plantar fascitis.pptx management and clinical features

Foot and ankle diseases

1. PLANTAR FASCITIS Presenter :Dr .Tooba Mariyam PGY-1 Department of Orthopaedics Moderator :Dr.NAVEED Assistant Professor Department of Orthopaedics

2. 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.

3. ANATOMY The plantar aponeurosis consists of three bands: lateral, medial and central. The central band originates from the medial tubercle on the plantar surface of the calcaneus and travels toward the toes as a tight band of tissue. Just proximal to crossing the metatarsal heads, it divides into five slips. Each slip further divides in half to insert on the proximal phalanx of each toe.

4. The plantar fascia gets functionally shortened when the toes are extended (as it wraps around each metatarsal head) producing the characteristic “windlass effect” The windlass effect assists in supinating the foot during the latter portion of the stance phase and provides stability to the toes. The plantar fascia is a continum of Achilles tendon fibers

5. Muscles and nerves in the vicinity play an important role in clinical assessment of pain. Three muscles: the flexor digitorum brevis, abductor hallucis and quadratus plantae have the same origin and insertions as that of plantar aponeurosis so could be the source of origin of pain. The tibial nerve divides into the medial and lateral plantar nerves while traveling through the tarsal tunnel; these and their branches (including the second branch of the lateral plantar nerve, also referred to as “Baxter’s nerve”) can get entrapped causing “tarsal tunnel syndrome.” The plantar heel pad is supplied by medial calcaneal branches of tibial nerv e

6. The most common site of abnormality in patients with plantar fasciitis is near the origin or enthesis of the central band of the plantar aponeurosis at the medial plantar tubercle of the calcaneus. Occasionally, the pain could be located at the mid-portion of the central band, just prior to it splitting into the five slips. Plantar fasciitis occurs as an enthesopathy in patients with a seronegative arthropathy (Reiter’s syndrome, psoriatic arthropathy, ankylosing spondylitis and enteropathic spondyloarthropathy).

7. 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

8. Weak perone i Congenital problems such as Pescavus and Pesplanus Obesity Reiters disease,Ankylosing spondylitis,Diffuse idiopathic skeletal hyperostosis Some of the causes of plantar fascitis may include: Excessive running or even walking uphill Lack of stretching prior to exercise

9. RISK FACTORS AGE: M ost common between the ages of 40 and 60. SEX :Women are more likely t han 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.

10. 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. 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.

11. 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.

12. CLINICAL FEATURES Pain is most severe in the mornings on getting out of bed, and in the beginning of a run Most patients report heel pain and tightness after standing up and taking first step from bed in the morning (“start-up” pains) or after they have been seated for a prolonged time (as in movie theaters). The heel pain commonly improves within a few steps if they walk through the pain but in a few, the pain could intensify by day’s end if the patient continues to walk or stand for a long time.

13. Physical Examination Patients may walk with equinus gait to avoid placing pressure on the painful heel. Tenderness on medial plantar calcaneal region is commonly reported as a sharp stabbing pain. Passive ankle or first toe dorsiflexion (windlass test) elicits pain. Clinicians use validated self-report questionnaires, such as the Foot Function Index (FFI), Foot Health Status Questionnaire (FHSQ), or the Foot and Ankle Ability Measure (FAAM), before and after interventions.

14. SPECIAL TEST 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.

15. Diagnosis The diagnosis is quite easily made by the following characteristic findings: Morning start-up pains that relieve by few steps of ambulation, pain reappears after prolonged sitting (watching TV) No history of trauma but a history of recent changed activities (starting walking or running) Pain localized to plantar heel more on the medial aspect with absence of paresthesias.

16. Differential Diagnosis Heel contusion Plantar fascia rupture Bone bruise Posterior tibial tendinitis Achilles tendinitis Retrocalcaneal bursitis S1 radiculopathy and referred pain Calcaneal stress fracture Fat pad atrophy

17. Tarsal tunnel syndrome Neuropathy Calcaneal neoplasia Systemic arthritis including rheumatoid arthritis Metastasis Paget’s disease of bone.

18. Imaging S oft tissue radiographs are more sensitive and informative. - Plantar fascia thickness and fat pad abnormalities are the two best factors for differentiation of plantar fasciitis, with a sensitivity of 85% and a specificity of 95%. Ultrasonography - Positive finding favoring plantar fasciitis is proximal plantar fascia thickness greater than 4 mm and areas of hypoechogenicity.

19. MRI is the modality of choice for assessing causes of recalcitrant heel pain. Diagnosis relies on finding thickened plantar fascia with increased signal intensity on T2- weighted and short tau inversion recovery images.

20. MANAGEMENT MEDICAL:- Nonsteroidal anti-inflammatory drugs comprise the primary modality of treatment to reduce pain and swelling associated with acute exacerbation of symptoms. This is combined with activity modification, ice massage or contrast water bath (alternate hot and cold fomentation). DRUGS INCLUDE: Diclofenac sodium lbu profen lndomethacin

21. Night splints prevent plantar fascia contracture by keeping the foot and ankle in a neutral 90° position, preventing foot plantar flexion during sleep. Night splints used alone have been shown to improve plantar fasciitis pain. Medial arch supports are not used in isolation but are commonly combined with silicone soft soles. They disable the tendency of feet to go into pronation

22. Silicone full length soft soles or heel cups provide good pain relief and prefabricated ones are no inferior to custom made ones. Foot orthoses can reduce the strain in the plantar fascia during static loading, reduce the collapse of the medial longitudinal arch, and reduce elongation of the foot associated with pronation. The compliance is also good

23. Injections Corticosteroid injections have proven effective. Injection of 0.1 to 0.2 ml of corticosteroid is given from the medial side of heel; Percutaneous fenestration (dry needling) has been shown to reduce pain in as early as 4 weeks Hyperosmolar dextrose (prolotherapy) using 25% dextrose/lidocaine solution Botulinum toxin-A (Botox) shown to relieve pain for as long as 14 weeks after injection.

24. Whole blood—Intralesional whole blood injections do not appear to be as effective as corticosteroid injections Platelet-rich plasma—Platelet-rich plasma is produced via centrifuged autologous blood. The plasma collected is rich with platelets that release growth factors to stimulate healing in degenerative tissue.

25. ELECTRO THERAPY MODALITIES 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.

26. PHONOPHORESIS It is the movement of the drugs through the skin in to subcutaneous tissue under the influence of ultrasound. Drugs used: - Hvdrocortisone ointment -S teroid type drugs such as Salicylates, NSAIDS. -Anti inflammatory analgesic cream such as trolamine sulphate

27. 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 mor e effective than heat or contrast bath in reducing odema

28. ACETIC ACID IONTOPHORESIS: lontophoresis 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.

29. Plantar fasciotomy Plantar fasciotomy can be performed when all conservative measures have been ineffective. Both open and endoscopic methods have been used.