Dr. NTR UNIVERSITY OF HEALTH SCIENCES

HYDERABAD – 500033.A PROJECT REPORT ON

PLANTAR FASCITIS

PROJECT GUIDE:MR.VIJAY KRISHNA

PROJECT BYC.DEEPTHI H.T.NO.07042010

APOLLO COLLEGE OF PHYSIOTHERAPYAPOLLO HOSPITAL EDUCATIONAL AND RESEARCH FOUNDATION

JUBILEE HILLS, HYDERABAD - 500033

Apollo College of Physiotherapy(Apollo Hospital Educational & Research Foundation)

Jubilee Hills, Hyderabad-500033

CERTIFICATE

This is to certify that the Project work entitled “CERVICAL RIB” is a bonafide work

carried out by C.DEEPTHI in partial fulfillment for the award of Degree of BACHELOR OF PHYSIOTHERAPY of Dr. NTR UNIVERSITY OF HEALTH SCIENCES, Vijayawada

during the year August 2011.

Project Guide Principal

MR.K.VIJAYA KRISHNA Ms. HANNAH RAJSEKHAR

Internal Examiner External Examiner

ACKNOWLEDGEMENT

It is my immense pleasure to present this project work on “PLANTAR FASCITIS’’

My greatful thanks to Mrs. Hannah Rajsekhar, principal of Apollo college of

physiotherapy, for providing me the base and background for pursuing this project.

I extend my sincere gratitude to my project guide Mr K.VIJAYA KRISHNA for her

valuable inputs, continuous support and perseverance in guiding me all through my

project.

I have learnt a lot from her through this project and she has inspired me to work harder.

I am thankful to my faculty for their timely advice and helpful suggestions.

I am thankful for my parents, family members, friends, and the librarian for

supporting me and without their blessings this project would not have been completed

successfully.

Special thanks to all my patients without whom the success of my project would have

been indefinite.

Above all I am extremely thankful to God for his grace and blessings.

This work is the reflection of the above personnels collective talent and their expertile in

the field of my project.

C.DEEPTHI

PLANTAR FASCIITIS

INDEX

1. INTRODUCTION.

2. ANATOMY OF PLANTAR FASCIA.

3. BIOMECHANICS.

4. SIGNS AND SYMPTOMS.

5. DIAGNOSIS.

6. PREVENTION.

7. TREATMENT PLAN.

8. PHYSIOTHERAPY MANAGEMENT.

9. ASSESSMENT.

10.CASE STUDIES.

11.LITERATURE REVIEW

12.CONCLUSION.

13.BIBILIOGRAPHY.

INTRODUCTION 

The plantar fascia is a thick fibrous band that runs the length of the

sole of the foot.

The plantar fascia helps maintain the complex arch system of the

foot and plays a role in one's balance and the various phases of

gait.

Injury to this tissue, called plantar fasciitis, is one of the most

disabling running injuries and also one of the most difficult to

resolve.

Plantar fasciitis represents the fourth most common injury to the

lower limb and represents 8 -10% of all presenting injuries to sports

clinics.

Rehabilitation can be a long and frustrating process.

The use of preventive exercises and early recognition of danger

signals are critical in the avoidance of this injury.

Definition

FASCIA a band or sheath of connective tissue investing, supporting, or

binding together internal organs or parts of the body.

Plantar fasciitis Plantar fascitis an inflammation (irritation and swelling with presence of

extra immune cells) of the thick tissue on the bottom of the foot that

causes heel pain and disability.

Plantar fascitis, which may cause the heel to hurt, feel hot or swell, is

inflammation of the plantar fascia, a thin layer of tough tissue supporting

the arch of the foot. Repeated microscopic tears of the plantar fascia

cause pain.

Typically with plantar fascitis, the pain is worse when first getting out of

bed, or is noticeable at the beginning of an activity and gets better as the

body warms up. Prolonged standing may cause pain, as well. In more

severe cases, the pain may worsen toward the end of the day.

INCIDENCE:

There is a greater incidence of plantar fascitis in males than females While

no direct cause could be found it could be argued that males are generally

heavier which, when combined with the greater speeds, increased ground

contact forces, and less flexibility, may explain the greater injury

predisposition.

RISK GROUPSProfessions involving prolonged standing like,

Traffic police

Teaching

Hill trekking

Doctors

Security guards etc

RISK FACTORSExtrinsic risk factors

Training errors during sports are among the major causes of plantar

fascitis.

Athletes 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 fascitis.

Running on poorly cushioned surfaces is also a risk factor.

AGE

The exact incidence and prevalence by age of plantar fascitis is

unknown but the condition is seen in adults essentially of all ages

usually patients of aged 30 to 50 years are more prone to this condition.

