Planter facitis

I Dr. NIRAJ Kumar currently work at the Department of Physiotherapy, Shri Guru Ram Rai Institute of Medical & Health Science.

1. Planter Fasciitis DR. NIRAJ KUMAR BPT, MPT (ORTHO), MHA, Ph.D. Physiotherapy (Orthopedics)* Associate Professor Physiotherapy Dept. Shri Guru Rai Institute Of Paramedical Sciences , Dehradun

2. ANATOMICAL DESCRIPTION The plantar aponeurosis (PA) is a fibrous triangular structure originating from the medial process of the calcaneal tuberosity. The PA has 3 main parts: the thick central slip and the thinner lateral and medial bands. The central slip becomes 5 digital slips at the mid-tarsal level, which insert at the base of the proximal phalanges (heads of the metatarsal bones ). The PA interacts with the hind foot and forefoot to function as a shock absorber during activity and to support the longitudinal arch of the foot. It forms a windlass mechanism with the bony longitudinal arch that, when engaged during hallux dorsiflexion at the metatarsophalangeal joint, results in tightening of the PA. This stabilizes the longitudinal arch and causes inversion of the hind foot.

3. BIOMECHANICS The plantar fascia contributes to support of arch of the foot. The plantar fascia also has an important role in dynamic function during gait The plantar fascia prevents foot collapse by virtue of its anatomical orientation and tensile strength. The plantar aponeurosis originates from the base of the calcaneus and extends distally to the phalanges. Stretch tension from the plantar fascia prevents the spreading of the calcaneus and the metatarsals and maintains the medial longitudinal arch.( Lori A. Bolgla and Terry R. Malone. 2004)

4. Definition Plantar fasciitis is one of the most common causes of heel pain . Plantar fasciitis is a painful foot condition caused by inflammation of insertion of the plantar fascia on the medial process of the calcaneal tuberosity. Plantar fasciitis is an inflammation of the plantar fascia that extends from the heel to the toes. In plantar fasciitis, the fascia first becomes irritated and then inflamed, resulting in heel pain. The most common cause of plantar fasciitis relates to faulty structure of the foot. For example, people who have problems with their arches, either overly flat feet or high-arched feet are more prone to developing plantar fasciitis.  

5. PATHOMECHANICS Tibialis posterior weakness- The Tibialis posterior eccentrically control pronation during foot flat and midstance phase of gait cycle. Weakness of this muscle can cause excessive pronation of the sub-talar joint and this can also leads to plantar fasciitis.

6. AETIOLOGY Exact causes is unknown. But there are following risk factors Foot arch Obesity or sudden weight gain Long-distance running Tight Achilles tendon Shoes with poor arch support or soft soles Tightness of gastro soles muscles. During midstance to heel off phase of gait cycle there is 5 degree dorsiflexion is needed, in order to clear the surface. (anterior translation of tibia over the talus. closed kinematics )

7. CLINICAL FEATURE Pain- Pain on the bottom of the heel and in the arch of the foot, the pain as worse when they get up in the morning or after they’ve been sitting for long periods of time. After a few minutes of walking the pain decreases, because walking stretches the fascia. Tenderness Swelling Warmth of the affected area Redness of the adjacent skin

8. Differential Diagnosis Soft tissue pathology Achilles tendinopathy ; Retrocalcaneal bursitis Heel fat-pad atrophy Overload heel pain syndrome Tendinitis of the posterior tibialis or flexor digitorum longus Plantar fascia rupture Piezogenic papules Skeletal pathology Calcaneal stress fracture Bone contusion Osteomyelitis Haglund deformity

9. Neurologic pathology Nerve entrapment or compression syndromes: entrapment of the posterior tibial nerve (tarsal tunnel syndrome); posterior tibial nerve; the first branch of the lateral plantar nerve (Baxter nerve) Neuropathic pain S1 radiculopathy Inflammatory pathology Rheumatoid arthritis Spondyloarthritides ± enthesitis (inflammation at tendon insertion into bone)

10. MANAGEMENT Drug management and supportive therapy Oral non-steroidal anti-inflammatory drugs such as ibuprofen (Advil, Motrin IB) and naproxen (Aleve) recommended reducing pain and inflammation associated with plantar fasciitis. Wearing supportive shoes that have good arch support and a slightly raised heel reduces stress on the plantar fascia . Physiotherapy Treatment The following protocol was followed. Rest: Rest is the first treatment for plantar fasciitis. Ask patient to keep weight off foot and weight shifting during standing until the inflammation goes away. Swimming is the best alternative activity . Activity Modification: Decrease distance and duration of walking or particularly running, switching from jumping or running activity to activities such as swimming or cycling to reduce the stress on foot, changing the exercise surface(e.g. from concrete to grass ).

11. Shoes modification: Shoes should have an arch support and cushioned heels. Worn shoes may aggravate plantar fasciitis because of lack of cushioning. However, too much arch support can cause the fascia to stretch a longer distance. Ice : Ice is applied in the treatment of plantar fasciitis by ice massage, or by an ice pack. Ice packs are usually used for 15 to 20 minutes. Icing is usually done after completing exercise, stretching, strengthening and after a day’s work. Contrast Bath: Also play important role in reduction of swelling and inflammation by vasoconstriction and vasodilatation effects. 3:1 is used for in it with starting from hot water and also end with hot water, given for 15 min. Stretching : As soon as swelling and pain begin to subside it is important to start a proper stretching program. The stretching should be gentle and prolonged, using a slow, static stretch. Each stretch should be performed three times a day holding each stretch for 15-20 sec. and repeating five times each session. 1. Calf Stretch in sitting and standing position for 15-30 seconds and Repeat 7-10 times. 2. Plantar fascia stretch: Ask patient to roll bare injured foot back and forth from heel to mid-arch over a frozen ice filled bottle. Repeat for 3 to 5 minutes. This exercise is particularly helpful if done first thing in the morning.

12. 3. Soleus and Posterior Tibialis Muscle stretch: Lean against a wall for support and to assist with stretching. Position as above: however, this time gradually bend both knees toward the wall until feel a mild pull in the back of legs. Remember to keep heels in contact with the ground and keep the toes pointing forward. Hold position for 10 seconds and repeat 7 to 10 times. Strengthening: The following exercises performed three times per day for 30 times each session will help provide muscular support to a weakened plantar fascia. 1. Towel curls to strengthen intrinsic muscles of the foot 2. Towel pickup 3. Calf raises (unilateral and bilateral) 4. Picking up marbles 5. Resisted Thera -Band exercises for the lower leg(Resisted dorsiflexion, planterflexion , inversion and eversion)

13. Ultrasound: Ultrasound is given to prevent formation and to remove inflammatory exudates from the site of inflammation. Hence ultrasound has more roles in decreasing pain and prevents adhesion formation and inflammation. (Angela forster and Nigel Palastanga 2002), Dosage in acute stage Frequency: 1 MHz, Mode: pulsed Intensity: 0.2-0.8 watt\cm2 Dosage in chronic stage Frequency: 1 MHZ, Mode: Continuous Intensity: 1.8 wa tt /cm, Duration: 8 min

14. Thank You