running and jumping activities as ruptures of the PA (either complete or partial) are caused by forcible plantar flexion and are common in competitive athletes.

Repetitive stress or minor trauma to the PA, however, also may result in rupture

Spontaneous rupture of the PA may occur in patients with prior plantar fasciitis, especially in those treated with local steroid injections

INVESTIGATIONS

X-RAYS

•An X-ray may be taken to rule out a stress fracture of the heel bone

•X-rays of patient with heel pain sometimes reveal a calcification of the plantar aponeurosis at the origin on the calcaneus, commonly referred to as a heel spur

MRI: Show thickening of plantar fascia

BONE SCAN: It show increase uptake at the calcaneus

RHEUMATOLOGIC SCREENING: It can be important to rule out inflammatory arthrides.

plantar aponeurosis as uniform bandlike structure of low signal intensity (arrows).

thickening of central component of plantar aponeurosis (large arrows). Extensive edema infiltrates perifascial soft tissue (curved arrows).

complete rupture of plantar aponeurosis after local corticosteroid injections for chronic plantar fasciitis. Lateral radiograph of foot shows calcaneal enthesophyte (curved arrow) with erosion of undersurface of calcaneus (straight arrows) and small bone fragment (open arrow).

complete rupture of plantar aponeurosis after local corticosteroid injections for chronic plantar fasciitis.

Posttraumatic acute complete rupture of plantar aponeurosis

Partially circumferential high SIaround Achilles tendon indicate peritendinitis

Edema withinKager’s fat padanterior to AchillesTendon indicate paratendinitis

leads to thickened tendon with normal SI indicate tendinosis

Insertional tendinopathy leads to enthesophyte

absenceof normal radiolucency inposteroinferior corner of Kager’sfat pad +/- erosion of calcaneus

Indicate retrocalcaneal bursitis

LABORATORY INVESTIGATIONS:

May be necessary in some cases to rule out a systemic illness causing the heel pain, such as rheumatoid arthritis, Reiter's syndrome, or ankylosing spondylitis. These are diseases that affect the entire body but may first show as pain in the heel.

SPECIAL TEST

•This is good test to diagnose plantar fascitis.

•Plantar fascitis have more tenderness in the plantar fascia when it is stretched and less tenderness when the fascia is relaxed. The plantar fascitis test uses this property to diagnose patients with plantar fascitis. •To perform this test, first stretch plantar fascia. Then use your thumb or finger to feel the plantar fascia. If plantar fascia is tender, then try the same maneuver with plantar fascia relaxed.

•If pushing the stretched plantar fascia causes more tenderness than pushing on the relaxed plantar fascia, then the plantar fascia is likely the source of the pain and the patient have plantar fascitis.

MANAGEMENTMEDICAL:-•Anti inflammatory medications are sometimes used to decrease the inflammation in the fascia and reduce pain. Studies show that many people get better with anti-inflammatory as those who don’t have any improvement. Since these medications are rarely used , it’s difficult to judge their true effectiveness.•Botulinum toxin otherwise known as BOTOX has been used to treat plantar fasciitis .The chemical is injected in to the area to paralysis the muscles. BOTOX has direct analgesic (pain relieving) and anti-inflammatory effects.STEROID INJECTION: Injection of 0.1 to 0.2 ml of corticosteroid is given from the medial side of heel;

Into the tender area may be helpful to avoid steroid-induced atrophy of the fat pad, inject deep in to the plantar fascia;Often the plantar fascia pain will be removed.

DRUGS INCLUDE:oDiclofenac sodiumoIbu profenoIndomethacin

Plantar fascia and nerve release.

A, Incision is made over first branch of lateral plantar nerve.

B, Superficial fascia of abductor hallucis muscle is released.

C, Abductor hallucis muscle is reflected proximally.

D, Abductor hallucis muscle is retracted distally.

E, Cross-sectional anatomy of heel along course of first branch of lateral plantar nerve.

F, Resection of small medial portion of plantar fascia.

Endoscopic Plantar Fascia Release A, Incision placement measured from non–weight bearing lateral projection.

B, Endotrac system.

C, Palpation of plantar fascia with fascial elevator.

D, Obturator-cannula system is advanced laterally while superficial to plantar fascia.

E, Double markings show approximate location of medial plantar fascia investment.

F, Single marking shows approximate location of medial intermuscular septum.

G, Complete thickness of plantar fascia is visualized while viewing from lateral to medial.

•Release pressure on the small nerves in the area

Usually the procedure is done through a small incision on the edge of the foot, although some surgeons now perform this type of surgery using an endoscope. NEUROLYSIS: Involves cutting the nerve sheath of the abductor digiti minimi muscle and breaking up adhesions to free the nerve and relieve the pressure and pain. Radio frequency, heat, or chemical injection, have also been used.

PHYSIOTHERAPY TREATMENTGOALS:

SHORT TERM GOALS:To reduce painTo reduce inflammationTo reduce swellingTo reduce tenderness

LONG TERM GOALS:•To maintain the muscle property•To normalize the function•To improve flexibilityTo improve strength of the muscleTo maintain balance

ELECTRO THERAPY MODALITIES

ULTRASOUND:

Extracorporeal shock wave therapy for treatment of insertional plantar fasciitis.

Extracorporeal shock wave therapy is a technology that delivers concentrated ultrasound energy to a localized area of collagen disruption, hemorrhage, and presumably neovascularization to chronic degenerative fully vascularized tissue, such as the insertion of the plantar fascia into the calcaneal tuberosity.

