Oral Revalida Written Report:

Plantar Fasciitis

Submitted by:

Karla Suzatte M. Dasargo

DDC- PT Intern 2014

November 11, 2013

PLANTAR FASCIITIS

It is also referred to as plantar heel pain syndrome, heel spur syndrome, or painful heel

syndrome.

Definition

It is a painful inflammatory process of the plantar fascia, the connective tissue or ligament on

the sole of the foot. It is often caused by overuse of the plantar fascia, increases in activities,

weight or age.

Description

It is an overload injury usually associated with biomechanical abnormalities such as tight plantar

flexors and short flexor muscles.

Etiology

Deterioration of the plantar fascia. Connective tissue deterioration is associated with

many systemic factors that alter microcirculation within tissue, such as the patient’s age,

arteriosclerosis, lipid abnormalities, tobacco abuse, and diabetes mellitus. Rheumatoid

arthritis, ankylosing spondylitis, and other seronegative arthropathies can be associated

with plantar fasciitis and other enthesopathies.

Mechanical overload of the plantar fascia has been suspected to play a significant role in

the development of plantar fasciitis. Several studies have identified associations of

plantar fasciitis with obesity and poor ankle flexibility; both of these factors would be

expected to add to the mechanical load of the forefoot.

The plantar fascia also may be damaged by direct impact on the heel through gait or

repetitive trauma to or overloading of the front of the foot through gait abnormalities,

posture, and other tendon contractures (eg, hamstring tendon contractures).

Damage to other supporting structures that assist in arch stabilization may increase the

stress on the plantar fascia; this may include injuries to the posterior tibial tendon or

intrinsic plantar ligaments, resulting in acquired flatfoot deformity, or “fallen arches,” and

instability caused by midfoot arthritis. The intrinsic musculature may be compromised in

many ways, including weakness resulting from compressive or peripheral neuropathy

and deconditioning because of the patient’s age or the use of overprotective footwear or

arch supports.

Epidemiology

Plantar fasciitis, reportedly the most common cause of pain in the inferior heel

Estimated to account for 11 to 15 percent of all foot symptoms requiring professional

care among adults.

It is the most common cause of heel pain and affects 15-20% of runners and is also

common among military personnel.

The incidence reportedly peaks in people between the ages of 40 and 60 years in the

general population and in younger people among runners.

The predominance of the condition according to sex varies from one study to another.

The condition is bilateral in up to a third of cases.

Anatomy

Foot

The foot supports the body weight and provides leverage for walking and running. It is unique in

that it is constructed in the form of arches, which enable it to adapt its shape to uneven urfaces.

It also serves as a resilient spring to absorb shocks, such as in jumping.

The Sole of the Foot

Skin

The skin of the sole of the foot is thick and hairless. It is firmly bound down to the underlying

deep fascia by numerous fibrous bands. The skin shows a few flexure creases at the sites of

skin movement. Sweat glands are present in large numbers.

The sensory nerve supply to the skin of the sole of the foot is derived from the medial calcaneal

branch of the tibial nerve, which innervates the medial side of the heel; branches from the

medial plantar nerve, which innervate the medial two thirds of the sole; and branches from the

lateral plantar nerve, which innervate the lateral third of the sole.

Deep Fascia

The plantar aponeurosis is a triangular thickening of the deep fascia that protects the underlying

nerves, blood vessels, and muscles. Its apex is attached to the medial and lateral tubercles of

the calcaneum. The base of the aponeurosis divides into five slips that pass into the toes.

In younger people the plantar fascia is also intimately related to the Achilles tendon, with a

continuous fascial connection between the two from the distal aspect of the Achilles to the origin

of the plantar fascia at the calcaneal tubercle. However, the continuity of this connection

decreases with age to a point that in the elderly there are few, if any, connecting fibers.

There are also distinct attachments of the plantar fascia and the Achilles tendon to the

calcaneus so the two do not directly contact each other. Nevertheless, there is an indirect

relationship whereby if the toes are dorsiflexed, the plantar fascia tightens via the windlass

mechanism. If a tensile force is then generated in the Achilles tendon it will increase tensile

strain in the plantar fascia.

Muscles of the Sole of the Foot

The muscles of the sole are conveniently described in four layers from the inferior layer

superiorly.