MODIFICATIONS

 wear an appropriate shoe type according to the foot type and activity

Sports shoes rapidly lose cushioning properties. Those 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.

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 ante version.

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.

Leg-length discrepancy, excessive lateral tibial torsion, and excessive

femoral ante version 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 fascitis. Reduced

dorsiflexion has been shown to be an important risk factor for this

condition.

Weakness of the gastrocnemius, soleus, and intrinsic foot muscles is

also considered a risk factor for plantar fascitis.

Degenerative risk factors

Aging and

Heel fat pad atrophy are two degenerative risk factors for plantar fascii.

ANATOMY OF PLANTAR FASCIA

The foot and ankle can be divided into the rear foot, midfoot, and

forefoot. The rear foot consists of four bones: the distal aspects of the

tibia and fibula (leg bones), the calcaneus (heel bone), and the talus.

The midfoot consists of five bones: the cuboid, the navicular, and three cuneiforms. The forefoot consists of 19 bones: five metatarsal bones and 14 phalanges. The plantar fascia originates from the medial calcaneal tuberosity and

divides into medial, central, and lateral bands that attach to the superior

surface of the abductor hallucis, flexor digitorum brevis, and abductor

digiti minimi muscles, respectively. The fascia then splits into five slips

that cross the metatarsophalangeal joints and insert onto the phalanges

of the digits.

The structure of the foot's MEDIAL LONGITUDINAL ARCH resembles

two rods: a rear rod consisting of the calcaneus and talus, and an

anterior rod consisting of the navicular, three cuneiforms, and the first

three metatarsals.

These rods are connected at their bases by the plantar fascia. When

force is applied to the apex of the Medial longitudinal arch, the arch

depresses, the two rods separate, and tension is distributed throughout

the plantar fascia

The main ligaments that aid in supporting the Medial longitudinal arch

are the long and short plantar ligaments and the calcaneonavicular

ligament (spring ligament).

During static stance, the Medial longitudinal arch is supported by the

plantar fascia, the ligaments, and the osseous architecture of the foot.

During late ambulation, the plantar fascia assumes a dynamic role in

reconfiguring both the Medial longitudinal arch and the rear foot in

preparation for toe-off.

FOOT AND ANKLE BIOMECHANICS

Gait can be separated into the stance phase and the swing phase.

During the stance phase, the foot contacts and adapts to the ground

surface.

During the swing phase, the swing leg accelerates forward and

prepares for ground contact. The stance phase consists of four sub

phases: initial contact, loading response, midstance, and terminal

stance.

During initial contact, the heel contacts the ground surface. The

loading response occurs immediately after initial contact, ending

when the contra lateral foot lifts off of the ground surface.

Midstance starts when the contra lateral foot lifts off of the ground

surface.

The contra lateral leg is now in swing phase. The midstance phase

ends as tension on the gastrocnemius, soleus, and Achilles tendon

(triceps surae) of the stance leg causes the heel to lift.

Terminal stance phase begins when the heel lifts and ends when the

swing leg contacts the ground.

The plantar fascia and extrinsic and intrinsic musculature of the foot

play an active role in guiding the foot as it transitions from initial

contact to toe-off.

Efficient function of the plantar fascia and musculature of the foot

depends on the configuration of the rear foot and midfoot articulations

during the different sub phases of gait.

The rear foot comprises the talocrural and the subtalar joints. The

talocrural joint (ankle mortise) consists of the articulation of the distal

aspect of the tibia and fibula with the trochlea of the talus. It facilitates

two primary movements: dorsiflexion, pulling the toes up and back

toward the tibia, and plantar flexion, pointing the toes downward.

The subtalar joint(STJ) consists of the articulation of the undersurface

of the talus with the calcaneus. Movement of the subtalar joint is

pivotal in transforming the foot from a rigid lever during initial ground

contact to a mobile shock absorber during loading response and early

midstance, and back into a rigid lever as the foot prepares for toe-off.

The two primary movements that occur at the Sub talar joint are

pronation and supination. Pronation of the Sub talar joint normally

occurs during loading response and into early midstance. In Subtalar

joint pronation, the calcaneus turns outward (everts); the talus drops

downward distally and adducts toward the midline; and the talocrural

joint dorsiflexes.

During initial contact, the Sub talar joint is normally supinated. It

pronates from loading response to early midstance and then

resupinates later in midstance and into terminal stance.

In Subtalar joint supination, the calcaneus turns inward (inverts); the

talus moves upward proximally and abducts away from the midline;

and the talocrural joint plantar-flexes. Freedom of movement in the

midfoot depends on the position of the Sub talar joint.

