Plantar fasciitis is a common cause of heel pain that results from inflammation of the plantar fascia. It occurs when excess stress is placed on the fascia, often due to activities like long-distance running. Symptoms include pain along the bottom of the heel that is usually worst with first steps in the morning. Risk factors include age over 40, obesity, tight calf muscles, and wearing poorly fitting shoes. Diagnosis is based on symptoms and examination, while imaging can show thickening of the plantar fascia. Treatment focuses on reducing inflammation and stress on the fascia through stretching, orthotics, night splints, and heel pads.

1. PLANTAR FASCITIS
PRESENTER : ANKUR MITTAL

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.
Arches of the foot help in fast walking, running, jumping, weight bearing
and in providing upright posture.
Arches are supported by intrinsic and extrinsic muscles of the sole in
addition to ligaments, aponeurosis and shape of the bones.

3. The frequency of ankle or foot problems can be traced readily by the
complex structure of the foot and their participation in all weight bearing
activities.
Structural abnormalities can lead to altered movements between joints
& contribute to excessive stresses on tissues of the foot and ankle that result in
injury
The foot has to suffer from many disorders because of tight shoes
or high heels which we wear for various reasons and also over using the foot
may cause microtears and inflammation.
Plantar fascia acts like a shock-absorbing bowstring, supporting the arch in
foot. But if any tension on that bowstring becomes too great, it can create small
tears in the fascia; repetitive stretching & tearing can cause the fascia to
become 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 of
plantar fasciitis.

4. 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 is
worst when getting out of bed in the morning or after sitting for a long time. It is
caused by too much pressure or trauma to the bottom of the foot resulting from
wearing old "dead" shoes or weight gain. Recovery takes several weeks, aided
by icing and taping of the foot and anti-inflammatory medication.‟‟

5. RELEVANT ANATOMY
The os calcis is elveated 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
The heel fat pad has many fat globules
enclosed by multiple fibroelastic septa
These septa act like hydraulic chamber
to bear weight evenlly across the os
calsis during locomotion
And after 40 years this fat pad begin to
atrophy and degenerate

6. The plantar aponeurosis is an inelastic facia that arises from the os calcis and
is composed of three segments
Covers
undersurface of
abductor
haluucis
Anteriomedial
tuberosity

7. Windlass mechanism of the plantar fascia as
the toes are dorsiflexed.
The plantar fascia, which originates from the
anteriomedial plantar aspect of the calcaneal
tuberosity and 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 drum
of the windlass (metatarsal heads). 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.
This mechanism whereby the arch is raised and
supported with dorsiflexion of toes providing
more flexibilty and rigidity to the foot..

8. •Excessive foot pronation: Excessive pronation or inward rolling of the foot
also inhibits efficient use of the windlass mechanism. This decreases shock
absorption through the plantar fascia which in turn increases the tension on the
plantar fascia.
•Tight calf muscles: Having tight calf muscles can cause excessive foot
pronation contributing to excessive foot mobility which increases the level of
stresses on the plantar fascia.
•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.
•Excessive walking and running on hard surfaces: This increases the shock
transmitted to the plantar fascia, increasing the strain on the plantar fascia.
•Overweight: 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 fasci

9. Another finding that supports this theory is that the most dense, unyielding
section of the plantar aponeurosis originates from the location on the
tuberosity of the calcaneus where the most common point of local
tenderness is found during physical examination. It is not far-fetched to
compare this to tennis elbow. In fact, Woolnough called this entity “tennis
heel
Aging and repeated trauma, repetitive traction and aging could produce
microscopic tears and cystic degeneration in the origin of the plantar fascia
and the flexor digitorum brevis immediately beneath the plantar fascia.
Furthermore, it is noted that the location of the familiar traction spur on
the anteromedial, plantar aspect of the calcaneal tuberosity coincides with
the origin of the flexor digitorum brevis.

10. Enterapment of nerve to
abductor digiti mini can occur
between abductor hallucis
and the medial margin of
medial head of quadratus
plantae muscle

11. •Structurally there are three arches
(transverse, longitudinal, lateral) that
provide support, stability and aid in
locomotion.
•The three- arch system contains an
elaborate support system of ligaments,
tendons and muscles
•There is only one plantar arch in the sole.
•All the intrinsic muscles of the sole only
are supplied by either of the two plantar
nerves.
•The extrinsic muscles of the sole are
supplied by the nerve of the respective
compartment.