First layer: Abductor hallucis, flexor digitorum brevis, abductor digiti minimi

Second layer: Quadratus plantae, lumbricals, flexor digitorum longus tendon, flexor hallucis

longus tendon

Third layer: Flexor hallucis brevis, adductor hallucis, flexor digiti minimi brevis

Fourth layer: Interossei, peroneus longus tendon, tibialis posterior tendon

Arteries of the Sole of the Foot

Medial Plantar Artery

The medial plantar artery is the smaller of the terminal branches of the posterior tibial artery. It

arises beneath the flexor retinaculum and passes forward deep to the abductor hallucis muscle.

It ends by supplying the medial side of the big toe. During its course, it gives off numerous

muscular, cutaneous, and articular branches.

Lateral Plantar Artery

The lateral plantar artery is the larger of the terminal branches of the posterior tibial artery. It

arises beneath the flexor retinaculum and passes forward deep to the abductor hallucis and the

flexor digitorum brevis. On reaching the base of the 5th metatarsal bone, the artery curves

medially to form the plantar arch and at the proximal end of the first intermetatarsal space joins

the dorsalis pedis artery. During its course, it gives off numerous muscular, cutaneous, and

articular branches. The plantar arch gives off plantar digital arteries to the toes.

Dorsalis Pedis Artery (The Dorsal Artery of the Foot)

On entering the sole between the two heads of the first dorsal interosseous muscle, the dorsalis

pedis artery immediately joins the lateral plantar artery Branches the first plantar metatarsal

artery, which supplies the cleft between the big and second toes. Veins of the Sole of the Foot

Medial and lateral plantar veins accompany the corresponding arteries, and they unite behind

the medial malleolus to form the posterior tibial venae comitantes.

Nerves of the Sole of the Foot

Medial Plantar Nerve

The medial plantar nerve is a terminal branch of the tibial nerve. It arises beneath the flexor

retinaculum and runs forward deep to the abductor hallucis, with the medial plantar artery. It

comes to lie in the interval between the abductor halluces and the flexor digitorum brevis.

Lateral Plantar Nerve

The lateral plantar nerve is a terminal branch of the tibial nerve. It arises beneath the flexor

retinaculum and runs forward deep to the abductor hallucis and the flexor digitorum brevis, in

company with the lateral plantar artery. On reaching the base of the fifth metatarsal bone, it

divides into superficial and deep branches.

Ligaments of the sole of the foot

Spring ligament (Plantar calcaneonavicular)

The plantar calcaneonavicular ligament is strong and runs from the anterior margin of the

sustentaculum tali to the inferior surface and tuberosity of the navicular bone. The superior

surface of the ligament is covered with fibrocartilage and supports the head of the talus.

Long plantar ligament

The long plantar ligament is a strong ligament on the lower surface of the joint. It is attached to

the under surface of the calcaneum behind and to the under surface of the cuboid and the

bases of the third, fourth, and fifth metatarsal bones in front. It bridges over the groove for the

peroneus longus tendon, converting it into a tunnel.

Short plantar ligament (Calcaneocuboid)

The short plantar ligament is a wide, strong ligament that is attached to the anterior tubercle on

the under surface of the calcaneum and to the adjoining part of the cuboid bone.

The Arches of the Foot

The foot has three such arches, which are present at birth: the medial longitudinal, lateral

longitudinal, and transverse arches. In the young child, the foot appears to be flat because of

the presence of a large amount of subcutaneous fat on the sole of the foot.

The medial margin of the foot, from the heel to the 1st metatarsal head, is arched above the

ground because of the important medial longitudinal arch. The pressure exerted on the ground

by the lateral margin of the foot is greatest at the heel and the 5th metatarsal head and least

between these areas because of the presence of the low-lying lateral longitudinal arch.

The transverse arch involves the bases of the five metatarsals and the cuboid and cuneiform

bones. This is, in fact, only half an arch, with its base on the lateral border of the foot and its

summit on the foot’s medial border.

The body weight on standing is distributed through a foot via the heel behind and six points of

contact with the ground in front, namely, the two sesamoid bones under the head of the first

metatarsal and the heads of the remaining four metatarsals.

The Bones of the Arches

Medial longitudinal arch

This consists of the calcaneum, the talus, the navicular bone, the three cuneiform bones, and

the first three metatarsal bones.

Lateral longitudinal arch

This consists of the calcaneum, the cuboid, and the 4th and 5th metatarsal bones

Transverse arch

This consists of the bases of the metatarsal bones and the cuboid and the three cuneiform

bones.

Biomechanics of Plantar fascia

The plantar fascia contributes to support of arch of the foot by acting as a tie-rod, where

it undergoes tension when the foot bears weight.

