Plantar Fasciitis

INTRODUCTION

Plantar fasciitis is the result of collagen degeneration of the plantar fascia at the origin, the calcaneal tuberosity of the heel as well and the surrounding perifascial structures.

• The plantar fascia plays an important role in the normal biomechanics of the foot.
• The fascia itself is important in providing support for the arch and providing shock absorption.
• Despite containing this condition is characterized by an absence of inflammatory cells, hence it is considered degenerative, and not an inflammatory pathology As such, “fasciosis” or “fasciopathy” are increasingly used to refer to this condition

The pathology is characterized by medial heel pain that worsens with weight-bearing, as well as after rest or non-weight-bearing. Plantar fasciitis often presents chronically with symptoms lasting over a year in duration.

Etiology

Often presents as an overuse injury, primarily due to repetitive strain causing micro-tears of the plantar fascia but can occur as a result of trauma or other multifactorial causes.There are many risk factors for plantar heel pain including but not limited too:

• Reduced dorsiflexion and first metatarsophalangeal joint extension are weakly associated
• Increased plantar flexion range
• Pes cavus or pes planus deformities
• Excessive foot pronation dynamically
• Impact/weight-bearing activities such as prolonged standing, running, etc.
• Improper shoe fit
• Elevated BMI

Characteristics/Clinical Presentation

• 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
• In the athletic population, BMI is not associated with increased plantar fasciitis risk, however, evidence suggests BMI is associated with increased risk in the non-athletic population^. There is some evidence that weight loss could possibly reduce foot pain
• The presence of a sub-calcaneal spur
• Diabetes Mellitus (and/or other metabolic condition)
• Leg length discrepancy
• Tightness and/or weakness of Gastrocnemius, Soleus, Tendoachilles tendon, and intrinsic muscle
• Low-quality evidence suggests an association between weight-bearing activities and plantar fasciitis

A 2016 systematic review found strong evidence for 3 associations for plantar fasciitis; a thickened plantar fascia, the presence of a sub calcaneal spur, and a high BMI in a non-athletic population.

Physical Therapy Management

 Patient Education

• Patients need to be told that symptoms may take weeks or even months to improve (depending on the circumstances of the injury).
• To follow the advice given e.g. rest from aggravating activities initially, ice, and stretch.
• Be aware of the importance of a home exercise plan

The Clinical Practice Guidelines provide recommended physical therapy interventions based on available evidence. Interventions most recommended include manual therapy, stretching, taping, foot orthoses, and night splints.^[36]

1. Manual Therapy should include soft tissue and joint mobilization
   1. Myofascial release can be helpful in reducing pain
2. Stretching should include the plantar fascia and gastrocnemius/Soleus complex
   1. Stretching the plantar fascia consists of the patient crossing the affected leg over the contralateral leg and using the fingers across the base of the toes to apply pressure into the toe extension until a stretch can be felt along the plantar fascia.
   2. Achilles tendon stretching can be performed in a standing position with the affected leg placed behind the contralateral leg with the toes pointed forward. The front knee is then bent, keeping the back knee straight and the heel on the ground. The back knee could then be in a flexed position for more of a soleus stretch.
3. Taping should prevent pronationLow dye is the most commonly used taping technique and can improve pain in the short term, yet there is a lack of evidence for its long-term effects A combined approach of taping with stretching may yield better results than stretching alone
4. Foot orthoses can be prefabricated or custom-made. They must support the medial longitudinal arch and provide cushioning to the heel.
5. If the patient has pain with initial steps in the morning, a night splint would be beneficial.
   1. Posterior-night splints maintain ankle dorsiflexion and toe extension, allowing for a constant stretch on the plantar fascia
6. Footwear should include a rocker-bottom shoe
7. If weight is a concern, the patient should be referred to a more appropriate healthcare provider for nutritional advice.
8. Therapeutic exercise and neuromuscular re-education should focus on reducing pronation and improving weight distribution in weight bearing.
   1. 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 The systematic review suggests there is minimal evidence to support the use of foot muscle training in patients with plantar fasciitis