12. •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 and
divide the subcutaneous fat in to small tight compartment which serves as
water-cushions and reinforce the spring-effect of the arches of the foot during
walking, running and jumping
•The largest bone in the foot is the calcaneus. The most common site of injury
in the plantar fascia is at the attachment point of the plantar fascia on the
medial tubercle of the calcaneus
• Muscles of the foot are arranged in four layers with neuro vascular bundles
between first and second layers and then between third and fourth layers.

13. MUSCLES OF SOLE OF THE FOOT Muscles of third layer of the sole
Muscles 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
•Interosseus
Muscles of second layer of the sole
•Three plantar and four dorsal interosseus
•Flexor digitorum longus
•Flexor digitorum accessories
•Lumbricals
•Flexor hallucis longus

14. These are small muscles placed between the
metatarsal bone.
Plantar facitis occurs when these tissues are
inflammed and irritated. Two muscles the quadratus
plantae &the flexor digitorum brevis contribute to the
problem.

15. 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 don't protect your feet
-Injuries to the planter fascia.

16. In patients with idiopathic heel pain, the differential diagnosis should include
rheumatoid arthritis,
ankylosing spondylitis,
Reiter syndrome, and
osteoarthritis.
In addition, especially in patients with diabetes, deep soft-tissue abscess should
be considered.
In men younger than 40 years with bilateral painful heels, ankylosing spondylitis
and Reiter syndrome should be ruled out.
Women with bilateral symptoms should be evaluated for rheumatoid arthritis.

17. RISK FACTORS
AGE:
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 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, adding
stress on the plantar fascia.
OBESITY:
Excess weight put extra stress on your plantar fascia.

18. OCCUPATION:
People with occupations that require a lot of walking or standing on hard
surfaces such as factory workers, teachers and waitresses can damage their
plantar fascia.
IMPROPER SHOES:
Shoes that are thin soled, loose, lacking arch support or the ability to
absorb shock cannot protect the feet.
If we wear high heels regularly, the Achilles tendon which is attached to the
heel can contract and shorten, causing strain, on the tissue around the heel.

19. PATHOLOGY
The plantar fascitis injury sequence:
•Repetitive impact on feet for long time causes flexor muscles/tendons to
become short and tight.
•An impact on short, tight muscles/tendons causes micro tearing at the point
where 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.

20. •Magnetic resonance imaging (MRI) studies of patients with heel pain often
reveal abnormalities of only the central or intermediate portion of the fascia.
•Fasciitis is actually not an accurate description for the condition. Microscopic
studies of the plantar fascia in patients with heel pain usually reveal
disorganization 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 symptomatic
patients. 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 more
appropriate term than plantar fasciitis because there is no evidence of
inflammation.

21. •Micro tears of the collagen fibers are thought to be the cause of the
microscopic changes.
• It seems that heel impact does not cause the pathologic changes in patients
with heel pain syndromes.
• Specifically, gait studies performed on patients with heel pain demonstrate no
difference 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 plantar
aponeurosis at the origin on the calcaneus, commonly referred to as a heel
spur.
• The heel spur represents a marker for chronic heel pain but is not the cause of
the pain.
• In fact, foot x-rays of patients often reveal spurs in patients who are
asymptomatic.
•In addition, the presence or absence of a spur does not change the response
to therapy.

22. 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 the
bottom of the foot.

23. DIFFERENTIAL DIAGNOSIS OF HEEL PAIN
CONDITION CHARATERISTICS
NEUROGENIC
Abductor digiti mini nerve entrapment Burning heel pain
Lumbar spine disorders Pain radiating down to the leg.heel
and abnormal reflexes
Neuropathies common in patients who abuse
alchohol and in patients with
diabetes
Diffuse foot pain and night pain
Tarsal tunnel syndrome Pain, burning sensation and
paraesthesisa on sole of foot

24. SOFT TISSUE
Achilllis tendonitis Pain in retrocalcaneal area
Fat pad atrophy pain in area of atrophic heel pad
Heel contusion History of trauma
Plantar fascia rupture intense tearing sensation on the
bottom of foot
Posterior tibial tendonitis pain on the inside of foot and
ankle
Retrocalcaneal bursitis pain in retrocalcaneal area