One biomechanical model estimated it carries as much as 14% of the total load of the

foot.

Complete rupture or surgical release of the plantar fascia leads to a decrease in arch

stiffness and a significant collapse of the longitudinal arch of the foot.

Surgical release also significantly increases both stress in the plantar ligaments and

plantar pressures under the metatarsal heads.

The plantar fascia also has an important role in dynamic function during gait. It was

found the plantar fascia continuously elongated during the contact phase of gait. It went

through rapid elongation before and immediately after mid-stance, reaching a maximum

of 9% to 12% elongation between mid-stance and toe-off. During this phase the plantar

fascia behaves like a spring, which may assist in conserving energy.

The plantar fascia has a critical role in normal mechanical function of the foot,

contributing to the "windlass mechanism". When the toes are dorsiflexed in the

propulsive phase of gait, the plantar fascia becomes tense, resulting in elevation of the

longitudinal arch and shortening of the foot.

Therefore, the plantar fascia has a number of roles, the most important of these

including supporting the arch of the foot and contributing to the windlass mechanism.

Pathology

The site of abnormality is typically near the site of origin of the plantar fascia at the

medial tuberosity of the calcaneus.

Histologic examination of biopsy specimens from patients undergoing plantar fascia–

release surgery for chronic symptoms has shown degenerative changes in the plantar

fascia, with or without fibroblastic proliferation, and chronic inflammatory changes.

It is more likely caused by degeneration or weakening of the tissue. This process

probably begins with small tears that occur during activity and that, in normal

circumstances, the body simply repairs, strengthening the tissue as it does. That is the

point of exercise training.

But sometimes, for unknown reasons, this on-going tissue damage overwhelms the

body’s capacity to respond. The small tears don’t heal. They accumulate.

Most common Signs & Symptoms

Pain (throbbing, searing, or piercing) when they take their first steps after they get out of

bed or sit for a long time, you may have less stiffness and pain after you take a few

steps. But your foot may hurt more as the day goes on. It may hurt the most when you

climb stairs or after you stand for a long time.

Tenderness to palpation is present at the volar aspect of the heel, usually slightly medial

to midline

Antalgic gait

Examination & Diagnostic procedures

Ocular inspection – checks for a high arch, area of maximum tenderness on the bottom

of your foot, just in front of your heel bone, Pain that gets worse when you flex your foot

and the doctor pushes on the plantar fascia. The pain improves when you point your

toes down, Limited "up" motion of your ankle (DF).

X-ray- rule out a stress fracture of the heel bone and to see if a bone spur is present.

Bone scans - useful for distinguishing plantar fasciitis from calcaneal stress fracture

MRI- can show thickening of the plantar fascia

Laboratory tests - rule out a systemic illness causing the heel pain, such as rheumatoid

arthritis, Reiter's syndrome, or ankylosing spondylitis

Differential diagnosis

Neurologic Soft tissue Skeletal Others

Tarsal tunnel syndrome

Pain, burning sensation, and tingling on the sole of the foot

Achilles tendonitis

Pain is retrocal-caneal

Calcaneal stress fracture

Calcaneal swelling, warmth, and tenderness

Osteomal-acia

Diffuse skeletal pain, muscle weakness

Abductor digiti quinti nerve entrapment

Burning in heel pad

Heel contusion

History of trauma

Calcaneal epiphysitis (Sever’s disease)

Heel pain in adolescents

Tumors (rare)

Deep bone pain, night pain, constitutional symptom

Peripheral neuropathy

Common in patients who abuse alcohol and in patients with diabetes Diffuse foot pain, night pain

fat-pad atrophy

Pain in area of atrophic heel pad

Osteomyelitis Systemic symptoms (e.g., fever, night pain)

Vascular insufficie

ncy

Pain in muscle groups that is reproducible with exertion, abnormal vascular examination

Lumbar radiculopathy

Pain radiating down the leg to the heel, weakness, abnormal reflexes

Posterior tibial

tendonitis

Pain on the inside of the foot and ankle

Inflammatory arthropathies

With bilateral plantar fasciitis Multiple joints affected

Paget’s disease

Bowed tibias, kyphosis, headaches

Management

Medical and Surgical

Surgery is considered only after 12 months of aggressive nonsurgical treatment.

