Plantar fasciitis

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Plantar fasciitis

  1. 1. Oral Revalida Written Report: Plantar Fasciitis Submitted by: Karla Suzatte M. Dasargo DDC- PT Intern 2014 November 11, 2013
  2. 2. PLANTAR FASCIITIS It is also referred to as plantar heel pain syndrome, heel spur syndrome, or painful heel syndrome. Definition It is a painful inflammatory process of the plantar fascia, the connective tissue or ligament on the sole of the foot. It is often caused by overuse of the plantar fascia, increases in activities, weight or age. Description It is an overload injury usually associated with biomechanical abnormalities such as tight plantar flexors and short flexor muscles. Etiology     Deterioration of the plantar fascia. Connective tissue deterioration is associated with many systemic factors that alter microcirculation within tissue, such as the patient’s age, arteriosclerosis, lipid abnormalities, tobacco abuse, and diabetes mellitus. Rheumatoid arthritis, ankylosing spondylitis, and other seronegative arthropathies can be associated with plantar fasciitis and other enthesopathies. Mechanical overload of the plantar fascia has been suspected to play a significant role in the development of plantar fasciitis. Several studies have identified associations of plantar fasciitis with obesity and poor ankle flexibility; both of these factors would be expected to add to the mechanical load of the forefoot. The plantar fascia also may be damaged by direct impact on the heel through gait or repetitive trauma to or overloading of the front of the foot through gait abnormalities, posture, and other tendon contractures (eg, hamstring tendon contractures). Damage to other supporting structures that assist in arch stabilization may increase the stress on the plantar fascia; this may include injuries to the posterior tibial tendon or intrinsic plantar ligaments, resulting in acquired flatfoot deformity, or “fallen arches,” and instability caused by midfoot arthritis. The intrinsic musculature may be compromised in many ways, including weakness resulting from compressive or peripheral neuropathy and deconditioning because of the patient’s age or the use of overprotective footwear or arch supports. Epidemiology     Plantar fasciitis, reportedly the most common cause of pain in the inferior heel Estimated to account for 11 to 15 percent of all foot symptoms requiring professional care among adults. It is the most common cause of heel pain and affects 15-20% of runners and is also common among military personnel. The incidence reportedly peaks in people between the ages of 40 and 60 years in the general population and in younger people among runners.
  3. 3.  The predominance of the condition according to sex varies from one study to another. The condition is bilateral in up to a third of cases. Anatomy Foot The foot supports the body weight and provides leverage for walking and running. It is unique in that it is constructed in the form of arches, which enable it to adapt its shape to uneven urfaces. It also serves as a resilient spring to absorb shocks, such as in jumping. The Sole of the Foot Skin The skin of the sole of the foot is thick and hairless. It is firmly bound down to the underlying deep fascia by numerous fibrous bands. The skin shows a few flexure creases at the sites of skin movement. Sweat glands are present in large numbers. The sensory nerve supply to the skin of the sole of the foot is derived from the medial calcaneal branch of the tibial nerve, which innervates the medial side of the heel; branches from the medial plantar nerve, which innervate the medial two thirds of the sole; and branches from the lateral plantar nerve, which innervate the lateral third of the sole. Deep Fascia The plantar aponeurosis is a triangular thickening of the deep fascia that protects the underlying nerves, blood vessels, and muscles. Its apex is attached to the medial and lateral tubercles of the calcaneum. The base of the aponeurosis divides into five slips that pass into the toes. In younger people the plantar fascia is also intimately related to the Achilles tendon, with a continuous fascial connection between the two from the distal aspect of the Achilles to the origin of the plantar fascia at the calcaneal tubercle. However, the continuity of this connection decreases with age to a point that in the elderly there are few, if any, connecting fibers. There are also distinct attachments of the plantar fascia and the Achilles tendon to the calcaneus so the two do not directly contact each other. Nevertheless, there is an indirect relationship whereby if the toes are dorsiflexed, the plantar fascia tightens via the windlass mechanism. If a tensile force is then generated in the Achilles tendon it will increase tensile strain in the plantar fascia. Muscles of the Sole of the Foot The muscles of the sole are conveniently described in four layers from the inferior layer superiorly. First layer: Abductor hallucis, flexor digitorum brevis, abductor digiti minimi