The two main articulations of the midfoot are the talonavicular joint

and the calcaneocuboid joint. The midfoot revolves around two joint

axes: the longitudinal midtarsal joint angle and the oblique midtarsal

joint angle (OMJA). Movement of the midfoot around the longitudinal

midtarsal joint angle consists of inversion or eversion

Movement of the midfoot around the oblique midtarsal joint angle

consists of dorsiflexion and abduction, and plantar flexion and

adduction STJ pronation during loading response and into early

midstance causes the talonavicular joint to diverge and move distally

to the calcaneocuboid joint.

This reconfiguration unlocks the midfoot, allowing it to pronate around

the oblique midtarsal joint angle. Pronation of the midfoot around the

oblique midtarsal joint angle will stretch the plantar fascia slightly as

the Medial longitudinal arch is depressed, transforming the foot from

a rigid lever into a mobile adaptor that is better equipped to absorb

ground reaction forces. Shortly after early midstance, the SubTalar

Joint starts to resupinate and should resupinate back to neutral

before terminal stance.

Subtalar joint resupination causes the talonavicular joint to move

proximally to the calcaneonavicular joint, superimposing these joints

and limiting midfoot and forefoot ranges of motion.

Subtalar joint resupination during midstance locks the lateral column

of the foot, including the calcaneocuboid joint, allowing the muscles

and fascia of the leg and foot to function more efficiently in guiding

the foot into toe-off.8,19,20

The peroneus longus and the plantar fascia are actively involved in

preparing the foot for toe-off.

The tendon of the peroneus longus muscle passes over the outer,

plantar aspect of the calcaneocuboid joint and attaches to the

undersurface of the base of the first metatarsal.

During late midstance, the calcaneocuboid joint functions as a pulley

for the tendon of the peroneus longus. This allows the peroneus

longus tendon to stabilize the base of the first metatarsal and aid in

transferring body weight medially over digits one through three.

The stability of the calcaneocuboid joint pulley system depends on

the Subtalar joint resupinating during midstance.

Later, during terminal stance, the metatarsophalangeal joint of the

first digit should dorsiflex to approximately 65 degrees, causing the

distal aspect of the plantar fascia to wrap around the

metatarsophalangeal joint.

These coordinated movements that occur during terminal stance

have been termed a windlass mechanism.

During this motion, tension on the distal aspect of the plantar fascia

is transmitted to its proximal attachment on the medial aspect of the

heel, causing the calcaneus to invert and the medial arch to rise as

the forefoot pulls back toward the rear foot.

Studies have demonstrated that when 33% or more of the plantar

fascia is surgically released, the medial arch decreases in height and

the plantar fascia loses its ability to invert the calcaneus.

During late stance the dynamic action of the peroneus longus and the

plantar fascia prepares the foot for an energy-efficient, high-gear toe-

off that occurs in a horizontal line over the metatarsophalangeal joints

of digits one through three.

Inability of the STJ to resupinate to neutral before heel lift places an

increased load on the plantar fascia and peroneus longus as they

attempt to stabilize the foot for toe-off. This may predispose the

plantar fascia to injury and also result in a less efficient, low-gear toe-

off that occurs in an oblique line over the metatarsophalangeal joints

of digits three, four, and five.

Other muscles that help stabilize the Medial longitudinal arch (MLA)

and resupinate the foot includes the abductor hallucis, flexor

digitorum brevis, flexor digitorum longus, flexor hallucis longus, and

tibialis posterior.

The abductor hallucis and flexor digitorum brevis aid in restoring the

MLA to its arched position and stabilizing the foot before toe-off. The

flexor digitorum longus, flexor hallucis longus, and the tibialis

posterior have tendinous attachment sites near the Medial

longitudinal arch.

The former two muscles are active in resisting pronation from

midstance to toe-off, and the tibialis posterior decelerates pronation

from loading response to early midstance.

Under normal circumstances, the plantar fascia, plantar ligaments,

osseous architecture, and extrinsic and intrinsic muscles of the foot

and leg are able to absorb ground reaction forces without incurring

injury.

However, structural abnormalities may lead to faulty biomechanics of

the rear foot and midfoot. These abnormalities may cause excessive

and rapid pronation of the STJ during loading response and into early

midstance, or ill-timed pronation that continues into terminal stance.

This may lead to an increased strain on the plantar fascia and other

supporting structures of the foot, predisposing a person to developing

plantar fascitis. Structural abnormalities associated with excess,

prolonged, or ill-timed pronation may include ankle equinus, rear foot

varus, forefoot varus, pesplano valgus, and pes cavus.

