2. INTRODUCTION
The foot is really unique to human being. The structure of the foot allows
the foot to sustain large weight bearing stresses under a variety of surfaces and
activities that maximize stability and mobility.
Pain in the heel may occur from conditions from posterior and plantar
aspect, and from calcaneum, tendoachilles.
4. The heel fat pad has many fat
globules enclosed by multiple
fibroelastic septa
5. Biomechanics
• The calcaneum is elevated anteriorly so that during heel
strike, the posterior tubercle contacts the ground 1st and
transmits full body weight.
• This make the calcaneum vulnerable to trauma or micro
trauma
• Plantar fascia inserts through several slips into the plantar
plates of the metatarsophalangeal joints, the flexor tendon
sheaths, and the bases of the proximal phalanges of the
digits.
• , is under constant traction as it is pulled distally around the
metatarsal heads (drum of the windlass). This tightening
elevates the longitudinal arch, inverts the hind foot and
externally rotates the leg. This mechanism is passive and
depends entirely on bony and ligamentous instabilty.
6. Windlass mechanism of the plantar fascia
• As the toes are dorsiflexed
plantar fascia is under
constant traction as it is
pulled distally around the
metatarsal heads (drum of
the windlass).
• This tightening elevates the
longitudinal arch, inverts
the hind foot and
externally rotates the leg.
This mechanism is passive
and depends entirely on
bony and ligamentous
instabilty.
7. PLANTAR FASCIA
• The plantar fascia is the thick connective tissue which
supports the arch on the bottom of the foot
• It runs from the tuberosity of the calcaneus forward to the
heads of the metatarsal bones
8. Body weight
120 pounds
Rt. Foot - Talus
60 pounds
Lt. Foot - Talus
60 pounds
Rt. Calcaneus
30 pounds
Heads of
5 Meta tarsals
30 pounds
6 Bearing points
4 metatarsals + 2
sesmaoids under hallux
Each 5 founds
1
2
3
4
5
6
10. Plantar fasciitis
• Plantar fasciitis is a painful foot condition caused by
inflammation of insertion of the plantar fascia on the medial
process of the calcaneal tuberosity.
11. Aetiology
• AGE:Plantar fasciitis 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 tissue-such as long distance running, ballet
dancing and aerobics can contribute to an earlier onset of
plantar fascitis.
• FAULTY FOOT MECHANICS:Being flat-footed, having a high
arch or even having an abnormal pattern of walking can
adversely affect the weight distribution when standing, and
walking.
•Mechanical overload of the plantar fascia
• Damaged by direct impact or repetitive trauma
12. •Mechanical overload of the plantar fascia
• Damaged by direct impact or repetitive trauma
•Common among military personal
•Poor arch support in the shoe
•Prolonged standing
•Over use may cause microtears and inflammation
•Obesity
13. •In case of gastro soles shortness,-there is limited range of
dorsi-flexion and these short musculature don’t allow tibia to
glide anteriorly.
•This can be compensated by pronation of the subtalar joint.
•This pronated foot causes lots of stress over the plantar fascia
during the push of phase of gait.
•That will lead to plantar fasciitis.
14. •Absence of windlass mechanism
• During propulsive phase of gait cycle dorsiflexion of the 1stmtp will occur.
•That’s winds the plantar fascia around the head of the meta tarsal causing
calcaneal inversion,shortening the truss and lead to subtalar jt supination.
•Absence of this mechanism affects the subtalar jt supination that will lead to
plantar fasciitis.
15. • Tibialis posterior weakness
The tibialis posterior eccentrically control pronation during
footflat and midstance phase of gait cycle.
• Weakness of this muscle can cause excessive pronation of
the subtalar joint and this can also leads to plantar fasciitis.
16. •Excessive walking and running on hard surfaces: This
increases the strain on the plantar fascia.
•obesity: Being overweight increases the level of stresses
applied to the fascia due to the added body weight on the foot,
increasing the strain on the plantar fascia.
People having BMI >30 are prone to get plantar fasciitis.
17. •High arched foot:
•A high arched foot lacks the normal joint mobility which reduces the
foot’s ability to absorb shock from the ground, thereby increasing the
stresses on the plantar fascia.
•ill-fitting or worn out shoes:
•Wearing ill-fitting or worn out shoes may change the foot
biomechanics, causing undue strain on the plantar fascia.
18. Clinical features
• Pain under the heel
• Severe pain & inability to walk in morning after getting from sleep or
after sitting for long time and getting up to walk.
• Pain gets better after taking few steps
• Worsening of pain after prolonged standing or walking
• Localized tenderness over inferomedial aspects of anterior part of
calcaneal tuberosity.
• Passive dorsiflexion of toes accentuates the pain.
