A detailed description of the anatomy, physiology of arches. Plantar fasciitis is covered thoroughly from Mann's foot and ankle surgery book.

1. Dr Nirav Mungalpara (MS Ortho)
Arches of foot and plantar
fascitiis

2. Arches of the foot
• The foot is formed of 28 bones which are arranged in the transverse arch and
in a longitudinal arch.
• Arches of the foot are spatial orientations of the bone and its ligaments to take
a maximum advantage in term of bipedal walking and running activity.
• Human foot acts as lever to propel the body forward during locomotion.

3. • Arched foot acts as segmented lever
a. Triceps surae act in a simple lever
b. Long and short flexors muscles acts on
segmented lever – exerts muscles
actions on forefoot, during take off point
c. Lumbricals prevent the toes from
buckling under.

4. Medial column
The medial column is
• more mobile and
• consists of the talus, navicular, medial
cuneiform, 1st metatarsal, and great
toe.
Column of the foot
Lateral column
Lateral column is
• stiffer and
• consists of the calcaneus, cuboid,
and the 4th and 5th metatarsals.

5. Arches of foot
We will discuss this in 2 parts
(1) Anatomy of the arch (Making of the arch)
(2) Maintaining of the arch (Physiology of the arch)

6. Arches of the foot
Longitudinal
arches
Medial
Lateral
Transverse
arches
Anterior
Posterior
Most important

8. (1) Anatomy of the arch (Making of the arch)
• Each arch has following parts
(a) Anterior & Posterior ends
(b) Anterior & Posterior pillars
(c) Summit
(d) Main joints

9. “Key stone” and “Staples”

10. Medial Longitudinal Arch
• Anterior end – Head of the medial
three metatarsals.
• Posterior end – Medial tubercle of the
calcaneum
• Summit – trochlear (upper articular
surface) of the talus
• Anterior pillar – shafts of the medial
three metatarsals
• Posterior pillar – medial part of the
calcaneum
• Main Joint – Talo-calcaneo navicular
joint
• Key stone – Talus

11. Lateral Longitudinal Arch
• Anterior end – Head of the 4th
and 5th metatarsals.
• Posterior end – Lateral
tubercle of the calcaneum
• Summit – facet on the superior
articular surface of the
calcaneum
• Anterior pillar – shafts of the 4th
and 5th metatarsals
• Posterior pillar – lateral part of
the calcaneum
• Main Joint – calcaneo-cuboid
joint
• Key stone - Cuboid

12. Anterior Transverse Arch
• The anterior transverse arch is formed by
the heads of the five metatarsal bones.
• It is complete because the heads of the
first and fifth metatarsals both come in
contact with the ground and form the two
ends of the arch.

13. Posterior Transverse Arch
• The posterior transverse arch is established by the greater parts of the tarsus (cuneiform
and cuboid) and bases of the all 5 metatarsus.
• It is incomplete because only the lateral end comes in contact with the ground, the arch
forming a ‘half dome’ which is completed by a similar half-dome of the opposite foot.

14. MAINTENANCE OF ARCHES
(1) shape of the bones. “key-stones”
(2) Intersegmental ties / staples or ligaments (and muscles) that hold the
different segments of the arch together.
(3) Tie beams or bowstrings that connect the two ends of the arch.
(4) Slings that keep the summit of the arch pulled up.
(5) Suspension

15. “Key stone” and “Staples”

16. “Tie beam” and “Suspension”

17. Diff between Sling & Suspension
Sling & suspension

19. Maintenance of medial longitudinal arch
• Shape (key stone) -talus
• Staples:
Short and Long Plantar ligaments,
 Plantar calcaneo-navicular ligament
(Spring ligament),
Dorsal ligaments.

20. • Tie beam:
o Medial part of plantar aponeurosis,
Medial part of the intrinsic muscles
of the sole of the foot mainly flexor
halluces brevis and flexor
digitorum brevis.
o Partly by medial part of Flexor
digitorum and halluces longus

21. • Suspension: Tibialis anterior, Tendons passing from the posterior
compartment of the leg into the sole, i.e. tibialis posterior, flexor hallucis
longus, flexor digitorum longus. And medial (deltoid) ligaments of ankle
joint.