  4. 4. Second layer: Quadratus plantae, lumbricals, flexor digitorum longus tendon, flexor hallucis longus tendon Third layer: Flexor hallucis brevis, adductor hallucis, flexor digiti minimi brevis Fourth layer: Interossei, peroneus longus tendon, tibialis posterior tendon Arteries of the Sole of the Foot Medial Plantar Artery The medial plantar artery is the smaller of the terminal branches of the posterior tibial artery. It arises beneath the flexor retinaculum and passes forward deep to the abductor hallucis muscle. It ends by supplying the medial side of the big toe. During its course, it gives off numerous muscular, cutaneous, and articular branches. Lateral Plantar Artery The lateral plantar artery is the larger of the terminal branches of the posterior tibial artery. It arises beneath the flexor retinaculum and passes forward deep to the abductor hallucis and the flexor digitorum brevis. On reaching the base of the 5th metatarsal bone, the artery curves medially to form the plantar arch and at the proximal end of the first intermetatarsal space joins the dorsalis pedis artery. During its course, it gives off numerous muscular, cutaneous, and articular branches. The plantar arch gives off plantar digital arteries to the toes. Dorsalis Pedis Artery (The Dorsal Artery of the Foot) On entering the sole between the two heads of the first dorsal interosseous muscle, the dorsalis pedis artery immediately joins the lateral plantar artery Branches the first plantar metatarsal artery, which supplies the cleft between the big and second toes. Veins of the Sole of the Foot Medial and lateral plantar veins accompany the corresponding arteries, and they unite behind the medial malleolus to form the posterior tibial venae comitantes. Nerves of the Sole of the Foot Medial Plantar Nerve The medial plantar nerve is a terminal branch of the tibial nerve. It arises beneath the flexor retinaculum and runs forward deep to the abductor hallucis, with the medial plantar artery. It comes to lie in the interval between the abductor halluces and the flexor digitorum brevis. Lateral Plantar Nerve The lateral plantar nerve is a terminal branch of the tibial nerve. It arises beneath the flexor retinaculum and runs forward deep to the abductor hallucis and the flexor digitorum brevis, in company with the lateral plantar artery. On reaching the base of the fifth metatarsal bone, it divides into superficial and deep branches.
  5. 5. Ligaments of the sole of the foot Spring ligament (Plantar calcaneonavicular) The plantar calcaneonavicular ligament is strong and runs from the anterior margin of the sustentaculum tali to the inferior surface and tuberosity of the navicular bone. The superior surface of the ligament is covered with fibrocartilage and supports the head of the talus. Long plantar ligament The long plantar ligament is a strong ligament on the lower surface of the joint. It is attached to the under surface of the calcaneum behind and to the under surface of the cuboid and the bases of the third, fourth, and fifth metatarsal bones in front. It bridges over the groove for the peroneus longus tendon, converting it into a tunnel. Short plantar ligament (Calcaneocuboid) The short plantar ligament is a wide, strong ligament that is attached to the anterior tubercle on the under surface of the calcaneum and to the adjoining part of the cuboid bone. The Arches of the Foot The foot has three such arches, which are present at birth: the medial longitudinal, lateral longitudinal, and transverse arches. In the young child, the foot appears to be flat because of the presence of a large amount of subcutaneous fat on the sole of the foot. The medial margin of the foot, from the heel to the 1st metatarsal head, is arched above the ground because of the important medial longitudinal arch. The pressure exerted on the ground by the lateral margin of the foot is greatest at the heel and the 5th metatarsal head and least between these areas because of the presence of the low-lying lateral longitudinal arch. The transverse arch involves the bases of the five metatarsals and the cuboid and cuneiform bones. This is, in fact, only half an arch, with its base on the lateral border of the foot and its summit on the foot’s medial border. The body weight on standing is distributed through a foot via the heel behind and six points of contact with the ground in front, namely, the two sesamoid bones under the head of the first metatarsal and the heads of the remaining four metatarsals. The Bones of the Arches Medial longitudinal arch This consists of the calcaneum, the talus, the navicular bone, the three cuneiform bones, and the first three metatarsal bones. Lateral longitudinal arch This consists of the calcaneum, the cuboid, and the 4th and 5th metatarsal bones