19. • Plantar fasciitis have more tenderness in the plantar fascia
when it is stretched and less tenderness when the fascia is
relaxed.
20. INVESTIGATIONS
X-RAYS -An X-ray may be taken to rule out a stress fracture of
the calcaneum
• X-rays reveal a calcification of the plantar aponeurosis at
the origin on the calcaneus, commonly referred to as a
calcaneum spur
• MRI: Show thickening of plantar fascia
• BONE SCAN: It show increase uptake at the calcaneus
21. plantar aponeurosis as uniform bandlike
structure of low signal intensity.
thickening of central component of plantar
aponeurosis . Extensive edema infiltrates
perifascial soft tissue .
22. RETROCALCANEAL BURSITIS
• Inflammation of bursa between anterior aspect of
tendoachilles and calcaneum.
• Midline swelling present at level of shoe counter.
• Swelling is tender
• Dorsiflexion of foot increases the pain
23. FAT PAD ATROPHY
• Elastic adipose tissue covers the plantar aspect of
calcaneum.
• With advancing age it degenerates and get atrophied.
• There is loss of shock absorbing capacity.
• Pain present beneath the heel in posterior weight-bearing
portion of tuberosity, chiefly on standing.
24. TARSAL TUNNEL SYNDROME
• It occurs due to entrapment of posterior tibial nerve within
tarsal tunnel.
• Pain and paraesthesia in the distribution of tibial nerve.
• Night pain may be present.
• Causes-
• ill fitting footware
• Post-traumatic fibrosis
• Tendon sheath cyst
• Thickened flexor retinaculum
25. HAGLUND’s DEFORMITY
• Abnormal prominence of posterosuperior border of
calcaneus.
• It is frequently a bony spur acquired as a result of poorly
fitting shoes or rubbing of counter of shoe.
• Seen in Adolescent females, ice skaters, soccer players,
runners
• It present as a bump located on postero superior aspect of
heel.
26. • Increasing heel height or one shoe size and using soft
counter shoe relives the pain
27. CALCANEAL EPIPHYSITIS
• It is mild traction injury.
• During puberty epiphyseal junction is weak, so prone to calf
muscles pull ended by microscopic fracture separation.
• Pain and tenderness is localized at tendoachilles insertion.
• Pain aggravated by wearing low heel, pressure of rigid shoe
counter and relieved by resting with knee flexion and foot in
equinus.
• Radiography-increased density of epiphysis and
fragmentation of epiphysis.
29. Achilles tendonopathy
• It is classified by
• Tendinitis-Inflammation of tendoachilles
• Tendinosis-Degenrative process occuring withing tendon itself.
• Tendoachilles is placed under extreme and rapid loading
activities like running, basketball playing, soccer.
• Clinical features include gradual onset of pain and swelling
2-3cms proximal to TA insertion.
• Pain increases during running.
• Tenderness is present 2-3cms proximal to TA insertion.
31. Calcaneum stress fracture
• Stress fracture occurs after repeatative submaximal loading
of bone.
• Causes are
• sudden increase of jogging or running distance.
• Running on hard surface
• Improper running shoes
• Malalignment of lower extremity.
• Abnormal arches of foot.
33. Rest
• Avoid
precipitating
activity
• Take few days off
jogging prolonged
standing/walking.
• Can reduce
severity of pain &
allow
inflammation to
lower down.
Ice packs
• Can reduce
inflammation and
pain
• Usually helpful in
acute conditions.
Anti
inflammatory
medications
• Decreases pain
• Reduces
inflammation
34. FOOTWEAR MODIFICATION
• Modified Foot wear can help to reduce pain.
• Footwears that provide sock-absorbation and proper arch-
support.
• Footwear having soft rubber healpad with concavity
scooped out.
• Footwear with heel lift inside relives pain in bursitis,
haglund’s deformity and Achilles tendinitis.
• High heel footwear transfer the w999Increasing shoe’s size
relives pain in haglund’s deformity.
36. ORTHOSIS
• Night splint is used for patient with symptoms greater than
6 months in duration.
• The desire length of time for wearing the splint is 1 to
3months.
• This splint maintain ankle in neutral position and toes in
slight extension.
Shoe inserts
38. TAPING
• Calcaneal taping or low-dye taping used for short-term pain
relief.
• Taping does cause re-inforcing medial longitudinal arch and
calcaneal fat pad
39. Injection Therapy : Local corticosteroid injections
can help to reduce inflammation and relieve pain.
41. Operative treatment
• Operative-(indicated in long term unresponsive cases or
when conservative management fails)
• Plantar fascia release
• Retrocalcaneal bursa excision
• Resection of Hugland’s deformity
• Drilling of multiple holes in calcaneum
• Gastroc lengthening
• Tarsal tunnel decompression