22. Maintenance of lateral longitudinal arch
• Shape (key stone-cuboid)
• Staples: Lateral part of Long and short
plantar ligaments, dorsal ligaments.
• Tie beam:
o Lateral part of plantar aponeurosis, Lateral
part of the intrinsic muscles of the sole of the
foot mainly flexor digitorum brevis and
longus.
o Abductor digiti minimi and flexor digiti minimi
brevis
• Suspension: peroneus longus and brevis.

24. Maintenance of transverse arch
• Shape (key stone) –intermediate
cuneiform
• Staples: deep transverse ligaments,
dorsal interossei, adductor hallucis
• Tie beam: tendon of peroneus longus
• Suspension: tendon of peroneus
brevis and tertius lateral side, tendon
of tibialis anterior medial side.

25. Sling for longitudinal arch
• Sling for longitudinal arch is formed by
o Tendons of tibialis anterior medially
o Peroneus longus laterally
together serve a sling (stirrup) which keeps
the middle of the foot pulled upwards, thus
supporting the longitudinal arches.

26. Sling of transverse arch
• Sling for transverse arch is formed by
o Tendons of tibialis posterior medially
o Peroneus longus laterally
• As the tendon of the peroneus longus runs transversely across the sole, it
pulls the medial and lateral margins of the sole closer together, thus
maintaining the transverse arches.

27. Plantar fascitiis

28. Plantar fasciitis
• Most common cause of heel pain
• All heel pain are not plantar fasciitis.
• Approx 1 out of 10 people will develop heel pain during their lifetime.

29. Title to be discussed
• Anatomy overview
• Etiology
• Patient’s History and presentation
• Role of imaging and other diagnostic modality
• Non operative treatment
• Operative indications and options
• Differential diagnosis (Most important)

30. Anatomy of plantar fascia
• Originates at the medial tubercle of the
calcaneus and inserts at 3 locations in the
forefoot, creating 3 distinct bands:
A) Medial (Most imporatnat, aka Plantar
Aponeurosis, thickest, strongest, and most
often involved in pathology)
B) Central,
C) Lateral.
• The medial band overlies and inserts onto the
muscles of the hallux, and the lateral band
inserts on the base the fifth metatarsal.

31. Physiology (windlass mechanism)
• Dorsiflexion of the toes tensions the
plantar fascia around the metatarsal
heads leading to an increase in the
height and stability of the longitudinal
arch of the foot, this effect is known as
the “Windlass” mechanism.

32. Plantar fascitiis
Etiology
 Mechanical injury in which excessive tensile strain within the plantar fascia
produces microscopic tears leading to chronic inflammation.
It is seen mainly in runners, footballer, rope jumpers and any athlete that pushes
the limit of elasticity of plantar fascia.
It may be degenerative because of senile changes like loss of elasticity of plantar
fascia, atrophy of plantar heel pad etc. That is why it is a “fasciosis” rather than a
fasciitis, where tensile strain is the key feature in the pathogenesis.
 Seronegative arthropathy related injury where PF is part of enthesitis.

33. Patient’s presentation
Typical presentation
• Dull aching or throbbing pain, which is localized to the area around the origin
of the medial or slight central part of plantar fascia on the calcaneus.
• This pain is usually worst with the first step in the morning and when getting up
from sitting. It often gets better with activity, but then worsens as the activity
becomes prolonged.
On examination
• The plantar fascia and its origin at the calcaneus should be palpated, to elicit
tenderness. It is typically on the centro-medial part of the heel.
• Silverskiold test to see gastrocnemius tightness.
• Routine foot and ankle examination to see pes planus, pes cavus or any gait
abnormality that may have contributed for development of PF.

