Transcript Plantar Fasciitis

Plantar Fasciitis
Etiology
Pathophysiology
Medical Management
Joshua Griffith
7/10/2014
Anatomy
 The plantar fascia is a thickened fibrous
aponeurosis that originates from the
medial tubercle of the calcaneus, runs
forward to insert into the deep, short
transverse ligaments of the metatarsal
heads, dividing into 5 digital bands at
the metatarsophalangeal joints and
continuing forward to form the fibrous
flexor sheathes on the plantar aspect
of the toes. Small plantar nerves are
invested in and around the plantar
fascia, acting to register and mediate
pain.
Anatomy
 The plantar fascia is made up of 3
distinct parts: the medial, central, and
lateral bands.
 The central plantar fascia is the
thickest and strongest section, and
this segment is also the most likely to
be involved with plantar fasciitis. In
normal circumstances, the plantar
fascia acts like a windlass mechanism
to provide tension and support
through the arch.
 It functions as a tension bridge in the
foot, providing both static support
and dynamic shock absorption.
What is Plantar Fasciitis?
• Plantar fasciitis (PLAN-tur fas-e-I-tis) is one of the most common
causes of heel pain.
• It involves pain and inflammation of a thick band of tissue,
called the plantar fascia, that runs across the bottom of your
foot and connects your heel bone to your toes.
• Plantar fasciitis commonly causes stabbing pain that usually
occurs with your very first steps in the morning. Once your foot
limbers up, the pain of plantar fasciitis normally decreases, but
it may return after long periods of standing or after getting up
from a seated position.
Etiology
 The cause of plantar fasciitis is often unclear and may be
multifactorial. Because of the high incidence in runners, it is best
postulated to be caused by repetitive microtrauma. Possible risk
factors include obesity, occupations requiring prolonged standing
and weight-bearing, and heel spurs. Other risk factors may be
broadly classified as either extrinsic (training errors and
equipment) or intrinsic (functional, structural, or degenerative).
 Extrinsic risk factors
 Training errors are among the major causes of plantar fasciitis.
Athletes 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 the development of plantar fasciitis. Running indoors on poorly
cushioned surfaces is also a risk factor.
Etiology
 Appropriate equipment is important. Athletes and others
who spend prolonged time on their feet should wear an
appropriate shoe type for their foot type and activity (see
Treatment).Athletic shoes rapidly lose cushioning
properties. Athletes who use shoe-sole repair materials
are especially at risk if they do not change shoes often.
Athletes who train in lightweight and minimally cushioned
shoes (instead of heavier training flats) are also at higher
risk of developing plantar fasciitis.
Etiology
 Intrinsic risk factors
 Structural risk factors include pes planus, overpronation, pes cavus,
leg-length discrepancy, excessive lateral tibial torsion, and
excessive femoral anteversion.
 Athletes 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.
Etiology
 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.
 As regards 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 this condition.[17] Weakness of
the gastrocnemius, soleus, and intrinsic foot muscles is also
considered a risk factor for plantar fasciitis.
 Aging and heel fat pad atrophy are 2 degenerative risk factors
for plantar fasciitis
Symptoms
 Plantar fasciitis typically causes a stabbing pain in the
bottom of your foot near the heel. The pain is usually
worst with the first few steps after awakening,
although it can also be triggered by long periods of
standing or getting up from a seated position.
Causes
 Under normal circumstances, your plantar fascia acts
like a shock-absorbing bowstring, supporting the arch
in your foot. If tension on that bowstring becomes
too great, it can create small tears in the fascia.
Repetitive stretching and tearing can cause the fascia
to become irritated or inflamed.
Risk Factor
 Factors that may increase your risk of developing plantar fasciitis include:
 Age. Plantar fasciitis is most common between the ages of 40 and 60.
 Certain types of exercise. Activities that place a lot of stress on your heel
and attached tissue — such as long-distance running, ballet dancing and
dance aerobics — can contribute to an earlier onset of plantar fasciitis.
