Plantar+Fasciitis


 * Plantar Fasciitis**

Biomechanics/Anatomy
The plantar fascia, also known as aponeurosis, is made up of three bands: medial, central, and lateral. These bands originate on the medial tubercle of the calcaneus and travel across the plantar surface of the foot, dividing into 5 slips just before reaching the metatarsal heads, and inserting on the proximal phalanx of each toe. Because of this attachment, the plantar fascia tightens and elevates the arch when the toes are extended. The most common area of abnormality and discomfort in patients with diagnosed plantar fasciitis is near the origin of the central band at the medial tubercle of the calcaneus. Some patients will complain of symptoms in the mid-portion of the central band, prior to it splitting into the 5 slips.



Mechanism of Injury
Plantar fasciitis occurs when the plantar fascia on the bottom of the foot becomes inflamed due to overstretch or overuse thus creating tiny tears in the ligament. Various conditions might lead to this inflammation, including foot arch abnormalities (flat foot or high arches), obesity or sudden weight gain, running long distances, tight achilles tendon, or wearing shoes with poor arch support. Also, a sudden increase in weight-bearing activity and the initial steps after a period of inactivity may increase the likelihood of developing plantar fasciitis.

**Signs and Symptoms**
//**Signs**// The physician will preform a physical exam that may show:
 * Tenderness on the planter aspect of the foot
 * Arch abnormalities such as flat feet of high arches
 * Mild foot inflammation and redness
 * Stiffness of the arch
 * If pain is severe enough patient might present with an antalgic gait

The patient may present with complaints of:
 * //Symptoms//**
 * Pain and stiffness in the calcaneus( pain may be described as dull, sharp, achy, or burning)
 * Pain with activities such as standing for prolonged periods of time, climbing stairs, or any vigorous activity
 * Pain usually being worse in the morning when taking the first few steps, however some patients may complain of worsening pain at the end of the day following prolonged activity
 * Paresthesia, though this symptom is not as common
 * Increased pain due to a recent change in activity level



Practical Presentation
Plantar fasciitis is most commonly seen in women more than men between the ages of 40 and 60 commonly with patients who are overweight. Certain types of activities or occupations may put one at a higher risk of developing this pathology. This may include long distance running, dancing, or occupations that require prolonged standing. Pregnancy can also be considered a risk factor due to the additional load placed on the body.

( Goff & Crawford, 2011 )
 * Differential Diagnosis of Plantar Heel Pain **
 * ~ //Etiology// ||~ //Associated characteristics// ||
 * **Neurologic** ||  ||
 * Medial calcaneal and abductor digiti quinti nerve entrapment || Pain and burning sensation in the medial plantar region ||
 * Neuropathies || Diabetes mellitus, alcohol abuse, vitamin deficiency ||
 * Tarsal tunnel syndrome || Burning sensation in medial plantar region ||
 * **Skeletal** ||  ||
 * Acute calcaneal fracture || Direct trauma, unable to bear weight ||
 * Calcaneal apophysitis (Sever disease) || Adolescent, posterior calcaneal pain ||
 * Calcaneal stress fracture || Insidious onset of pain, repetitive loading ||
 * Calcaneal tumor || Deep bone pain ||
 * Systemic arthritides (e.g., rheumatoid arthritis, Reiter syndrome, psoriatic arthritis) || Multiple joint pain, bilateral heel pain ||
 * **Soft tissue** ||  ||
 * Achilles tendinitis || Posterior calcaneal/tendon pain ||
 * Heel contusion || Direct fall on heel with bone/fat pad pain ||
 * Plantar fascia rupture || Sudden plantar heel pain and ecchymosis ||
 * Posterior tibial tendinitis || Posterior medial ankle/foot pain ||
 * Retrocalcaneal bursitis || Pain in the retrocalcaneal region ||

Duration
Treatment duration can vary from 4-12 weeks depending on the severity and patient compliance to therapy. Most patients are seen 2 times a week initially and then decreased depending on the therapists discretion, progress made, as well as insurance qualifications.

