Planter fasciitis

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

3. 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.

4. 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 ).

5. 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.

6. 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.

7. 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.

8. 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 .

9. 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.

10. 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.

11. 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

12. 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.

13. 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 .

14. 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 .

15. 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 .

16. 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)

17. 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.

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

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

24. 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.

25. 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.

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

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

28. 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.

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

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

31. 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.

32. 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.

33. 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.

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

35. 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.

36. Endoscopic plantar fasciotomy

37. 2-physical therapy management A-Therapeutic exercise The most common treatments include: 1\ strengthening exercise for the fascia . 2\stretchingexercise of the gastroconemious – soleus- plantar fascia . 3\ joint mobilization- manipulation.

38. 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.

39. With the towel or small pall

40. 2-Stretching  exercise

41. Another stretching ex..

42. 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.

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

44. 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.

45. 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.

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

47. 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.

48. 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.

49. 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

50. 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)

51. 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.

52. 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 .‏