Plantar fasciitis: Symptoms, Causes, and Treatment- HeyPhysio


Definition/Description

                             
                              If the bottom of your foot hurts when you walk, or kind of heel pain, you may have Plantar fasciitis. Plantar fasciitis may be referred to as plantar fasciosis, plantar heel pain, plantar fascial fibramatosis, among others. Because many cases diagnosed as “plantar fasciitis” are not inflammatory conditions, this condition may be best referred to as "plantar fasciosis." This is confirmed through histological analysis which demonstrates plantar fascia fibrosis, collagen cell death, vascular hyperplasia, random and disorganized collagen, and avascular zones.

                               There are many different sources of pain in the plantar heel beside the plantar fascia, and therefore the term "Plantar Heel Pain" serves best to include a broader perspective when discussing this and related pathology.

Anatomy 

                              The plantar fascia is comprised of white longitudinally organized fibrous connective tissue which originates on the periosteum of the medial calcaneal tubercle, where it is thinner but it extends into a thicker central portion. The thicker central portion of the plantar fascia then extends into five bands surrounding the flexor tendons as it passes all 5 metatarsal heads. Pain in the plantar fascia can be insertional and/or non-insertional and may involve the larger central band, but may also include the medial and lateral band of the plantar fascia.
                             The plantar fascia is best referred to as fascia because of it's relatively variable fiber orientation as opposed to the more linear fiber orientation of aponeurosis. The plantar fascia blends with the paratenon of the Achilles tendon, the intrinsic foot musculature, and even the skin and subcutaneous tissue. The thick viscoelastic multilobular fat pad is responsible for absorbing up to 110% of body weight during walking and 250% during running and deforms most during barefoot walking vs. shod walking.

During weight-bearing, the tibia loads the foot “truss” and creates tension through the plantar fascia (windlass mechanism). The tension created in the plantar fascia adds critical stability to a loaded foot with minimal muscle activity.  Evidence of the important stabilizing nature of the plantar fascia is evidence when following cases post-surgical release which may lead to midfoot arthritis, rupture of the secondary stabilizers of the arch (e.g spring ligament), as well as other pathologies.

Characteristics/Clinical Presentation/ Clinical features


  • Heel pain with first steps in the morning or after long periods of non-weight bearing
  • Tenderness to the anterior medial heel
  • Limited dorsiflexion and tight Achilles tendon
  • A limp may be present or may have a preference to toe walking
  • Pain is usually worse when barefoot on hard surfaces and with stair climbing
  • Many patients may have had a sudden increase in their activity level prior to the onset of symptoms


Diagnostic Procedures

                 Plantar fasciitis is a clinical diagnosis. It is based on patient history and physical exam. Patients can have local point tenderness along the medial tuberosity of the os calcis, pain on the first steps or after training. Plantar facia pain is especially evident upon dorsiflexion of the patients pedal phalanges, which further stretches the plantar fascia.
                Therefore, any activity that would increase the stretch of the plantar fascia, such as walking barefoot without any arch support, climbing stairs, or toe walking can worsen the pain. The clinical examination will take into consideration a patient's medical history, physical activity, foot pain symptoms and more. The doctor may decide to use Imaging studies like radiographs, diagnostic ultrasound, and MRI.

Physical Therapy Management

                 The most common treatments include stretching of the gastroc/soleus/plantar fascia, orthotics, ultrasound, iontophoresis, night splints, and joint mobilization/manipulation.


  1. Strength Training.  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.
  2. Stretching consists of the patient crossing the affected leg over the contralateral leg and using the fingers across to the base of the toes to apply pressure into the toe-extension until a stretch can be felt along the plantar fascia. Achilles tendon stretching can be performed in a standing (self-stretching) position with the affected leg placed behind the contralateral leg with the toes pointed forward. The front knee was then bent, keeping the back knee straight and heel on the ground. The back knee could then be in a flexed position for more of a soleus stretch
  3. Mobilizations and manipulations have also been shown to decrease pain and relieve symptoms in some cases.  Posterior talocrural joint mobilisations and subtalar joint distraction manipulation have been performed with the hypomobile talocrural joint.
  4. Posterior-night splints maintain ankle dorsiflexion and toe extension, allowing for a constant stretch on the plantar fascia.
  5. Foot orthoses produce small short-term benefits in function and may also produce small reductions in pain for people with plantar fasciitis.
  6. iontophoresis combined with taping gave greater relief from stiffness symptoms.

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