 Faulty foot mechanics. Being flat-footed, having a high arch or even having
an abnormal pattern of walking can adversely affect the way weight is
distributed when you're standing and put added stress on the plantar fascia.
 Obesity. Excess pounds put extra stress on your plantar fascia.
 Occupations that keep you on your feet. Factory workers, teachers and
others who spend most of their work hours walking or standing on hard
surfaces can damage their plantar fascia.
Test and Diagnosis
 During the physical exam, your doctor checks for points of
tenderness in your foot. The location of your pain can help
determine its cause.
 Imaging tests
 Usually no tests are necessary. The diagnosis is made based on
the history and physical examination. Occasionally your doctor
may suggest an X-ray or magnetic resonance imaging (MRI) to
make sure your pain isn't being caused by another problem, such
as a stress fracture or a pinched nerve.
 Sometimes an X-ray shows a spur of bone projecting forward
from the heel bone. In the past, these bone spurs were often
blamed for heel pain and removed surgically. But many people
who have bone spurs on their heels have no heel pain.
Medical Management
 Medications
 Pain relievers such as ibuprofen (Advil, Motrin IB, others) and naproxen (Aleve) may
ease the pain and inflammation associated with plantar fasciitis.
 Therapies
 Stretching and strengthening exercises or use of specialized devices may provide
symptom relief. These include:
 Physical therapy. A physical therapist can instruct you in a series of exercises to
stretch the plantar fascia and Achilles tendon and to strengthen lower leg muscles,
which stabilize your ankle and heel. A therapist may also teach you to apply athletic
taping to support the bottom of your foot.
 Night splints. Your physical therapist or doctor may recommend wearing a splint that
stretches your calf and the arch of your foot while you sleep. This holds the plantar
fascia and Achilles tendon in a lengthened position overnight and facilitates
stretching.
 Orthotics. Your doctor may prescribe off-the-shelf heel cups, cushions or customfitted arch supports (orthotics) to help distribute pressure to your feet more evenly.
Medical Management
 Surgical or other procedures
 When more-conservative measures aren't working, your doctor might recommend:
 Steroid shots. Injecting a type of steroid medication into the tender area can provide
temporary pain relief. Multiple injections aren't recommended because they can
weaken your plantar fascia and possibly cause it to rupture, as well as shrink the fat
pad covering your heel bone.
 Extracorporeal shock wave therapy. In this procedure, sound waves are directed at
the area of heel pain to stimulate healing. It's usually used for chronic plantar fasciitis
that hasn't responded to more-conservative treatments. This procedure may cause
bruises, swelling, pain, numbness or tingling and has not been shown to be
consistently effective.
 Surgery. Few people need surgery to detach the plantar fascia from the heel bone.
It's generally an option only when the pain is severe and all else fails. Side effects
include a weakening of the arch in your foot.

Medical Management
The aims of plantar fasciitis rehabilitation are to
decrease pain and inflammation, improve flexibility
and strength then gradually return to full fitness. Any
biomechanical problems of the foot must also be
looked at to avoid plantar fasciitis recurring in the
future.
Pathophysiology
 Biomechanical dysfunction of the foot is the most common etiology
of plantar fasciitis; however, infectious, neoplastic, arthritic,
neurologic, traumatic, and other systemic conditions can prove
causative. The pathology is traditionally believed to be secondary to
the development of microtrauma (microtears), with resulting
damage at the calcaneal-fascial interface secondary to repetitive
stressing of the arch with weight bearing.[8, 9, 10]
 Excessive stretching of the plantar fascia can result in microtrauma
of this structure either along its course or where it inserts onto the
medial calcaneal tuberosity. This microtrauma, if repetitive, can
result in chronic degeneration of the plantar fascia fibers. The
loading of the degenerative and healing tissue at the plantar fascia
may cause significant plantar pain, particularly with the first few
steps after sleep or other periods of inactivity.