Although the preponderance of literature has evaluated high-energy devices, there are reports of low-energy devices being used for the same purpose.

PHONOPHORESIS:

•It is the movement of the drugs through the skin in to subcutaneous tissue under the influence of ultrasound.

•Drugs used: →Hydrocortisone ointment →Steroid type drugs such as Salicylates, NSAIDS. →Anti inflammatory analgesic cream such as trolamine sulphate

Treatment time depends upon the area to be treated Ex: 1 minute of treatment time for 10 cm2 area.

TENS:•TENS is the application of a pulse rectangular wave current via surface electrodes on patient skin.•HIGH TENS: Frequency : 100 to 150 Hz Pulse width : 100 to 500us Intensity : 12 to 30 mA Treatment time : Daily treatment session upto 40 min.•LOW TENS: Frequency : 1 to 5 Hz Pulse width : 100 to 150 us Intensity : >30mA Treatment time : Daily treatment session upto 40 min.•It gives sharp nociceptive stimulus and possibly muscle twitch.

CRYOTHERAPY:•Apply ice as soon as possible after exercise sessions•Maximum duration should be 20 to 25 minutes•Reactive hyperemic redness should resolve in 15 to 20 minutes•Ice packs, ice massage or ice immersion are effective in reducing pain,odema and inflammation•Immersion in ice water for 20 minutes at 50-60 F has been found to be more effective than heat or contrast bath in reducing odema’

ACETIC ACID IONTOPHORESIS:•Iontophoresis is a non invasive drug delivery system that uses a low electrical current to deliver aqueous ionic solutions transversally to superficial areas•Acetic acid iontophoresis for chronic heel pain has shown good results within 3-4 weeks•The aqueous acetic acid is ionized to form the negatively charged acetate ion that is transmitted through the skin. •Physiological responses to chronically inflamed tissue results from higher concentration of insoluble calcium carbonate to an injured area which contributes to the ongoing pain cycle and abnormal restructuring of myofascial tissue.

THERAPEUTIC EXERCISESFREE EXERCISES:Free exercises are practiced every hour in lying with legs elevated.•Feet pushing down and pulling up•Feet turning out and holding•Feet turning out and upwards•Feet turning out and downwards•Foot pulling up and in then pushing down and out•Foot pulling up and out then pushing down and in. Each movement should be repeated 5 to 10 times.STRETCHING EXERCISES: →The Rotational Hamstring Stretch →The Trip lane Achilles Stretch →The Rotational Plantar Fascia Stretch

TRI –PLANE ACHILLES STRETCH:

ROTATIONAL PLANTAR FASCIA STRETCH:

PLANTAR FASITIS TAPING METHODS:•With this technique, the plantar fascia is supported and its movement becomes limited.

1.Start by taping around the ball-of-the-foot (metatarsal) area. Next, wrap another piece of tape around the heel attach it to the tape around the ball-of-the-foot.2.Place a strip of tape around the metatarsal region and then cross the mid foot diagonally before wraping it around the heel and crossing the mid-foot again.

This is going to make an X –shape across the mid-foot and will be responsible for giving support to the plantar fascia.

EXERCISE TO CONTROL EXCESSIVE PRONATION:

IMPROVE TIBIALIS POSTERIOR STRENGTH:•Ankle inversion using elastic band.•Side-lying: Ankle inversion using ankle weight, emphasizing eccentric phase control.•Single leg stance balance activities with a neutral foot position

IMPROVE ANKLE PLANTAR FLEXOR STRENGTH:•Heel rises with the foot in a toed position.

IMPROVE INTRINSIC FOOT MUSCULAR STRENGTH:•Arches of the foot are raised in weight bearing position.•Stand and bring the foot in to and out of weight bearing pronation-supination•.IMPROVE PROXIMAL HIP MUSCULATURE STRENGTH:•Wall slides with a neutral foot position.

PREVENTIONTake some simple steps to prevent painful steps later :

•CHOOSE SUPPORTIVE SHOES: - Avoid shoes with high heels. Buy shoes with a low to moderate heel, good arch support and shock absorbency. Don’t go barefoot, especially on hard surfaces.

•DONT WEAR WORN-OUT ATHLETIC SHOES:

•START SPORTS ACTIVITIES SLOWLY:- •WAKE UP WITH A STRETCH: •Using sole that support the arch and reduce tension on the ligament. •Stretching calf muscle to reduce tightness.•Wearing proper footwear everyday and in sport activities. •Making use of a heel pad, heel cushion or slight heel lift to relieve pressure and reduce inflammation of the plantar fascia at its attachment to the heel bone.•Correcting leg length discrepancy via an adjustable heel lift.•Maintaining length of the tight calf muscle with the use of a night splint.

SUMMARY

Plantar fascitis is the inflammation of the plantar fasica. It is common in athletes and women. It is treatable condition by using various physiotherapy modalities like iontophoresis, ultrasound, cryotherapy, if it is diagnosed in acute stages.

The sub actue and chronic conditions will have poor prognosis where steroids and the surgical procedures plays the major role in management.

Acetic acid iontophoresis and ultrasound are proved to be effective in acute conditions. Strengthening and stretching exercises are also useful to manage plantar fascitis.

MCR chapels with arch support are helpful for the patients with plantar facitis. Properly casted and designed foot orthoses should be cornerstone of non surgical treatment of sub calcaneal pain.

The prognosis of the plantar fascitis will be better with the physiotherapy manoveours in acute stages where the sub acute and chronic has poor prognosis.

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