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.
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.
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.‟‟
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
The plantar aponeurosis is an inelastic facia that arises from the os calcis andis composed of three segmentsCoversundersurface ofabductorhaluucis Anteriomedial tuberosity
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..
•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 foot‟s 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
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.
Enterapment of nerve toabductor digiti mini can occurbetween abductor hallucisand the medial margin ofmedial head of quadratusplantae muscle
•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 muscles•There 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.
•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 jumping•The 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.
MUSCLES OF SOLE OF THE FOOT Muscles of third layer of the soleMuscles of first layer of the sole •Flexor hallucis brevis•Flexor digitorum brevis •Adductor hallucis•Abductor hallucis •Flexor digiti minimi brevis•Abductor digiti minimi Muscles of fourth layer of the sole •InterosseusMuscles of second layer of the sole •Three plantar and four dorsal interosseus•Flexor digitorum longus•Flexor digitorum accessories•Lumbricals•Flexor hallucis longus
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.
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 dont protect your feet -Injuries to the planter fascia.
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.
RISK FACTORSAGE: 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 distancerunning, ballet dancing and aerobics can contribute to an earlier onset ofplantar fascitis.FAULTY FOOT MECHANICS: Being flat-footed, having a high arch or even having an abnormal pattern ofwalking can adversely affect the weight distribution when standing, addingstress 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 hardsurfaces such as factory workers, teachers and waitresses can damage theirplantar fascia.IMPROPER SHOES: Shoes that are thin soled, loose, lacking arch support or the ability toabsorb shock cannot protect the feet. If we wear high heels regularly, the Achilles tendon which is attached to theheel can contract and shorten, causing strain, on the tissue around the heel.
PATHOLOGYThe plantar fascitis injury sequence:•Repetitive impact on feet for long time causes flexor muscles/tendons tobecome short and tight.•An impact on short, tight muscles/tendons causes micro tearing at the pointwhere 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 oftenreveal abnormalities of only the central or intermediate portion of the fascia.•Fasciitis is actually not an accurate description for the condition. Microscopicstudies of the plantar fascia in patients with heel pain usually revealdisorganization 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 symptomaticpatients. 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 moreappropriate term than plantar fasciitis because there is no evidence ofinflammation.
•Micro tears of the collagen fibers are thought to be the cause of themicroscopic changes.• It seems that heel impact does not cause the pathologic changes in patientswith heel pain syndromes.• Specifically, gait studies performed on patients with heel pain demonstrate nodifference 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 plantaraponeurosis at the origin on the calcaneus, commonly referred to as a heelspur.• The heel spur represents a marker for chronic heel pain but is not the cause ofthe pain.• In fact, foot x-rays of patients often reveal spurs in patients who areasymptomatic.•In addition, the presence or absence of a spur does not change the responseto 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 thebottom of the foot.
DIFFERENTIAL DIAGNOSIS OF HEEL PAINCONDITION CHARATERISTICSNEUROGENICAbductor digiti mini nerve entrapment Burning heel painLumbar spine disorders Pain radiating down to the leg.heel and abnormal reflexesNeuropathies common in patients who abuse alchohol and in patients with diabetes Diffuse foot pain and night painTarsal tunnel syndrome Pain, burning sensation and paraesthesisa on sole of foot
SOFT TISSUEAchilllis tendonitis Pain in retrocalcaneal areaFat pad atrophy pain in area of atrophic heel padHeel contusion History of traumaPlantar fascia rupture intense tearing sensation on the bottom of footPosterior tibial tendonitis pain on the inside of foot and ankleRetrocalcaneal bursitis pain in retrocalcaneal area
SkeletalCalcaneal epiphysitis (Sever’s disease) Heel pain in adolescentsCalcaneal stress fracture Calcaneal swelling, warmth, and tendernessInfections Osteomyelitis Systemic symptoms (e.g., fever, night pain)Inflammatory arthropathies More likely with bilateral plantar fasciitis Multiple joints affectedSubtalar 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 childrenTumors (rare) Deep bone pain, night pain, constitutional symptomsVascular 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 inrunning and jumping activities as ruptures of the PA (either complete orpartial) are caused by forcible plantar flexion and are common in competitiveathletes.Repetitive stress or minor trauma to the PA, however, also may result inrupture Spontaneous rupture of the PA may occur in patients with prior plantarfasciitis, especially in those treated with local steroid injections
INVESTIGATIONSX-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 theplantar aponeurosis at the origin on the calcaneus, commonly referred toas a heel spurMRI: Show thickening of plantar fasciaBONE SCAN: It show increase uptake at the calcaneusRHEUMATOLOGIC SCREENING: It can be important to rule out inflammatory arthrides.
thickening of central component of plantar aponeurosis (large arrows). Extensive edemaplantar aponeurosis as uniform bandlike infiltrates perifascial soft tissue (curvedstructure of low signal intensity (arrows). arrows).
complete rupture of plantar aponeurosis after complete rupture of plantar aponeurosislocal corticosteroid injections for chronic after local corticosteroid injections forplantar fasciitis. Lateral radiograph of foot chronic plantar fasciitis.shows calcaneal enthesophyte (curved arrow)with erosion of undersurface of calcaneus(straight arrows) and small bone fragment(open arrow).
