PLANTAR FASCIITIS

Anatomy-

The plantar fascia is a band of fibrous connective tissue which originates from the periosteum of the medial tubercle of the calcaneus and extends to all five metatarsal heads. It is the basic structure to support the medial arch of the foot. It is a plantar aponeurosis band that comprises longitudinally organized fibrous connective tissue that gets split into three bands – lateral, central, and medial on its distal end. It is made up of collagen fibers and acts as a shock absorber. Studies say that plantar fascia is an aponeurosis and not a true fascia.

Introduction-

Plantar fasciitis occurs due to degeneration of the collagen fibers at the origin of the plantar fascia. It is one of the most common causes of heel pain and can occur at any age but is mostly seen in adults. It is a painful foot condition that is caused by inflammation at the insertion of the plantar fascia on the medial process of the calcaneal tuberosity.

Functions of the plantar fascia-

  • Maintains the medial arch of the foot
  • Shock absorption
  • Maintains the biomechanical structure of the foot
  • Play a major role in gait training
  • Maintain the flexibility of the foot

Causes-

  • Obesity
  • Long-standing
  • Decreased ankle dorsiflexion
  • Congenital- pes cavus, pes planus
  • Weight-bearing activities like – dancing, running, jumping especially on hard surfaces
  • Calf muscle tightness and weak intrinsic foot muscles
  • Wearing shoes that do not fit
  • Diabetes Mellitus
  • Females are more affected than males

Pathophysiology-

  • Chronic overuse leads to microtears in the origin of the plantar fascia and repetitive trauma leads to recurrent inflammation.
  • Affects mostly the age of 25-65 years.
  • Since the periosteum is affected, if the plantar fascia is left undiagnosed or untreated it can further lead to a calcaneal spur.

Clinical features-

  • Sharp heel pain- insidious onset, often with first steps in the morning after a long period of non weight bearing.
  • Gets worse at the end of the day after prolonged standing, relieved by ambulation.
  • Tender on palpation at the medial tuberosity of the calcaneus.
  • Dorsiflexion of toes and feet may increase tenderness with palpation.
  • Worsens with walking barefoot and walking upstairs.
  • Limited dorsiflexion
  • Limp while walking

Diagnosis and Investigations-

  • Consider the medical history and clinical features.
  • MRI shows thickening of the plantar fascia 
  • X-RAY is normal but if progressed to calcaneal spur heel spur may be seen.

Diagnostic tests-

  • Dorsiflexion test- Pain on passive dorsiflexion of foot and toe 
  • Pain on palpating medial calcaneal tubercle

Differential diagnosis-

  • Tarsal tunnel syndrome
  • Tendo Achilles
  • Paget’s disease
  • Rheumatoid arthritis
  • Infections

Prognosis-

Prognosis for plantar fasciitis is generally good. Only 5 out of 100 people suffering from plantar fasciitis have to undergo surgical release whereas the others recover within 6-12 months with a combination of medical, conservative and physical therapy management.

Medical management and Surgical management-

  • NSAIDs ( Ibuprofen, Naproxen)
  • Corticosteroids- can be given through injections or by ultrasound ( iontophoresis)
  • Botox injection
  • If medical management fails then go for surgical management. Surgery includes surgical release with plantar fasciotomy.

Conservative management-

  • Ice therapy for pain relief
  • Shoe inserts and orthotics
  • Night splints
  • Deep friction massage at the arch ( plantar fascia )
  • Contrast bath (Simultaneously dip the affected foot first in hot water for 3-4 min and then in cold water for approx 1 min.)

Physiotherapy Management-

Patient education-

  • The patient should be told that the symptoms may take weeks or even months to improve.
  • Advice for rest from aggravating activities initially.
  • Importance of home exercise program should be explained.

Modalities- 

  • Ultrasound 
  • Iontophoresis
  • Faradic foot bath

Strength training-

  • High load strength training appears to be effective.
  • It may aid in quicker reduction of pain and improvement in function
  • Towel pick up exercise
  • Resisted ankle joint ROM by either manually or by using sandbags or therabands
  • Prone hip extensions
  • Step up and step down

Stretching-

  • It consists of patient crossing the affected leg over the contralateral leg and using the fingers across to the first base of toes to apply pressure into toe extension until a stretch can be felt along the plantar fascia
  • Achilles tendon stretching can be performed in standing position with the affected leg placed behind the contralateral leg with toes pointed forward. Bend the knee of the unaffected leg towards the wall keeping your back straight, lean towards the wall and hold the stretch for 30 seconds.
  • Towel stretch
  • Kneel sitting to stretch dorsiflexors
  • Plantar fascia stretch- While standing at the corner of the wall or at the staircase. Keep one end (heel) on the lower surface of platform and other end (fingers) at the adjacent wall or staircase and stretch the plantar fascia
  • Toe stretch- raise your body on your toes with a towel roll beneath it.

Mobilization and manipulation-

  • May decrease pain and relieve symptoms in some cases
  • It is done for treating hypomobility of the talocrural joint.
  • Ankle, subtalar and mid foot joint mobilization is given.

Posterior night splints-

To maintain ankle dorsiflexion and toe extension allowing constant stretch on plantar fascia.

Taping and release of plantar fascia-

  • Iontophoresis can be combined with taping. Calcaneal taping can be used for short term pain relief but does not cause improvement in function
  • Plantar fascia can be released manually by applying gentle pressure to it.

Foot orthosis-

  • Foot orthosis produces small term benefit in function and also produces small reduction in pain but they do not have long term benefit.
  • When used in conjunction with stretching, shoe insert is more likely to produce improvement in symptoms.
  • Silicon gel cushioned heel pads are also effective

Home programme-

  • Patient is instructed to have contrast bath
  • Patient is asked to walk on toes after getting up from bed and not directly walk on the whole foot.
  • Heel pad can be inserted into the shoes while walking for comfort and pain relief.
  • Intrinsic muscle strengthening should be done.
  • Advice to drink water and be hydrated
  • Follow the home exercise program including stretches
  • Releasing plantar fascia with tennis ball under the sole of foot and moving foot over it back and forth

Advanced techniques-

  • IASTM
  • MFR