o Surgical plantar fasciotomy with or without heel spur removal. There is a

method, through an open procedure, percutaneously or most common

endoscopically that release of the plantar fascia. This is an effective treatment,

without the need for removal of a calcaneal spur, when present. There is a

professional consensus, 70-90% of heel pain patients can be managed by non-

operative measures. Surgery of plantar fasciitis should be considered only after

all other forms of treatment have failed. With endoscopic plantar fasciotomy,

using the visual analog scale, the average post-operative pain was improved

from 9.1 to 1.6. For the second group (ESWT), using the visual analog scale the

average post-operative pain was improved from 9 to 2.1. Endoscopic plantar

fasciotomy gives better results than extra-corporeal shock wave therapy, but with

liability of minor complications

o Gastrocnemius recession. This is a surgical lengthening of the calf

(gastrocnemius) muscles. Because tight calf muscles place increased stress on

the plantar fascia, this procedure is useful for patients who still have difficulty

flexing their feet, despite a year of calf stretches. The procedure can be

performed with a traditional, open incision or with a smaller incision and an

endoscope. Complication rates for gastrocnemius recession are low, but can

include nerve damage.

Pharmacology

o Nonsteroidal anti-inflammatory medication. Drugs such as ibuprofen or

naproxen reduce pain and inflammation. Using the medication for more than 1

month should be reviewed with your primary care doctor.

o Cortisone injections. Cortisone, a type of steroid, is a powerful anti-

inflammatory medication. It can be injected into the plantar fascia to reduce

inflammation and pain. Your doctor may limit your injections. Multiple steroid

injections can cause the plantar fascia to rupture (tear), which can lead to a flat

foot and chronic pain.

Physical Therapy

More than 90% of patients with plantar fasciitis will improve within 10 months of starting

simple treatment methods

o General measures

Rest. Decreasing or even stopping the activities that make the pain worse

is the first step in reducing the pain. You may need to stop athletic

activities where your feet pound on hard surfaces (for example, running or

step aerobics).

Ice. Rolling your foot over a cold water bottle or ice for 20 minutes is

effective. This can be done 3 to 4 times a day

o Taping

No studies have adequately evaluated the effectiveness of taping or

strapping for managing plantar fasciitis.

o Shoe inserts

magnet-embedded insoles

custom orthotics and prefabricated shoe inserts (e.g., silicone heel pad,

felt pad, rubber heel cup) combined with stretching

o Night splints

Posterior-tension night splints maintain ankle dorsiflexion and toe

extension, creating a constant mild stretch of the plantar fascia that allows

it to heal at a functional length.

o Stretching

Stretching protocols often focus on the calf muscles and Achilles tendon

or on the plantar fascia. The benefits of stretching both the plantar fascia

and the Achilles tendon are unknown.

Combined with strengthening of the short foot & plantar flexors

o Modalities

Therapeutic ultrasound

Extracorporeal shockwave therapy (ESWT). During this procedure,

high-energy shockwave impulses stimulate the healing process in

damaged plantar fascia tissue. ESWT has not shown consistent results

and, therefore, is not commonly performed.

o Deep tissue massage / MFR

Promotes relaxation

Sources:

Journals and articles

H. B. Kitaoka, Z. P. Luo, E. S. Growney, L. J. Berglund and K. N. An (October 1994). "Material

properties of the plantar aponeurosis". Foot & ankle international 15 (10): 557–

560. PMID 7834064

G. A. Arangio, C. Chen and W. Kim (June 1997). "Effect of cutting the plantar fascia on

mechanical properties of the foot". Clinical orthopaedics and related research (339): 227–231.

PMID 9186224.

Jump up ^ Amit Gefen (March 2003). "The in vivo elastic properties of the plantar fascia during

the contact phase of walking". Foot & ankle international 24 (3): 238–244. PMID 12793487

Plantar Fasciitis, Rachelle Buchbinder, M.B., B.S., F.R.A.C.P., N Engl J Med 2004; 350:2159-

2166May 20, 2004 http://www.nejm.org/doi/full/10.1056/NEJMcp032745

No Consensus on a Common Cause of Foot Pain,nytimes; Dr. Terrence M. Philbin, a board-

certified orthopedic surgeon at the Orthopedic Foot and Ankle Center in Westerville, Ohio;

http://well.blogs.nytimes.com/2013/02/20/no-consensus-on-a-common-cause-of-foot-pain/?_r=0

http://www.webmd.com/a-to-z-guides/plantar-fasciitis-topic-overview

Books

Physical Medicine & rehabilitation 3rd edition by Randall L. Braddom

Clinical Anatomy by regions 9th edition by Richard Snell

Sports medicine Just the Facts by Francis G. O’Connor, MD, FACSM et. Al

Therapeutic exercises by Kisner