Plantar Fasciitis

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More information on plantar fasciitis that is needed to be shared is as under;

Causes:

Extrinsic risk factors

Training errors

Training errors are among the major causes of plantar fasciitis.

Patients usually have a history of an increase in distance, intensity, or duration of activity.

The addition of speed workouts, plyometrics, and hill workouts are particularly high-risk behaviors for development of plantar fasciitis.

Running indoors on poorly cushioned surfaces is also a risk factor.

Equipment

The patient shoes rapidly lose cushioning properties. Patients using shoe sole repair materials are especially at risk if they do not change shoes often enough.

Patients who train in lightweight and minimally cushioned shoes (instead of heavier training flats) are also at higher risk of developing plantar fasciitis. Athletes should be wearing an appropriate shoe type for their foot type and activity.

Intrinsic risk factors

Structural risk factors

Structural risk factors include pes planus, overpronation, pes cavus, leg-length discrepancy, excessive lateral tibial torsion, and excessive femoral anteversion.

Patients with pes planus (low-arched) or pes cavus (high-arched) feet have increased stress placed on the plantar fascia with foot strike.

Pronation is a normal motion during walking and running, providing foot-to-ground surface accommodation and impact absorption by allowing the foot to unlock and become a flexible structure. Overpronation, on the other hand, can lead to increased tension on the plantar fascia.

Leg-length discrepancy, excessive lateral tibial torsion, and excessive femoral anteversion can lead to an alteration of running biomechanics, which may increase plantar fascia stress.

Functional risk factors: Tightness in the gastrocnemius and soleus muscles and the Achilles tendon is considered a risk factor for plantar fasciitis. Reduced dorsiflexion has been shown to be an important risk factor for plantar fasciitis Weakness of the gastrocnemius, soleus, and intrinsic foot muscles is also considered a risk factor.

Degenerative risk factors: Aging and heel fat pad atrophy are 2 degenerative risk factors for plantar fasciitis

Physical Therapy:

Initial or Acute Phase:

The initial physical therapy program for plantar fasciitis stresses stretching of the calf and foot. The stretching program should include wall stretches with the knee both in the extended and flexed positions.

To perform a wall stretch, the athlete should stand 3 feet from a wall, placing the hands on the wall. Keeping the toes pointed straight and the heel on the ground, the athlete leans the hips toward the wall and holds this position for 30-40 seconds. Stretches targeted at the plantar fascia are particularly important.

Iontophoresis has been found in one study to increase the speed of resolution of plantar fasciitis, although it had no effect on long-term outcome.

Ice is the first-line anti-inflammatory treatment for plantar fasciitis. This treatment can be applied by ice massage, ice bath, or ice pack.


For ice massage, the patient freezes water in a small paper or Styrofoam cup and then rubs the ice over the painful heel, using circular motion and moderate pressure for 5-10 minutes.


For an ice bath, a shallow pad is filled with water and ice. The athlete soaks the heel for 10-15 minutes; to prevent cold injuries, the athlete should use neoprene toe covers or keep the toes out of the ice water.


An ice pack can be made by placing crushed ice in a plastic bag wrapped in a towel. The use of crushed ice allows the ice pack to be molded to the foot and increase the contact area; a good alternative is a bag of prepackaged frozen corn kernels wrapped in a towel. Ice packs usually are placed for 15-20 minutes. Icing should be performed after completing exercise, stretching, and strengthening.


Recovery phase:

Physical Therapy: A strengthening program emphasizing foot intrinsic muscle strengthening is added in the next phase of physical therapy. Exercises include towel curls, marble pick-ups, and toe taps.

For a towel curl, the patient sits with the foot lying flat on the end of a towel placed on a smooth surface. The patient pulls the towel toward the body by curling up the towel with the toes while keeping the heel on the floor. As the patient improves, add weight to the far end of the towel to increase the difficulty of this exercise.

To do marble pick-ups, the patient places a few marbles on the floor near a cup, picks them up with the toes, and drops them in the cup while keeping the heel on the floor. For a greater challenge, the athlete may try to pick up coins instead of marbles.

To do toe taps, the patient lifts all toes off the floor; while keeping the heel on the floor and the outside 4 toes in the air, repetitively taps just the big toe to the floor. Next, the patient reverses the process and repetitively taps the outside 4 toes to the floor while keeping the big toe in the air .