  6. 6. Transverse arch This consists of the bases of the metatarsal bones and the cuboid and the three cuneiform bones. Biomechanics of Plantar fascia        The plantar fascia contributes to support of arch of the foot by acting as a tie-rod, where it undergoes tension when the foot bears weight. One biomechanical model estimated it carries as much as 14% of the total load of the foot. Complete rupture or surgical release of the plantar fascia leads to a decrease in arch stiffness and a significant collapse of the longitudinal arch of the foot. Surgical release also significantly increases both stress in the plantar ligaments and plantar pressures under the metatarsal heads. The plantar fascia also has an important role in dynamic function during gait. It was found the plantar fascia continuously elongated during the contact phase of gait. It went through rapid elongation before and immediately after mid-stance, reaching a maximum of 9% to 12% elongation between mid-stance and toe-off. During this phase the plantar fascia behaves like a spring, which may assist in conserving energy. The plantar fascia has a critical role in normal mechanical function of the foot, contributing to the "windlass mechanism". When the toes are dorsiflexed in the propulsive phase of gait, the plantar fascia becomes tense, resulting in elevation of the longitudinal arch and shortening of the foot. Therefore, the plantar fascia has a number of roles, the most important of these including supporting the arch of the foot and contributing to the windlass mechanism. Pathology     The site of abnormality is typically near the site of origin of the plantar fascia at the medial tuberosity of the calcaneus. Histologic examination of biopsy specimens from patients undergoing plantar fascia– release surgery for chronic symptoms has shown degenerative changes in the plantar fascia, with or without fibroblastic proliferation, and chronic inflammatory changes. It is more likely caused by degeneration or weakening of the tissue. This process probably begins with small tears that occur during activity and that, in normal circumstances, the body simply repairs, strengthening the tissue as it does. That is the point of exercise training. But sometimes, for unknown reasons, this on-going tissue damage overwhelms the body’s capacity to respond. The small tears don’t heal. They accumulate. Most common Signs & Symptoms  Pain (throbbing, searing, or piercing) when they take their first steps after they get out of bed or sit for a long time, you may have less stiffness and pain after you take a few
  7. 7.   steps. But your foot may hurt more as the day goes on. It may hurt the most when you climb stairs or after you stand for a long time. Tenderness to palpation is present at the volar aspect of the heel, usually slightly medial to midline Antalgic gait Examination & Diagnostic procedures      Ocular inspection – checks for a high arch, area of maximum tenderness on the bottom of your foot, just in front of your heel bone, Pain that gets worse when you flex your foot and the doctor pushes on the plantar fascia. The pain improves when you point your toes down, Limited "up" motion of your ankle (DF). X-ray- rule out a stress fracture of the heel bone and to see if a bone spur is present. Bone scans - useful for distinguishing plantar fasciitis from calcaneal stress fracture MRI- can show thickening of the plantar fascia Laboratory tests - rule out a systemic illness causing the heel pain, such as rheumatoid arthritis, Reiter's syndrome, or ankylosing spondylitis Differential diagnosis Neurologic Tarsal tunnel Pain, syndrome burning sensation, and tingling on the sole of the foot Abductor Burning in digiti quinti heel pad nerve entrapment Soft tissue Achilles Pain is tendonitis retrocalcaneal Heel contusion History of trauma Skeletal Calcaneal Calcaneal stress fracture swelling, warmth, and tenderness Others Osteomal Diffuse -acia skeletal pain, muscle weakness Calcaneal epiphysitis (Sever’s disease) Heel pain in adolescents Tumors (rare) Peripheral neuropathy Common in patients who abuse alcohol and in patients with diabetes Diffuse foot pain, night pain fat-pad atrophy Pain in area of atrophic heel pad Osteomyelitis Systemic symptoms (e.g., fever, night pain) Vascular insufficie ncy Lumbar radiculopathy Pain radiating down the leg to the heel, weakness, abnormal reflexes Posterior tibial tendonitis Pain on the inside of the foot and ankle Inflammatory arthropathies With bilateral plantar fasciitis Multiple joints affected Paget’s disease Deep bone pain, night pain, constitutiona l symptom Pain in muscle groups that is reproducible with exertion, abnormal vascular examination Bowed tibias, kyphosis, headaches
