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1. Planter fasciitis
The student Sohaib Shehada Alashqar
3rd level of physiotherapy
Orthopedics course
Supervisor Dr Fadel Naim
2nd March 2019

2. Introduction
The aponeurosis of the foot or plantar fascia is comprised of
three distinct bands of dense connective tissue which support
the arch of the foot The plantar fascia originates at the medial
tubercle of the calcaneus extends distally into the five
metatarsophalangeal joints and ends at the proximal
phalanges of each digit.

4. Definition of the planter fasciitis
Plantar fasciitis has commonly been defined as an
inflammatory process resulting from repetitive microtrauma
leading to micro-tears of the plantar fascia However current
literature suggests plantar fasciitis is better referred to as
“plantar fasciosis” (PF) due to the chronic and degenerative
processes evident in the tissues rather than inflammation.

5. THE (PF)
Plantar fasciitis (PF) is the most common cause of chronic
pain beneath the heel in adults and may be treated using
different therapeutic strategies.
Conservative treatments have always been the first approach
for treating PF as recommended by the APTA (American
physical therapy association ).

6. THAT’S MEAN
The current literature has confirmed its degenerative rather
than inflammatory pathology and coined the term plantar
fasciosis instead of PF because of the histological evidence of
chronic inflammatory changes without fibroblastic proliferation
suggestive of degenerative changes.

7. CON..
During locomotion and standing plantar fascia acts as shock
absorbers and supports the arch of the foot It is an important
static stabilizer of the longitudinal arch of the foot.
However, when the pressure on the plantar ligament is
important in overweight or obese people or increases with
sudden weight gain (pregnant women, etc.) or with repetitive
activity (long-distance runner activity involving being on feet
often, etc.) the risk factor related to this overuse increases.

8. The causes
A- The lesion is usually an overuse phenomenon occurring in
the presence of predisposing anatomical biomechanical or
environmental factors that put too much strain on the plantar
fascia.
B-The condition seems to be more common in people with a
valgus deformity because this flattens the foot and puts more
strain on the fascia.

9. CON..
C- Short calf muscles can also be the cause of an overstrained
fascia.
In this is condition the Achilles tendon tends to pull the hell
upwards during standing which stresses the led longitudinal
arch an the fascia .

11. The risk factor
Common risk factors include
1-obesity
2-decreased ankle flexion
3- running
4- shortened or tight achilles tendon
5- high arches
6- flat feet
Women aged 40–60 years are more frequently diagnosed than
other demographics.

14. Statistic
The human foot has 26 bones 33 joints 107 ligaments 19
muscles and tendons.
That’s 52 bones in your feet which make up about 25 percent
of all the bones in your body.

15. CON..
Since a quarter of all the bones in the human body are down in
your feet when a great deal of force weight and pressure are
placed on them your chance of injury increases

16. CON..
In fact the American Podiatric Medical Association)APMA)
conducted a study that revealed 77 percent of Americans (18
and up) suffer from foot pain.
Approximately 2 million people in the United States will suffer
from Plantar Fasciitis one of the most common foot pains.

17. CON…
1- About 83 percent of active adults ages 25 to 65 will
experience plantars
2-Ten percent of runners will suffer from it
3-Fourteen percent reported improved symptoms simply from
changing their shoe .

18. The symptoms
The primary symptom complaint is pain in the arch of the foot
when bearing weight which is worse during the first few steps
in the morning and improves with rest .

19. Symptom of the (PF)
1-Tightness in the fascia
2- increased discomfort with passive dorsiflexion of great toe
3- standing on the tip of toe In majority it is a self-limiting
disease .

20. The Diagnosis
1-The diagnosis of PF is exclusively based on clinical history
2-physical examination it usually presents with severe sharp
early morning first step inferior heel pain that improves with
movements but aggravated by weight-bearing activities.
3- Imaging by (ultrasound MRI X- Rays)

21. CON…
Use of ultrasonography and magnetic resonance imaging is
reserved for recalcitrant cases or to rule out other heel
pathology findings of increased plantar fascia thickness and
abnormal tissue signal the diagnosis of plantar fasciitis.