Pathophysiology
 The term fasciitis may, in fact, be something of a misnomer,
because the disease is actually a degenerative process that
occurs with or without inflammatory changes, which may
include fibroblastic proliferation. This has been proven from
biopsies of fascia from people undergoing surgery for plantar
fascia release.
 Studies have introduced the etiologic concept of fasciosis as
the inciting pathology. Fasciosis, like tendinosis, is defined as a
chronic degenerative condition that is characterized
histologically by fibroblastic hypertrophy, absence of
inflammatory cells, disorganized collagen, and chaotic vascular
hyperplasia with zones of avascularity.[11, 12, 13, 14]
Pathophysiology
 These changes suggest a noninflammatory condition and dysfunctional
vasculature. With reduced vascularity and a compromise in nutritional
blood flow through the impaired fascia, it becomes difficult for cells to
synthesize the extracellular matrix necessary for repairing and
remodeling.[15]
 Biomechanics of running
 During running, the vertical forces in the foot at foot strike may reach 2-3
times an individual’s body weight.[16] The plantar fascia and longitudinal
arch are also part of the foot’s shock absorption mechanism. During the
heel-off phase of gait, tension increases on the plantar fascia, which acts as
a storage of potential energy. During toe-off, the plantar fascia passively
contracts, converting the potential energy into kinetic energy and
imparting greater foot acceleration
Lifestyle and Home Remedies
 To reduce the pain of plantar fasciitis, try these self-care tips:
 Maintain a healthy weight.This minimizes the stress on your plantar fascia.
 Choose supportive shoes. Avoid high heels. Buy shoes with a low to moderate
heel, good arch support and shock absorbency. Don't go barefoot, especially
on hard surfaces.
 Don't wear worn-out athletic shoes. Replace your old athletic shoes before
they stop supporting and cushioning your feet. If you're a runner, buy new
shoes after about 500 miles of use.
 Change your sport. Try a low-impact sport, such as swimming or bicycling,
instead of walking or jogging.
 Apply ice. Hold a cloth-covered ice pack over the area of pain for 15 to 20
minutes three or four times a day or after activity. Or try ice massage. Freeze a
water-filled paper cup and roll it over the site of discomfort for about five to
seven minutes. Regular ice massage can help reduce pain and inflammation.
 Stretch your arches. Simple home exercises can stretch your plantar fascia,
Achilles tendon and calf muscles.
Patient Education
 Patients should be informed that improvement often takes
many weeks or months and requires considerable effort to
maintain a heel-cord stretching program or to wear a night
splint. They should also be taught proper performance of a
home exercise program involving stretching the plantar fascia.
 The following recommendations are appropriate:
 Wear shoes with adequate arch support and cushioned heels;
discard old running shoes and wear new ones; rotate work
shoes daily
 Avoid long periods of standing
 Lose weight
Patient Education
 Stretch the plantar fascia and warm up the lower extremity before
participating in exercise
 For increased flexibility, stretch the plantar fascia and the calf after
exercise
 Do not exercise on hard surfaces
 Avoid walking barefooted on hard surfaces
 Avoid high-impact sports that require a great deal of jumping (eg,
aerobics and volleyball)
 Apply ice for 20 minutes after repetitive impact-loading activities
and at the end of the day
 Limit repetitive impact-loading activities such as running to every
other day, and consider rest or cross-training for nonrunning days
References
 http://www.mayoclinic.org/diseases-conditions/plantarfasciitis/basics/symptoms/con-20025664
 http://emedicine.medscape.com/article/86143-overview#a0104
 https://www.google.gy/search?q=plantar+fascia&biw=1280&bih=700&sourc
e=lnms&tbm=isch&sa=X&ei=mrEzVN2jL6XksATbvIKoBQ&ved=0CAYQ_AUo
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thclub.co.uk%252Fhealth-and-exercise%252Fplantarfasciitis%252F%3B439%3B245
 http://www.patient.co.uk/doctor/plantar-fasciitis
 http://www.sportsinjuryclinic.net/sport-injuries/foot-heel-pain/plantarfasciitis/plantar-fasciitis-rehabilitation