  8. 8. Management  Medical and Surgical Surgery is considered only after 12 months of aggressive nonsurgical treatment. o o   Surgical plantar fasciotomy with or without heel spur removal. There is a method, through an open procedure, percutaneously or most common endoscopically that release of the plantar fascia. This is an effective treatment, without the need for removal of a calcaneal spur, when present. There is a professional consensus, 70-90% of heel pain patients can be managed by nonoperative measures. Surgery of plantar fasciitis should be considered only after all other forms of treatment have failed. With endoscopic plantar fasciotomy, using the visual analog scale, the average post-operative pain was improved from 9.1 to 1.6. For the second group (ESWT), using the visual analog scale the average post-operative pain was improved from 9 to 2.1. Endoscopic plantar fasciotomy gives better results than extra-corporeal shock wave therapy, but with liability of minor complications Gastrocnemius recession. This is a surgical lengthening of the calf (gastrocnemius) muscles. Because tight calf muscles place increased stress on the plantar fascia, this procedure is useful for patients who still have difficulty flexing their feet, despite a year of calf stretches. The procedure can be performed with a traditional, open incision or with a smaller incision and an endoscope. Complication rates for gastrocnemius recession are low, but can include nerve damage. Pharmacology o Nonsteroidal anti-inflammatory medication. Drugs such as ibuprofen or naproxen reduce pain and inflammation. Using the medication for more than 1 month should be reviewed with your primary care doctor. o Cortisone injections. Cortisone, a type of steroid, is a powerful antiinflammatory medication. It can be injected into the plantar fascia to reduce inflammation and pain. Your doctor may limit your injections. Multiple steroid injections can cause the plantar fascia to rupture (tear), which can lead to a flat foot and chronic pain. Physical Therapy More than 90% of patients with plantar fasciitis will improve within 10 months of starting simple treatment methods o General measures  Rest. Decreasing or even stopping the activities that make the pain worse is the first step in reducing the pain. You may need to stop athletic activities where your feet pound on hard surfaces (for example, running or step aerobics).
  9. 9.  o o o o o o Ice. Rolling your foot over a cold water bottle or ice for 20 minutes is effective. This can be done 3 to 4 times a day Taping  No studies have adequately evaluated the effectiveness of taping or strapping for managing plantar fasciitis. Shoe inserts  magnet-embedded insoles  custom orthotics and prefabricated shoe inserts (e.g., silicone heel pad, felt pad, rubber heel cup) combined with stretching Night splints  Posterior-tension night splints maintain ankle dorsiflexion and toe extension, creating a constant mild stretch of the plantar fascia that allows it to heal at a functional length. Stretching  Stretching protocols often focus on the calf muscles and Achilles tendon or on the plantar fascia. The benefits of stretching both the plantar fascia and the Achilles tendon are unknown.  Combined with strengthening of the short foot & plantar flexors Modalities  Therapeutic ultrasound  Extracorporeal shockwave therapy (ESWT). During this procedure, high-energy shockwave impulses stimulate the healing process in damaged plantar fascia tissue. ESWT has not shown consistent results and, therefore, is not commonly performed. Deep tissue massage / MFR  Promotes relaxation
  10. 10. Sources: Journals and articles H. B. Kitaoka, Z. P. Luo, E. S. Growney, L. J. Berglund and K. N. An (October 1994). "Material properties of the plantar aponeurosis". Foot & ankle international 15 (10): 557– 560. PMID 7834064 G. A. Arangio, C. Chen and W. Kim (June 1997). "Effect of cutting the plantar fascia on mechanical properties of the foot". Clinical orthopaedics and related research (339): 227–231. PMID 9186224. Jump up ^ Amit Gefen (March 2003). "The in vivo elastic properties of the plantar fascia during the contact phase of walking". Foot & ankle international 24 (3): 238–244. PMID 12793487 Plantar Fasciitis, Rachelle Buchbinder, M.B., B.S., F.R.A.C.P., N Engl J Med 2004; 350:21592166May 20, 2004 http://www.nejm.org/doi/full/10.1056/NEJMcp032745 No Consensus on a Common Cause of Foot Pain,nytimes; Dr. Terrence M. Philbin, a boardcertified orthopedic surgeon at the Orthopedic Foot and Ankle Center in Westerville, Ohio; http://well.blogs.nytimes.com/2013/02/20/no-consensus-on-a-common-cause-of-foot-pain/?_r=0 http://www.webmd.com/a-to-z-guides/plantar-fasciitis-topic-overview Books Physical Medicine & rehabilitation 3rd edition by Randall L. Braddom Clinical Anatomy by regions 9th edition by Richard Snell Sports medicine Just the Facts by Francis G. O’Connor, MD, FACSM et. Al Therapeutic exercises by Kisner

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