Plantar Fascitis

Background

Plantar fascitis is , a repetitive strain injury of the medial arch and heel, is one of the most common causes of foot pain. It is an inflammation of the dense, fibrous connective tissue structure originating from the medial tuberosity of the calcaneus. It has 3 portions :- medial, lateral and calcaneal and the largest is calcaneal.

The function of the plantar fascia is twofold: statically, it stabilizes the medial longitudinal arch; dynamically, it restores the arch and aids in reconfiguring the foot for efficient toe-off. When this tissue
becomes damaged, pain and/or weakness may develop in the area.

Risk factors

• overweight
• training errors
• lack of stretching before sports
• repetitive strain injuries of foot
• occupations
• foot wear
• flat foot deformity
• prolonged standing, walking

Biomechanics of the foot and ankle during walking and running
A runner’s gait can be separated into two phases: the stance phase and the swing phase. During the stance phase, the foot contacts and adapts to the ground surface; during the swing phase, the leg accelerates forward and prepares for ground contact. The stance phase consists of the following four sub-phases: initial contact, loading response, midstance, and terminal stance. During initial contact, the heel contacts the ground surface. The loading response occurs immediately after initial contact, ending
when the contralateral foot lifts off of the ground surface. The midstance phase starts when the contralateral foot lifts off of the ground surface; the contralateral leg is now the swing leg. The midstance phase ends as the tension on the gastrocnemius, soleus, and achilles tendon of the stance leg causes the heel to lift off of the ground surface. The terminal stance phase begins when
the heel lifts off of the ground and ends when the swing leg contacts the ground

The subtalar joint consists of the articulation of the undersurface of the talus with the calcaneus.Movement of the subtalar joint is pivotal in transforming the foot from a rigid lever during initial ground contact to a mobile shock absorber during loading response and early midstance, and back into a rigid lever as the foot prepares for toe-off. The two primary movements that occur at the subtalar
joint (STJ) are pronation and supination.

Symptoms

• pain occurs when placing foot on the ground at very first in the morning
• swelling occurs
• limmited range of motion in severe cases
• inferior heel pain

Treatment
Literature indicates that plantar fasciitis may be successfully treated using a conservative approach.An understanding of the anatomy and kinematics of the foot and ankle, the static and dynamic function of the
plantar fascia during ambulation, and knowledge of the contributing risk factors associated with plantar fasciitis aid in developing a proper treatment and preventative protocol for this condition.

General principles of treatment

• examine lower extremity for possible factors :- pes cavus or pes planus, LLD, fat pad atrophy,signs of arthritis
• review questions for possible traning errors or overuse findibgd in runners and atheletes
• identify poor shoe wear, hard walking, or running surface,supinator or pronators like wear of running shoes
• assessment of tight calfs and hamstring that may contribute to this condition
• treatment are more aggressive or more invasive if first phase is unsuccessful
• patient education- to ensure patient does exs at home, time table

phase 1
SRICE
electrotherapy- ultrasound, TENS, cold pack, cryo
Plantar fascia stretching
1.Cross your affected leg over your other leg.


2.Using the hand on your affected side, take hold of your affected foot and pull your toes back towards shin. This creates tension/stretch in the arch of the foot/plantar fascia.

3.Check for the appropriate stretch position by gently rubbing the thumb of your unaffected side left to right over the arch of the affected foot. The plantar fascia should feel firm, like a guitar string.

4.Hold the stretch for a count of 10. A set is 10 repetitions.

5.Perform at least 3 sets of stretches per day. You cannot perform the stretch too often.

Calf stretch

Stand facing a wall with your hands on the wall at about eye level. Put the leg you want to stretch about a step behind your other leg.Keeping your back heel on the floor, bend your front knee until you feel a stretch in the back leg. Hold the stretch for 15 to 20 seconds. Repeat 4 times.

                                                                                    



Deep friction massage of the plantar fascia- Apply gentle pressure across the entire foot as you smoothly glide down the foot. This will help loosen the tendon and direct tissue towards the heel to either help prevent or heel a bone spur, a condition which often goes hand in hand with plantar fasciitits.

Exercises

• Marble lift- Put marbles on the floor next to a cup. Using your toes, try to lift the marbles up from the floor and put them in the cup.Repeat exercise 15 times.
• Toe curls on towel- curl up your toes on towel. Try to grab the towel with your toes. Hold for 10 seconds and do 20 reps
• Balance exercises on wobble board
• ROM exercises for ankle and toes

Shoe wear modifications ( Running shoes )

• Flared stable heel to help control heel stability
• Firm heel counter to control hindfoot
• Soft cushioning of the heel, raising the heel 12-15mm higher than the sole
• Well molded achilles pad
• Avoid rigid leather dress shoes that increase torque on the achilles tendon

Anti-inflammatories

Oran anti-inflammatories have variable results. Ex : cyclooxygenase



Myofascial techniques have been shown to stimulate fibroblast proliferation, leading to collagen synthesis that may promote healing of plantar fasciitis by replacing degenerative tissue with a
stronger and more functional tissue. There is considerable clinical evidenceto support the effectiveness

of deep tissue procedures in treatment of strain/sprain injuries.

Referrence

Department of Foot and Ankle surgery- Kaiser permanente

Kinesiology of the Musculoskeletal system- Donald A.Neumann