Medical Issues/Complications: Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used to treat plantar fasciitis. While there is controversy as to whether or not NSAIDs actually assist in the physiologic healing process, they can be useful as an adjunct to control pain while treating the plantar fasciitis with stretching, strengthening, and relative rest.

Surgical Intervention: For cases that do not respond to conservative treatment, a surgical release of the plantar fascia may be considered. Overall, surgical release has a 70-90% success rate in treating patients with plantar fasciitis: open, endoscopic, or radiofrequency lesioning techniques may be used.

Potential complications include flattening of the longitudinal arch and heel hypoesthesia, as well as the potential complications that are associated with plantar fascia rupture. Longitudinal arch strain appears to account for over 50% of the chronic complications.

Other Treatment:This may include corticosteroid injections and/or night splints.

Corticosteroids: In cases of recalcitrant plantar fasciitis, corticosteroid injection may be considered. Other causes of heel pain should be considered, and a plain radiograph of the foot or calcaneus always should be obtained before injecting steroids. A corticosteroid injection may be given through a plantar or a medial approach with or without ultrasound guidance. Studies have reported success rates of 70% or better. Potential risks include plantar fascia rupture, which was found in almost 10% of patients after plantar fascia injection in one series and fat pad atrophy. Long-term sequelae were found in approximately 50% the patients with plantar fascia rupture.

Night splints: Most people naturally sleep with their feet in a plantar-flexed position, which causes the plantar fascia to be shortened. Night splints are designed to keep the ankle in a neutral position during sleep, essentially passively stretching the calf and the plantar fascia for a prolonged period. Theoretically, the night splint allows the plantar fascia to heal in the elongated position, which in turn decreases the tension with the first step in the morning. A night splint can be molded either from plaster or fiberglass casting material, or a prefabricated and commercially produced plastic brace can be used. Studies have shown that approximately 80% of patients using night splints improved. The splints are especially useful in individuals who have had symptoms of plantar fasciitis for longer than 12 months.

Maintenance Phase:

Physical Therapy: To minimize the chances of reoccurrence, athletes should continue on a maintenance program of daily stretching and/or strengthening at least 2-3 times per week.

Other Treatment:

This may include orthotic devices and arch supports.

Patients with low arches have increased stress placed on the plantar fascia with foot strike and decreased ability to absorb the forces that are generated by foot strike. Mechanical corrections for pes planus include taping of the arches, over-the-counter (OTC) arch supports, and custom orthotic devices. Studies have found significant benefit to these treatments when used in appropriate patients.

Arch taping can be used as definitive treatment or as a trial to determine whether the expense of arch supports or orthotics is worthwhile. Taping may be more cost-effective for acute onset of plantar fasciitis, whereas OTC arch supports and orthotics may be more cost-effective for chronic or recurrent cases of plantar fasciitis and for prevention of injuries (arches must be retaped for each practice or game).

OTC arch supports usually last a full season; custom orthotic devices should last many seasons. OTC arch supports are especially useful in athletes with acute plantar fasciitis and mild pes planus, particularly adolescents whose rapid foot growth may require one or more new pairs of arch supports per season.

Custom orthotic devices are designed to control biomechanical risk factors such as pes planus, valgus heel alignment, and leg-length discrepancies. Athletes treated with orthotic devices usually require semi-rigid three-quarter to full-length orthotic devices with longitudinal arch support to control overpronation and metatarsal head motion, especially of the first metatarsal head .The main disadvantage of use of orthotic devices is the cost.

Summary of Treatment:

Initial or Acute Phase:

Stretching of Calf and foot

Iontophoresis

Ice application in form of Ice massage, ice bath and Ice cube Massage.

Recovery Phase:

A strengthening program emphasizing foot intrinsic muscle strengthening. Exercises include towel curls, marble pick-ups, and toe taps.

Nonsteroidal anti-inflammatory drugs useful as an adjunct to control pain while treating the plantar fasciitis with stretching, strengthening, and relative rest.

Surgical release of the plantar fascia.

In cases of recalcitrant plantar fasciitis, corticosteroid injections.

Night splints designed to keep the ankle in a neutral position during sleep, essentially passively stretching the calf and the plantar fascia for a prolonged period.

Maintenance Phase:

A maintenance program of daily stretching and/or strengthening at least 2-3 times per week.

Orthotic devices and arch supports.