Protocols
//Plantar Fascia-Specific Stretching Exercise Improves Outcomes in Patients with Chronic Plantar Fasciitis: A Prospective Clinical Trial with Two-Year Follow-Up// The study conducted by Digiovanni, B. et al. (2006) compared the outcomes of patients with plantar fasciitis treated with a plantar fascia stretching protocol or an achilles tendon stretching protocol. The plantar fascia stretching was performed in sitting by crossing the affected limb over the contralateral leg, applying force distal to the metatarsophalangeal joint on the painful foot, and pulling up toward the anterior leg until a stretch was felt in the plantar aspect of the foot. Patients were evaluated after 8 weeks of performing the stretches three times a day, and again with a 2-year follow-up. The results of the study supported the use of tissue-specific plantar fascia stretches for the treatment of plantar fasciitis. Patients experienced long-term benefits of the treatment such as drastic improvements in pain levels and functional limitations, as well as a high rate of satisfaction. ( Digiovanni et al., 2006 )

Another treatment protocol was contributed by Richard Bouche D.P.M., William Olson, D.P.M., Stephen Pribut, D.P.M., and Douglas Richie, Jr., D.P.M. and was listed in the American Academy of Podiatric Sports Medicine. It is a resistant plantar fasciitis treatment program: **PHASE 1- Acute Phase:** **PHASE 2- Rehabilitation Phase:** **PHASE 3- Functional Phase:** Note: this is probably the most important phase because it prepares the patient for their return to activity. Care needs to be taken at this stage not to allow the patient to overdo these exercises and stay within their limits as re-injury can easily occur.
 * Goal decrease acute pain and inflammation:
 * absolute or relative rest- Decrease sports activity to avoid rebound pain
 * ICE: 2 appliations of 20 minutes per day
 * NSAIDS
 * Further decrease pain and inflammation:
 * ultrasound
 * phonophoresis
 * neuroprobe
 * contrast baths
 * Maintain/increase flexibility of injured (and surrounding) tissue:
 *  gentle stretching exercises: calf, hamstring, posterior muscle groups
 * Functionally strengthen intrinsic muscles of the foot
 * <span style="color: #000000; font-family: Geneva,Arial,Helvetica,sans-serif; font-size: 12px;"> closed chain therapeutic exercise
 * <span style="color: #000000; font-family: Geneva,Arial,Helvetica,sans-serif; font-size: 12px;"> Doming of Arch (towel toe curl)
 * <span style="color: #000000; font-family: Geneva,Arial,Helvetica,sans-serif; font-size: 12px;">Protect injured area during functional activity
 * <span style="color: #000000; font-family: Geneva,Arial,Helvetica,sans-serif; font-size: 12px;">taping
 * <span style="color: #000000; font-family: Geneva,Arial,Helvetica,sans-serif; font-size: 12px;">stability running or other appropriate athletic shoes
 * <span style="color: #000000; font-family: Geneva,Arial,Helvetica,sans-serif; font-size: 12px;">orthoses as needed

<span style="color: #000000; font-family: Geneva,Arial,Helvetica,sans-serif; font-size: 12px;">**PHASE 4- Return To Activity** <span style="color: #000000; font-family: Geneva,Arial,Helvetica,sans-serif; font-size: 12px;">Return to desired sport activity: gradual, systematic, "to tolerance" Initiate preventive strategies: <span style="color: #000000; font-family: Geneva,Arial,Helvetica,sans-serif; font-size: 12px;">Note: Be careful in the first months return to exercise to avoid recurrence of pain. <span style="color: #000000; font-family: Geneva,Arial,Helvetica,sans-serif; font-size: 12px;">Consider shock wave therapy if there is a 6 month failure and a failure after repeated modification and remaking of orthotics.
 * orthoses PRN
 * appropriate athletic shoewear
 * functional exercises (i.e., pilates, plyometrics)
 * revise training program

Exercises
Stretches – DiGiovanni examined the effect of Achilles tendon stretches versus specific plantar fasciitis stretches. The Achilles tendon stretches were done in a weight bearing position immediately after getting out of bed. The plantar fasciitis stretch was performed before getting out of bed in a non-weight bearing position. Both groups held their stretches for 10 seconds and performed 10 reps. This was repeated twice more throughout the day. In addition to stretching both groups watched a video about plantar fasciitis, received NSAIDS, and received soft insoles for their shoes. Both groups had a significant reduction in pain from baseline. However the group that performed the plantar fasciitis stretches had significantly lower pain scores than the group that performed Achilles tendon stretches. Conclusion: Both stretches are effective but the plantar fasciitis stretch is provides the greatest pain relief. ( DiGiovanni et al., 2003 ) Other exercises for plantar fasciitis include:
 * Towel stretch (into dorsiflexion)
 * Towel curl
 * Marble pick-ups
 * Toe-taps
 * Achilles stretch (on a step)
 * Hamstring stretch