25. Skeletal
Calcaneal epiphysitis (Sever’s disease) Heel pain in adolescents
Calcaneal stress fracture Calcaneal swelling,
warmth, and tenderness
Infections Osteomyelitis
Systemic symptoms (e.g.,
fever, night pain)
Inflammatory arthropathies More likely with bilateral
plantar fasciitis
Multiple joints affected
Subtalar arthritis Heel pain is supracalcane

26. Miscellaneous
Metabolic 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 children
Tumors (rare) Deep bone pain, night pain,
constitutional symptoms
Vascular insufficiency Pain in muscle groups that is
reproducible with exertion,
abnormal vascular
examination

27. Haglunds Deformity
• Triad of thickening of the distal
Achilles tendon, retro-Achilles
bursitis, and retrocalcaneal bursitis
• “Pump bumps” - stiff heel counter
compresses posterior soft tissues
against the posterosuperior
calcaneus
• Calcaneal tuberosity may focally
enlarge in response to chronic
irritation
• Leads to cycle of injury, response to
injury and re-injury

28. Indications for imaging of the PA
Assessment of its anatomic integrity is important in athletes engaged in
running and jumping activities as ruptures of the PA (either complete or
partial) are caused by forcible plantar flexion and are common in competitive
athletes.
Repetitive stress or minor trauma to the PA, however, also may result in
rupture
Spontaneous rupture of the PA may occur in patients with prior plantar
fasciitis, especially in those treated with local steroid injections

29. INVESTIGATIONS
X-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 the
plantar aponeurosis at the origin on the calcaneus, commonly referred to
as a heel spur
MRI:
Show thickening of plantar fascia
BONE SCAN:
It show increase uptake at the calcaneus
RHEUMATOLOGIC SCREENING:
It can be important to rule out inflammatory arthrides.

30. thickening of central component of plantar
aponeurosis (large arrows). Extensive edema
plantar aponeurosis as uniform bandlike infiltrates perifascial soft tissue (curved
structure of low signal intensity (arrows). arrows).

31. complete rupture of plantar aponeurosis after complete rupture of plantar aponeurosis
local corticosteroid injections for chronic after local corticosteroid injections for
plantar 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).

32. Posttraumatic acute complete rupture of Partially circumferential high SI
plantar aponeurosis around Achilles tendon indicate
peritendinitis
Edema within
Kager’s fat pad
anterior to Achilles
Tendon indicate paratendinitis

33. leads to thickened tendon
with 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

34. LABORATORY INVESTIGATIONS:
May be necessary in some cases to rule out a systemic illness causing the
heel pain, such as rheumatoid arthritis, Reiter's syndrome, or ankylosing
spondylitis.
These are diseases that affect the entire body but may first show as pain
in the heel.

35. SPECIAL TEST
•This is good test to diagnose plantar fascitis.
•Plantar fascitis have more tenderness in the plantar fascia when it is stretched
and less tenderness when the fascia is relaxed. The plantar fascitis test uses
this property to diagnose patients with plantar fascitis.
•To perform this test, first stretch plantar fascia. Then use your thumb or finger
to feel the plantar fascia. If plantar fascia is tender, then try the same maneuver
with plantar fascia relaxed.
•If pushing the stretched plantar fascia causes more tenderness than pushing
on the relaxed plantar fascia, then the plantar fascia is likely the source of the
pain and the patient have plantar fascitis.

36. MANAGEMENT
MEDICAL:-
•Anti inflammatory medications are sometimes used to decrease the
inflammation in the fascia and reduce pain. Studies show that many people get
better with anti-inflammatory as those who don‟t have any improvement. Since
these medications are rarely used , it‟s difficult to judge their true effectiveness.
•Botulinum toxin otherwise known as BOTOX has been used to treat plantar
fasciitis .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 of
heel;
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

38. Plantar fascia and nerve release.
A, Incision is made over first branch of
lateral plantar nerve.
B, Superficial fascia of abductor hallucis
muscle is released.
C, Abductor hallucis muscle is reflected
proximally.
D, Abductor hallucis muscle is retracted
distally.
E, Cross-sectional anatomy of heel along
course of first branch of lateral plantar
nerve.
F, Resection of small medial portion of
plantar fascia.