22. Clinical Diagnosis
Diagnosis of plantar fasciitis is based on patient history risk
factors and physical examination findings.
Most patients have heel pain and tightness after standing up from
bed in the morning or after they have been seated for a
prolonged time.

23. CON..
Typically the heel pain will improve with ambulation but could
intensify by day's end if the patient continues to walk or stand
for a long time.
On physical examination patients may walk with their affected
foot in an equine position to avoid placing pressure on the
painful heel.

24. CON…
Palpation of the medial plantar calcaneal region will elicit a sharp
stabbing pain Passive ankle first toe dorsiflexion can cause
discomfort in the proximal plantar fascia it can also assess
tightness of the Achilles tendon.
Other causes of heel pain should be sought if history and
physical examination findings are atypical for plantar fasciitis.

25. Physical examination for the (PF)
 Medial plantar region of the
heel where most pain is
elicited when pressure is
applied during physical
examination or with walking
in patients with plantar
fasciitis.

26. Imaging
Imaging can aid in the diagnosis of plantar fasciitis.
Although not routinely needed initially imaging can be used to
confirm recalcitrant plantar fasciitis or to rule out other heel
pathology.

27. X-rays for the (PF)
 Lateral radiography of the
foot showing a large heel
spur

28. Ultrasonography
Ultrasonography is inexpensive and useful in ruling out soft
tissue pathology of the heel.
Findings that support the diagnosis of plantar fasciitis include
proximal plantar fascia thickness greater than 4 mm and
areas of hypoechogenicity.

29. MRI
Magnetic resonance imaging although expensive is a valuable
tool for assessing causes of recalcitrant heel pain.
Diagnostic findings include increased proximal plantar fascia
thickening with increased signal intensity on T2-weighted and
short tau inversion recovery images.

30. MRI for the (PF)
 Sagittal T2-weighted
magnetic resonance
imaging showing thickening
of the plantar fascia (short
arrows) and increased
signal intensity (long arrow).

31. The treatment
Include two type of management
1-medical management
2- physical therapy management

32. 1- Medical Management
When conservative measures fail, surgical plantar fasciotomy
with or without heel spur removal may be employed.
There is a method through an open procedure
percutaneously or most common endoscopic ally that
releases the plantar fascia this is an effective treatment.

33. Red flag
Surgery for plantar fasciitis should be considered only after all
other forms of treatment have failed.

34. The medical intervention
A- Corticosteroids
The most common treatment that has been employed over
the past decades is corticosteroid injections

35. B- Botulinum toxin Type-A
Traditionally botulinum toxin has been used in the treatment of
spasticity and nerve blocks.
Only recently has it found its way into musculoskeletal medicine.

36. CON..
Three RCTs compared the effect of botulinum toxin type-A
(BTA) on heel pain with steroids
The studies reported significant improvements with BTA.
Furthermore patients with plantar fasciitis who received BTA
had significantly longer lasting relief of dysfunction and pain
than those who received placebo further comparative studies
are needed with larger sample sizes.

37. C- Autologous platelet-rich plasma therapy
Platelet-rich plasma (PRP) therapy showed significant
improvements in the 3month follow-up.
The use of PRP improves blood flow at the site of injection
which aids in the regeneration at the site of pain and
inflammation and the boost that occurs after the injections
help the regeneration of the site of pain and inflammation.

38. D- Polydeoxyribonucleotide (PDRN)
injections
Clinical efficacy with no notable
complications and were associated with symptomatic
improvement in refractory plantar fasciitis.

39. E-Endoscopic plantar fasciotomy (EPF)
Is a minimally invasive and minimally traumatic surgical
treatment for the common problem of chronic plantar fasciitis.
This procedure is indicated only for the release of the proximal
medial aspect of the fascia in cases that do not respond to
aggressive conservative nonsurgical treatment.

