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PLANTAR FASCIITIS

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The plantar fascia is a dense, fibrous connective tissue structure originating from the medial tuberosity of the calcaneus . Of its 3 portions-medial, lateral and central bands – the largest is the central portion. [1]

The central portion of the fascia originates from the medial process of the calcaneal tuberosity superficial to the origin of the flexor digitorum brevis, quadratus plantae, and abductorhallucis muscle. The fascia extends through the medial longitudinal arch into individual bundles and inserts into each proximal phalanx.[1]

The plantar fascia is an imp static support for the longitudinal arch of the foot. Strain on the longitudinal arch exerts its maximal pull on the plantar fascia, especially its origin on the medial process of the calcaneal tuberosity. The plantar fascia elongates with increased loads to act as a shock absorber, but its ability to elongate is limited. Passive extension of the metatarsophalangeal joints pulls the plantar fascia distally and also increases the height of the arch of the foot.[1]

 

IMPAIRMENTS

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BODY STRUCTURES

  1. Inflammation of the plantar fascia

  2. Degeneration of plantar fascia

  3. Tightness of plantar fascia

  4. Tightness of calf muscles

  5. TA tightness 

  6. Pes cavus/ pes planus

 

BODY FUNCTIONS

  1. Heel Pain

  2. Tenderness

  3. Affected gait

  4. Stiffness 

 

GOALS

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  • Short term 

  1. Patient education

  2. Ergonomic advice

  3. Reduce pain

  4. Reduce inflammation

  5. Reduce tightness

  6. Improve gait

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  • Long term

  1. Maintain range of motion

  2. Maintain strength 

  3. Establish home exercise program 

 

MANAGEMENT​

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Patient education 

  • Educate about the condition and that exercise daily can be a benefit and may prevent complications .

  • To avoid standing for a long time on a hard surface and avoid painful activities.

  • To use proper comfortable footwear. 

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Phase 1

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Plantar fascia and calf stretching

  • 4-5 times a day, 5 -10 repetitions  

  • Before first step in the morning 

  • Before standing after long period of rest

  • Seated plantar fascia stretching 

  • Plantar fascia stretches against the wall

  • Runner’s stretch for the Achilles tendon 

  • Soleus runner’s stretch

  • Gastrocnemius runner’s stretch 

  • Achilles stretch on inclined board 

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Myofascial Release

  • Use of RockBlade or other instrumented assisted soft tissue mobilisation device to break the adhesions.

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Relative rest 

  • Discontinue running and walking for exercise until asymptomatic for 6 wks 

  • Switch to low impact exercise – stationary bicycling, swimming, deep water running with aqua belt

  • Weight loss

  • Modification of hard surfaces to soft surfaces

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Cushioned heel inserts

  • inexpensive

  • over-the-counter heel inserts

  • (pt with pes cavus or pes planus may benefit from the use of custom cushioned orthotics 

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Shoe wear modification 

  • Flared, stable heel to help control heel stability

  • Firm heel counter to control the hindfoot

  • Soft cushioning of the heel, raising the heel 12-15 mm higher than sole.

  • Well-molded Achilles pad.

  • Avoid rigid leather dress shoes that increase torque on Achilles tendon 

 

Low-dye taping

  • Some pt may obtain relief but daily taping is difficult to maintain

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Ice massage 

  • To the area of inflammation 

  • (use ice in a paper or Styrofoam cup for 5-7 min; make sure to avoid frostbite)

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Home Exercises 

  • Wrinkling or curling of a paper or a cloth using only the toes. 

  • Rolling of the heel back and forth on a tennis ball or frozen can with extension of mtp jt.

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Phase 2

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If phase 1 measures fail to relieve symptoms after several months, phase 2 treatments are used.

 

Casting

  • A shortleg walking cast can be used for 1 month, with the foot in neutral. 

  • A removable cast is used if the right foot is involved

  • Evaluate success for 1 month, consider an additional month if necessary 

  • Complete 2nd month of cast wear in removable boot to allow gradual transition from boot back into running shoes

 

Orthotics 

  • Patients with very high or very low arches may benefit from orthotic inserts

  • A less rigid, accommodative insert is applicable to a more rigid cavus type of foot, which requires more cushion and less hindfoot control.

  • A padded but rigid insert is indicated foe a more unstable foot with compensatory pronation, which requires more control.

 

Night splints

  • A 5 degree dorsiflexion night splint has been beneficial. The splint holds the plantar fascia in a continuously tensed state. 

  • Other night splints are placed at neutral. (0 degrees)

 

Modalities

  • Intophoresis

  • Ultrasound

  • Deep friction massage

  • Myofascial release 

  • Kinesio taping

 

Phase 3

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Patients in whom all phases 1, 2 have failed maybe candidates for surgical intervention ( plantar fascia release) 

(because of high complication rate from surgery, we extend our operative indications to failure of all phase1 and 2 treatment for 18 months.)

 

REFERENCES

S.Brent Brotzman, Kevin E. Wilk, Clinical Orthopaedic Rehabilitation, 2nd Edition,  Page no – 393-402

Carolyn Kisner, Lynn Allen Colby, Therapeutic Exercises Foundation and Techniques, 5th Edition, Page no- 776

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