Posttraumatic acute complete rupture of Partially circumferential high SIplantar aponeurosis around Achilles tendon indicate peritendinitis Edema within Kager’s fat pad anterior to Achilles Tendon indicate paratendinitis
leads to thickened tendonwith normal SI indicate tendinosis Insertional tendinopathy leads to enthesophyte absence of normal radiolucency in posteroinferior corner of Kager’s fat pad +/- erosion of calcaneus Indicate retrocalcaneal bursitis
LABORATORY INVESTIGATIONS: May be necessary in some cases to rule out a systemic illness causing theheel pain, such as rheumatoid arthritis, Reiters syndrome, or ankylosingspondylitis. These are diseases that affect the entire body but may first show as painin the heel.
SPECIAL TEST•This is good test to diagnose plantar fascitis.•Plantar fascitis have more tenderness in the plantar fascia when it is stretchedand less tenderness when the fascia is relaxed. The plantar fascitis test usesthis property to diagnose patients with plantar fascitis.•To perform this test, first stretch plantar fascia. Then use your thumb or fingerto feel the plantar fascia. If plantar fascia is tender, then try the same maneuverwith plantar fascia relaxed.•If pushing the stretched plantar fascia causes more tenderness than pushingon the relaxed plantar fascia, then the plantar fascia is likely the source of thepain and the patient have plantar fascitis.
MANAGEMENTMEDICAL:-•Anti inflammatory medications are sometimes used to decrease theinflammation in the fascia and reduce pain. Studies show that many people getbetter with anti-inflammatory as those who don‟t have any improvement. Sincethese medications are rarely used , it‟s difficult to judge their true effectiveness.•Botulinum toxin otherwise known as BOTOX has been used to treat plantarfasciitis .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 ofheel; 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 sodium oIbu profen oIndomethacin
Plantar fascia and nerve release. A, Incision is made over first branch oflateral plantar nerve.B, Superficial fascia of abductor hallucismuscle is released.C, Abductor hallucis muscle is reflectedproximally.D, Abductor hallucis muscle is retracteddistally. E, Cross-sectional anatomy of heel alongcourse of first branch of lateral plantarnerve.F, Resection of small medial portion ofplantar 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 thefoot, although some surgeons now perform this type of surgery usingan endoscope.NEUROLYSIS: Involves cutting the nerve sheath of the abductor digiti minimi muscle andbreaking 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 pain To reduce inflammation To reduce swelling To reduce tendernessLONG TERM GOALS: •To maintain the muscle property •To normalize the function •To improve flexibility To improve strength of the muscle To maintain balance
ELECTRO THERAPY MODALITIESULTRASOUND:Extracorporeal shock wave therapy for treatment of insertional plantar fasciitis.Extracorporeal shock wave therapy is a technology that delivers concentratedultrasound energy to a localized area of collagen disruption, hemorrhage, andpresumably neovascularization to chronic degenerative fully vascularized tissue, suchas the insertion of the plantar fascia into the calcaneal tuberosity.Although the preponderance of literature has evaluated high-energy devices, thereare 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 theinfluence of ultrasound.•Drugs used: →Hydrocortisone ointment →Steroid type drugs such as Salicylates, NSAIDS. →Anti inflammatory analgesic cream such as trolamine sulphateTreatment 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 surfaceelectrodes 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 electricalcurrent to deliver aqueous ionic solutions transversally to superficial areas•Acetic acid iontophoresis for chronic heel pain has shown good results within3-4 weeks•The aqueous acetic acid is ionized to form the negatively charged acetate ionthat is transmitted through the skin.•Physiological responses to chronically inflamed tissue results from higherconcentration of insoluble calcium carbonate to an injured area whichcontributes to the ongoing pain cycle and abnormal restructuring of myofascialtissue.
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 FASCIASTRETCH:
PLANTAR FASITIS TAPING METHODS:•With this technique, the plantar fascia is supported and its movement becomeslimited. 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 responsiblefor 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 phasecontrol.•Single leg stance balance activities with a neutral foot positionIMPROVE 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.
PREVENTION Take some simple steps to prevent painful steps later :•CHOOSE SUPPORTIVE SHOES: - Avoid shoes with high heels. Buy shoeswith a low to moderate heel, good arch support and shock absorbency. Don‟tgo 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 pressureand 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 inathletes and women. It is treatable condition by using various physiotherapymodalities like iontophoresis, ultrasound, cryotherapy, if it is diagnosed in acutestages. The sub actue and chronic conditions will have poor prognosis wheresteroids and the surgical procedures plays the major role in management. Acetic acid iontophoresis and ultrasound are proved to be effective in acuteconditions. Strengthening and stretching exercises are also useful to manageplantar fascitis. MCR chapels with arch support are helpful for the patients with plantarfacitis. Properly casted and designed foot orthoses should be cornerstone ofnon surgical treatment of sub calcaneal pain. The prognosis of the plantar fascitis will be better with the physiotherapymanoveours in acute stages where the sub acute and chronic has poorprognosis.