34. Silverskiold test
• The maximum passive ankle dorsiflexion is
compared with the knee (A) extended to (B)
flexed.
• The difference between dorsiflexion in these 2
positions is the contribution of the
gastrocnemius to the equinus contracture
because the gastrocnemius crosses both the
ankle and the knee joints whereas the other
plantarflexors of the ankle do not.
• A difference of greater than 10 degrees
confirms the presence of gastrocnemius
equinus contracture

35. Role of imaging
• Not needed if presentation is typical.
• Order when there is diagnosis dilemma.
(1) X ray
(2) USG
(3) MRI

36. X RAY
• If Weight-bearing lateral radiograph of
the foot demonstrating a large plantar
calcaneal spur, then it suggests chronic
heel cord tightness.
• The heel spur is a sign of calcification at
the origin of the flexor digitorum brevis
muscle, which develops in response to
chronic tightness of the heel cord. It is
seen in a number of disorders but is of
no functional significance, as neither the
shape of the spur nor its size correlates
with symptoms of PF.

37. USG
It demonstrates thickening (arrows) of
the proximal medial/central band
There is a small region of no
echogenicity (asterisk) within the
medial aspect of the central band
consistent with a moderate-grade
partial thickness tear.
• To diagnose the condition
Diagnosis - A plantar fascia thickness
>4.5 mm and the presence of
hypoechoic areas are specific for PF.
• To objectively measure the
treatment response –
extent of reduction of fascia thickness
is an objective measure of treatment
efficacy.

38. MRI
• Advice when you want to rule out the other condition like infection, tumour,
calcaenum stress fracture, baxter nerve entrapment etc that mimic the plantar
fasciitis.
• Typical, PF has increased signal intensity and proximal plantar fascia
thickening on T2- weighted and short tau inversion recovery images.

39. Non operative treatment
• Nonsteroidal anti-inflammatories (NSAIDs),
• Stretching of the gastrocnemius and the plantar fascia,
• Use of an orthosis (heel pads, heel cups, arch supports, or night splints)

40. • In the gastrocnemius stretch, the hands
are placed against the wall, the leg
being stretched is slid posteriorly with
the knee bent as far as it will go and
then the knee is straightened.
• In the plantar fascia stretch, the foot to
be stretched is placed on top of the
contralateral knee, the ankle is
maximally dorsiflexed, and then the
toes are pulled up, tensioning the
plantar fascia.

41. PFSS (Plantar Fascia specific Stretching)
• At least three times a day, first time in the morning before the first step in the
morning
• Max, patient can do 4-5 times a day
• Ideal improvement id 25% at about 6 week, another 25% at 12 week then it
burns itself out.
• Ideal period of recovery with conservative mx is 6-9 months.

43. Orthosis
Inshoes
Night splint
External
In-shoe orthoses :
(A)gel heel cups,
(B)over-the-counter arch
supports

44. Other modalities
1. Extra corporeal shock wave therapy
2. Local botulinium injection
3. Treatment of heel fat pad atrophy by silicon implant
4. Treatment of underlying systemic disease in case of sero-negative
arthropathy, rhumatological condition or any neurological cause

45. Treatment algorithm
First visit
• NSAIDS
• PFSS
• Night splint
• Day time in-
shoes orthosis
First visit after 6-8
week
• Expect at least
25%
improvement
• Encourage the
patient to adhere
with the
treatment
Failure of
conservative
management
• When no
significant
improvement
even after 9
months of
conservative
treatment.

46. Trial of below knee cast
Below knee cast in dorsiflexion of the toes and ankle can be given for 6 week if
• Non compliant to conservative treatment
• Psychologically challenged
• Can be given before offering the operative management in case of failure of
conservative management

47. Operative options
• Partial plantar release (open / endoscopic)
• Gastrocnemius lenghthening

48. Importanat D/D
1. Acute plantar fascia rupture
2. Entrapment of FBLPN (first branch of the lateral plantar nerve)
3. Calcaneal stress fracture
4. Tarsal tunnel syndrome
5. Plantar fibromatosis
6. Subcalcaneal bursitis
7. Flexor halluces longus tendonitis
8. S1 radiculopathy

50. Thank you for your
attention !