Modalities
Iontophoresis - Gudeman performed a double blinded placebo study examining the effects of iontophoresis with 0.4% dexamethasone sodium phosphate. Both groups received 6 sessions of physical therapy, however in addition to the physical therapy the experimental group recieved iontophoresis treatments. At post-treatment the group that received iontophoresis had significantly greater improvement in pain and function scores compared to the control group. At one month post-treatment there was no difference in the pain and function scores. (Gudeman, Eisele, Heidt, Colosimo, & Stroupe, 1997 ) Osborne also examined the effects of iontophoresis using a double blinded randomized placebo controlled study. The placebo group received 0.9% sodium chloride, one experimental group received 0.4% dexamethasone, and the second experimental group received 5% acetic acid. All patients received calf streatches and taping. The experimental groups treated with dexamethasone and acetic acid had increased short term pain relief compared to the control group. **Conclsion:** Dexamethasone and acetic acid are useful in treating pain in plantar fasciitis in the short term. For long term pain relief other treatment techniques should be utilized. (Osborne & Allison, 2006)

Ultrasound - The Cochrane review found no support in using ultrasound for the treatment of plantar fasciitis. A randomized study compared ultrasound at dosage of 0.5 W/cm², pulsed 1:4, 3 Mz for eight minutes and a placebo ultrasound. The two treatments were not statistically differenct in pain reduction.( Crawford & Thomson, 2003 )

Effectiveness of Pulsed radiofrequency electromagnetic field (PRFE) therapy on morning pain levels associated with plantar fasciitis was evaluated in double-blind, multicenter, randomized, placebo-controlled study. Experimental subjects were instructed to wear a small, wearable, extended-use PRFE device while sleeping and subjects recorded their pain measure according to a Visual Analog Scale in the morning and evening. The dosage of experimental PRFE was frequency 27.12 MHz, pulse rate 1000 pulses/sec, 100-μs burst width. Power 0.0098 W and a surface area of approximately 103 cm2. Experimental subjects showed progressive decline in morning pain. The AM-VAS scores declined by 40% in the experimental group and 7% in the control group over the 7-day treatment time, the difference between groups was significant (//p// = .03). The PM-VAS scores declined by 30% in the experimental group and 19% in the control group, the difference was not significant. ( Brook, Dauphinee, Korpinen, & Rawe, 2012 )

Night Splints - The Cochrane review found limited evidence to support night slints. One study found that subjects who used dorsiflexion splints had slightly better outcomes than those who did not. However another study found that there was no differnce in patient's pain levels when using night splints. Additionally patients were found to have poor compliance when using night splints due to the inability to tolerate the night splints.( Crawford & Thomson, 2003 )

Low-Dye Taping - Radford performed a study to examine the effectiveness of low-Dye taping. The control group received sham ultrasound treatments and the experimental group received low-Dye taping and sham ultrasound treatments. Low-Dye taping provided a small but statistically significant improvement in pain when compared to the control group. The tape specifically help reduce the "first step" pain that subjects experienced.( Radford, Landorf, Buchbinder, & Cook, 2006 )

Extracorporeal shock wave therapy (ESWT) was reviewed retrospectively of 225 patients (246 feet) who underwent consecutive ESWT treatments by a single physician. Subjects were included if they had plantar fasciitis for more than 6 months and a failure to response to at least 5 conservative modalities. Patients were evaluated prospectively with health questionnaires, Roles and Maudsley scores, and American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores at regular intervals. Multivariable analysis was performed to assess factors leading to successful outcomes: 4 of 6 criteria: greater than 50% improvement in VAS for the first morning steps, VAS for pain during daily activities, VAS for pain during exercise, greater than 50% reduction in pain with compression of the medial calcaneal tuberosity, AOFAS score increased by 30+ points, a Roles and Maudsley score of 1 or 2. Success rates of 70.7% at 3 months, 77.2% at 12 months, and 78.0% at the final 3 year follow-up. ( Chuckpaiwong, Berkson, & Theodore, 2009 )

Adjunct Treatment/ Alternative Treatment
Steroid Injection - McPoil performed a symstematic review of plantar fasciitis treatments and found limited evidence to support short term benefits of steroid injections. Although pain reduced in some patients in other patients pain did not increase. Additionally one study found that patients were at risk of an increase risk of rupture. ( McPoil et al., 2008 )