39. 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.

40. •Release pressure on the small nerves in the area
Usually the procedure is done through a small incision on the edge of the
foot, although some surgeons now perform this type of surgery using
an endoscope.
NEUROLYSIS:
Involves cutting the nerve sheath of the abductor digiti minimi muscle and
breaking up adhesions to free the nerve and relieve the pressure and pain.
Radio frequency, heat, or chemical injection, have also been used.

41. PHYSIOTHERAPY TREATMENT
GOALS:
SHORT TERM GOALS:
To reduce pain
To reduce inflammation
To reduce swelling
To reduce tenderness
LONG TERM GOALS:
•To maintain the muscle property
•To normalize the function
•To improve flexibility
To improve strength of the muscle
To maintain balance

42. ELECTRO THERAPY MODALITIES
ULTRASOUND:
Extracorporeal shock wave therapy for treatment of insertional plantar fasciitis.
Extracorporeal shock wave therapy is a technology that delivers concentrated
ultrasound energy to a localized area of collagen disruption, hemorrhage, and
presumably neovascularization to chronic degenerative fully vascularized tissue, such
as the insertion of the plantar fascia into the calcaneal tuberosity.
Although the preponderance of literature has evaluated high-energy devices, there
are reports of low-energy devices being used for the same purpose.

43. PHONOPHORESIS:
•It is the movement of the drugs through the skin in to subcutaneous tissue under the
influence of ultrasound.
•Drugs used:
→Hydrocortisone ointment
→Steroid type drugs such as Salicylates, NSAIDS.
→Anti inflammatory analgesic cream such as trolamine sulphate
Treatment time depends upon the area to be treated
Ex: 1 minute of treatment time for 10 cm2 area.

44. TENS:
•TENS is the application of a pulse rectangular wave current via surface
electrodes 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.

45. 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 electrical
current to deliver aqueous ionic solutions transversally to superficial areas
•Acetic acid iontophoresis for chronic heel pain has shown good results within
3-4 weeks
•The aqueous acetic acid is ionized to form the negatively charged acetate ion
that is transmitted through the skin.
•Physiological responses to chronically inflamed tissue results from higher
concentration of insoluble calcium carbonate to an injured area which
contributes to the ongoing pain cycle and abnormal restructuring of myofascial
tissue.

46. THERAPEUTIC EXERCISES
FREE 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

47. TRI –PLANE ACHILLES STRETCH:
ROTATIONAL PLANTAR FASCIA
STRETCH:

48. PLANTAR FASITIS TAPING METHODS:
•With this technique, the plantar fascia is supported and its movement becomes
limited.
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 responsible
for giving support to the plantar fascia.

49. EXERCISE TO CONTROL EXCESSIVE PRONATION:
IMPROVE TIBIALIS POSTERIOR STRENGTH:
•Ankle inversion using elastic band.
•Side-lying: Ankle inversion using ankle weight, emphasizing eccentric phase
control.
•Single leg stance balance activities with a neutral foot position
IMPROVE 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.

50. PREVENTION
Take some simple steps to prevent painful steps later :
•CHOOSE SUPPORTIVE SHOES: - Avoid shoes with high heels. Buy shoes
with a low to moderate heel, good arch support and shock absorbency. Don‟t
go 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 pressure
and 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.

51. SUMMARY
Plantar fascitis is the inflammation of the plantar fasica. It is common in
athletes and women. It is treatable condition by using various physiotherapy
modalities like iontophoresis, ultrasound, cryotherapy, if it is diagnosed in acute
stages.
The sub actue and chronic conditions will have poor prognosis where
steroids and the surgical procedures plays the major role in management.
Acetic acid iontophoresis and ultrasound are proved to be effective in acute
conditions. Strengthening and stretching exercises are also useful to manage
plantar fascitis.
MCR chapels with arch support are helpful for the patients with plantar
facitis. Properly casted and designed foot orthoses should be cornerstone of
non surgical treatment of sub calcaneal pain.
The prognosis of the plantar fascitis will be better with the physiotherapy
manoveours in acute stages where the sub acute and chronic has poor
prognosis.