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- 1. PLANTAR FASCITISPRESENTER : ANKUR MITTAL
- 2. INTRODUCTION The foot is really unique to human being. The structure of the foot allowsthe foot to sustain large weight bearing stresses under a variety of surfaces andactivities that maximize stability and mobility. Arches of the foot help in fast walking, running, jumping, weight bearingand in providing upright posture. Arches are supported by intrinsic and extrinsic muscles of the sole inaddition to ligaments, aponeurosis and shape of the bones.
- 3. The frequency of ankle or foot problems can be traced readily by thecomplex structure of the foot and their participation in all weight bearingactivities. Structural abnormalities can lead to altered movements between joints& contribute to excessive stresses on tissues of the foot and ankle that result ininjury The foot has to suffer from many disorders because of tight shoesor high heels which we wear for various reasons and also over using the footmay cause microtears and inflammation. Plantar fascia acts like a shock-absorbing bowstring, supporting the arch infoot. But if any tension on that bowstring becomes too great, it can create smalltears in the fascia; repetitive stretching & tearing can cause the fascia tobecome 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 ofplantar fasciitis.
- 4. 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 isworst when getting out of bed in the morning or after sitting for a long time. It iscaused by too much pressure or trauma to the bottom of the foot resulting fromwearing old "dead" shoes or weight gain. Recovery takes several weeks, aidedby icing and taping of the foot and anti-inflammatory medication.
- 5. RELEVANT ANATOMYThe os calcis is elveated anteriorly sothat during heel strike, the posteriortubercle contacts the ground 1st andtransmits full body weight.This make the calcaneum vulnerable totrauma or micro traumaThe heel fat pad has many fat globulesenclosed by multiple fibroelastic septaThese septa act like hydraulic chamberto bear weight evenlly across the oscalsis during locomotionAnd after 40 years this fat pad begin toatrophy and degenerate
- 6. The plantar aponeurosis is an inelastic facia that arises from the os calcis andis composed of three segmentsCoversundersurface ofabductorhaluucis Anteriomedial tuberosity
- 7. Windlass mechanism of the plantar fascia asthe toes are dorsiflexed. The plantar fascia, which originates from theanteriomedial plantar aspect of the calcanealtuberosity and inserts through several slipsinto the plantar plates of themetatarsophalangeal joints, the flexor tendonsheaths, and the bases of the proximalphalanges of the digits, is under constanttraction as it is pulled distally around the drumof the windlass (metatarsal heads). Thistightening elevates the longitudinal arch,inverts the hind foot and externally rotates theleg. This mechanism is passive and dependsentirely on bony and ligamentous instabilty.This mechanism whereby the arch is raised andsupported with dorsiflexion of toes providingmore flexibilty and rigidity to the foot..
- 8. Excessive foot pronation: Excessive pronation or inward rolling of the footalso inhibits efficient use of the windlass mechanism. This decreases shockabsorption through the plantar fascia which in turn increases the tension on theplantar fascia.Tight calf muscles: Having tight calf muscles can cause excessive footpronation contributing to excessive foot mobility which increases the level ofstresses on the plantar fascia.High arched foot: A high arched foot lacks the normal joint mobility whichreduces the foots ability to absorb shock from the ground, thereby increasingthe stresses on the plantar fascia.Ill-fitting or worn out shoes: Wearing ill-fitting or worn out shoes may changethe foot biomechanics, causing undue strain on the plantar fascia.Excessive walking and running on hard surfaces: This increases the shocktransmitted to the plantar fascia, increasing the strain on the plantar fascia.Overweight: Being overweight increases the level of stresses applied to thefascia due to the added body weight on the foot, increasing the strain on theplantar fasci
- 9. Another finding that supports this theory is that the most dense, unyieldingsection of the plantar aponeurosis originates from the location on thetuberosity of the calcaneus where the most common point of localtenderness is found during physical examination. It is not far-fetched tocompare this to tennis elbow. In fact, Woolnough called this entity tennisheelAging and repeated trauma, repetitive traction and aging could producemicroscopic tears and cystic degeneration in the origin of the plantar fasciaand the flexor digitorum brevis immediately beneath the plantar fascia.Furthermore, it is noted that the location of the familiar traction spur onthe anteromedial, plantar aspect of the calcaneal tuberosity coincides withthe origin of the flexor digitorum brevis.
- 10. Enterapment of nerve toabductor digiti mini can occurbetween abductor hallucisand the medial margin ofmedial head of quadratusplantae muscle
- 11. Structurally there are three arches(transverse, longitudinal, lateral) thatprovide support, stability and aid inlocomotion.The three- arch system contains anelaborate support system of ligaments,tendons and musclesThere is only one plantar arch in the sole.All the intrinsic muscles of the sole onlyare supplied by either of the two plantarnerves.The extrinsic muscles of the sole aresupplied by the nerve of the respectivecompartment.
- 12. 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 anddivide the subcutaneous fat in to small tight compartment which serves aswater-cushions and reinforce the spring-effect of the arches of the foot duringwalking, running and jumpingThe largest bone in the foot is the calcaneus. The most common site of injuryin the plantar fascia is at the attachment point of the plantar fascia on themedial tubercle of the calcaneus Muscles of the foot are arranged in four layers with neuro vascular bundlesbetween first and second layers and then between third and fourth layers.
- 13. MUSCLES OF SOLE OF THE FOOT Muscles of third layer of the soleMuscles of first layer of the sole Flexor hallucis brevisFlexor digitorum brevis Adductor hallucisAbductor hallucis Flexor digiti minimi brevisAbductor digiti minimi Muscles of fourth layer of the sole InterosseusMuscles of second layer of the sole Three plantar and four dorsal interosseusFlexor digitorum longusFlexor digitorum accessoriesLumbricalsFlexor hallucis longus
- 14. These are small muscles placed between themetatarsal bone. Plantar facitis occurs when these tissues areinflammed and irritated. Two muscles the quadratusplantae &the flexor digitorum brevis contribute to theproblem.
- 15. AETIOLOGYExcessive pronation of the foot.Poor arch support in the shoeFlat footProlonged standingFat pad atrophyTight triceps suraeRepetitive strength imbalancesStress,tension and pulling on the plantar fasciaOver use may cause microtears and inflammationWeak peroneiiCongenital problems such as Pescavus and PesplanusObesityReiters disease,Ankylosing spondylitis,Diffuse idiopathic skeletal hyperostosisSome 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 dont protect your feet -Injuries to the planter fascia.
- 16. In patients with idiopathic heel pain, the differential diagnosis should includerheumatoid arthritis,ankylosing spondylitis, Reiter syndrome, and osteoarthritis.In addition, especially in patients with diabetes, deep soft-tissue abscess shouldbe considered.In men younger than 40 years with bilateral painful heels, ankylosing spondylitisand Reiter syndrome should be ruled out.Women with bilateral symptoms should be evaluated for rheumatoid arthritis.
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