Acupuncture: Karagounis examined the effects of acupuncture on plantar fasciitis. There were two groups in this study. The control group received ice, NSAIDS, stretches, and strengthening exercises. The experimental group received acpuncture, ice, NSAIDS, stretches, and strengthening exercises. Both groups experienced pain relief, but there was no significant differenc of pain relief between the groups. This article concluded that acupuncture is a valid treatment to relieve plantar fasciitis pain as long as it is used with stretches, strengthening exercises, NSAIDS, and ice.( Karagounis, Tsironi, Prionas, Tsiganos, & Baltopoulos, 2011 )

Surgical release of the proximal medial head of gastrocnemius (PMGR) for plantar fasciitis. Isolated gastrocnemius contracture has been implicated to altered foot biomechanics and cause of a number of foot and ankle conditions. Seventeen patients (21 heels) who underwent surgically PMGR were followed over a 3-year period. Subjects had surgery after at least one year of conservative treatment and an isolated gastrocnemius contracture was confirmed using Silfverskiold’s test. 17/21 heels (81%) reported total or significant pain relief following the surgery and 0/21 reported worsening of their symptoms. Of the 17 improved heels, 10 (58%) improvement within 1 to 2 weeks and the remaining 7 showed progressive improvement over a 3- to 6-month period following surgery. ( Abbassian, Kohls-Gatzoulis, & Solan, 2012 )

**References**
Abbassian, A., Kohls-Gatzoulis, J., & Solan, M. C. (2012). Proximal medial gastrocnemius release in the treatment of recalcitrant plantar fasciitis. //Foot Ankle Int, 33//(1), 14-19.

Brook, J., Dauphinee, D. M., Korpinen, J., & Rawe, I. M. (2012). Pulsed Radiofrequency Electromagnetic Field Therapy: A Potential Novel Treatment of Plantar Fasciitis. //J Foot Ankle Surg//.

Chuckpaiwong, B., Berkson, E. M., & Theodore, G. H. (2009). Extracorporeal shock wave for chronic proximal plantar fasciitis: 225 patients with results and outcome predictors. //J Foot Ankle Surg, 48//(2), 148-155.

Crawford, F., & Thomson, C. (2003). Interventions for treating plantar heel pain. //Cochrane Database Syst Rev//(3), CD000416.

DiGiovanni, B. F., Nawoczenski, D. A., Lintal, M. E., Moore, E. A., Murray, J. C., Wilding, G. E., & Baumhauer, J. F. (2003). Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. //J Bone Joint Surg Am, 85-A//(7), 1270-1277.

Digiovanni, B. F., Nawoczenski, D. A., Malay, D. P., Graci, P. A., Williams, T. T., Wilding, G. E., & Baumhauer, J. F. (2006). Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. //J Bone Joint Surg Am, 88//(8), 1775-1781.

Goff, J. D., & Crawford, R. (2011). Diagnosis and treatment of plantar fasciitis. //Am Fam Physician, 84//(6), 676-682.

Gudeman, S. D., Eisele, S. A., Heidt, R. S., Jr., Colosimo, A. J., & Stroupe, A. L. (1997). Treatment of plantar fasciitis by iontophoresis of 0.4% dexamethasone. A randomized, double-blind, placebo-controlled study. //Am J Sports Med, 25//(3), 312-316.

Karagounis, P., Tsironi, M., Prionas, G., Tsiganos, G., & Baltopoulos, P. (2011). Treatment of plantar fasciitis in recreational athletes: two different therapeutic protocols. //Foot Ankle Spec, 4//(4), 226-234.

McPoil, T. G., Martin, R. L., Cornwall, M. W., Wukich, D. K., Irrgang, J. J., & Godges, J. J. (2008). Heel pain--plantar fasciitis: clinical practice guildelines linked to the international classification of function, disability, and health from the orthopaedic section of the American Physical Therapy Association. //J Orthop Sports Phys Ther, 38//(4), A1-A18.

//Pubmed health- plantar fasciitis//. (2011, February 19). Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/

Radford, J. A., Landorf, K. B., Buchbinder, R., & Cook, C. (2006). Effectiveness of low-Dye taping for the short-term treatment of plantar heel pain: a randomised trial. //BMC Musculoskelet Disord, 7//, 64.

Richie, D. (2004). Plantar Fasciitis: Treatment Pearls. //American Academy of Podiatric Sports Medicine.// Retrieved from http://www.aapsm.org/plantar_fasciitis.html/