40. Endoscopic plantar fasciotomy

41. 2-physical therapy management
A-Therapeutic exercise
The most common treatments include:
1 strengthening exercise for the fascia .
2stretchingexercise of the gastroconemious
– soleus- plantar fascia.
3 joint mobilization- manipulation.

42. 1-Strength exercise
Similar to tendinopathy management high-load strength training
appears to be effective in the treatment of plantar fasciitis.
High-load strength training may aid in a quicker reduction in pain
and improvements in function.

43. With the towel or small pall

44. 2-Stretching exercise

46. Another stretching ex..

47. 3-Mobilizations and manipulations
have also been shown to decrease pain and relieve symptoms
in some cases.
Posterior talocrural joint mobs and subtalar joint distraction
manipulation have been performed with the hypomobile
talocrural joint.
Massage for the sole is very effected in this is case.

48. B-The physical modalities
 1- Therapeutic Ultrasound
 2-Contras bath
 3- shock wave
 4-Intophoresis
 5-TENS

49. C-Foot orthoses
Foot orthotics are commonly recommended for persons with
plantar fasciitis to aid in preventing overpronation of the foot
and to unload tensile forces on the plantar fascia.
There are many different orthotics available.

50. CON…
Produce small short-term benefits in function and may also
produce small reductions in pain for people with plantar
fasciitis but they do not have long-term beneficial effects.

51. D-Posterior-night splints
Maintain ankle dorsiflexion and toe extension allowing for a
constant stretch on the plantar fascia.

52. Summery
Plantar fasciitis accounts for a large percentage of cases seen
by podiatric physicians and is often seen by general
practitioners and orthopedic surgeons.
Although most cases respond to 4–6 months of conservative
nonsurgical treatment 10–15% require surgery.

53. Summary
If aggressive conservative treatment for plantar fasciitis fails and
surgery is indicated the endoscopic approach is superior to
conventional open procedures and significantly minimizes
surgical trauma resulting in an earlier return to regular
activities with fewer complications.

54. The References
1-Lee, Tamsin L., and Benjamin L. Marx. "Noninvasive, Multimodality Approach
to Treating Plantar Fasciitis: A Case Study." Journal of acupuncture and
meridian studies 11.4 (2018): 162-164
2- Gonnade, Nitesh. "Regenerative efficacy of therapeutic quality platelet-rich
plasma injections versus phonophoresis with kinesiotaping for the treatment
of chronic plantar fasciitis: A prospective randomized pilot study." Asian
Journal of Transfusion Science 12.2 (2018): 105

55. CON..
3- Al- Boloushi, Z. "Minimally invasive non-surgical management of plantar fasciitis:
A systematic review." Journal of bodywork and movement therapies 2018
4- Hake, Daniel H. "Endoscopic plantar fasciotomy: A minimally traumatic procedure
for chronic plantar fasciitis." The Ochsner Journal 2.3 (2000): 175-178
5- Moyne-Bressand, Sébastien. "Effectiveness of Foot Biomechanical Orthoses to
Relieve Patients Suffering from Plantar Fasciitis: Is the Reduction of Pain Related
to Change in Neural Strategy?." BioMed research international 2018 (2018)

56. CON..
6- Crawford, R. "Diagnosis and treatment of plantar fasciitis." Am Fam Physician
84.6 (2011): 676-82
7-Carlson RE, Fleming LL, Hutton WC. The biomechanical relationship between the
tendoachilles, plantar fascia and metatarsophalangeal joint dorsiflexion angle. Foot
ankle Int / Am Orthop Foot Ankle Soc and Swiss Foot Ankle Soc. 21-1-
2000(18–25)
8- Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process
(fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003;93(3):234–7.

57. Last reference from a book
9-Ombregt Ludwig, Bisschop pierre, ter veer Herman
j. A System of Orthopaedic Medicine-E-Book.
Elsevier Health Sciences, 2013.