BIOMECHANICAL CONTRIBUTION OF PLANTAR FASCITIS DURING AMBULATION:

All though other passive structures contribute to arch support, the role

of the plantar aponeurosis is unique.

The plantar aponeurosis spans the entire length of the twisted plate

as in runs from posterior calcaneus to the bases of the proximal

phalanges of the toes.

The function of aponeurosis has been likened to the function of a TIE-

ROD on a truss.

The truss & the tie-rod form a triangle, the 2 struts of the truss form

the sides of the triangle and the tie-rod is the bottom.

The talus & calcaneus form the posterior strut, and the anterior strut

is formed by the remaining tarsal and metatarsal.

The plantar aponeurosis as does, the tie-rod, holds together the

anterior and posterior struts when the body weight is loaded on the

triangle.

The struts in weight bearing are subjected to compression forces

while the tie-rod is subjected to tension forces.

Increasing the load on the truss, or actually causing flattening of the

triangle, will increase tension in the tie-rod.

The tension in the plantar aponeurosis in the loaded foot is evident if

active or passive Metatarso phalangeal joints MTP extension is

attempted while the triangle is flattened.

Conversely, raising the height of triangle independent of the truss can

unload the tie-rod. For example, when the tibia is subjected to a

lateral rotator force, the hind foot will supinate and the planter fascia

will be unloaded.

With the in reduction in the tension in the planter fascia the range of

available toe hyperextension will increase.

Finally, increasing tension in tie-rod independent of loading the foot

will draw the two struts of the truss together, shortening and raising

the triangle.

This phenomenon can occur when the Metatarso phalangea joints

are extended.

Whether the are extending with distal lever free or the toes are being

extended as the heel raises in the weight bearing, the fascia is pulled

tighter and the arch can be raised simply through an increase in

passive tension in the aponeurosis.

Through the mechanism of planter aponeurosis, the Metatarso

phalangeal joints act interdependently with the joints of hind foot and

may contribute the supination of foot through the effect of Metatarso

phalangeal joint extension on the plantar aponeurosis.

Muscle activity appears to contribute little support to the

osteoligamentous plate in the normal static foot.

In gait, however, both the longitudinal and transversely oriented

muscles become active and contribute to support of twisted plate.

Key muscular support appears to be provided during gait by the

Tibialis posterior, with contributions also made by Flexor digitorum

longus, Flexor hallucis longus and Peroneous longus.

Muscle activity can either concentrically increase the twist or

eccentrically control some untwisting of the resilient plate to absorb

shock and allow foot to conform to an uneven supporting surface.

PATHO MECHANICS The development of plantar fascitis is thought to have a mechanical

origin

Excessive stretch of plantar fascia can result in micro trauma of the

plantar fascia at its insertion on the medial calcaneal tuberosity or

along the course of the fascia.This micro trauma, if repetitive can

result in chronic inflammation and degeneration of the plantar fascia

fibers.

Repetitive micro trauma at the plantar fascia may cause significant

plantar pain particularly with the first few steps after sleep other

periods of inactivity or prolonged walking especially stair climbing.

Vascular and metabolic disturbances, the formation of free radicals,

hyperthermia and genetic factors have also been linked to

degenerative change in connective tissues .

SIGNS AND SYMPTOMS

The most notable characteristic of plantar fascitis is pain upon rising,

particularly the first step out of bed.

This morning pain can be located with pinpoint accuracy at the bony

landmark on the anterior medial tubercle of the calcaneus.

The pain may be severe enough to prevent the patient from walking

barefooted in a normal heel-toe gait.

Other less common presentations include referred pain to the

subtalar joint, the forefoot, the arch of the foot or the Achilles tendon.

 After several minutes of walking the pain usually subsides only to

return with the vigorous activity of the day's training session.

The problem should be obvious to the coach as the patient will

exhibit altered gait and/ or an abnormal stride pattern, and may

complain of foot pain during running/jumping activities.

Consistent with plantar fascia problems the athlete will have a

shortened gastroc complex.

CLINICAL FEATURES

Sharp pain at medial aspect of heel.

Pain and stiffness are worse with rising in the morning or after prolonged

ambulation and may be exacerbated with climbing stairs.

Pain and stiffness –morning and prolonged rest.

Tenderness over plantar fascia in midfoot.

Dorsiflexion of toes increases pain.

DIAGNOSIS

Diagnosis can be made by careful examination and by the evidence

of clinical features, but in possible cases, it can be evidenced by poor

dorsiflexion (lifting the forefoot off the ground) or inability to perform

the "flying frog" position.

In the flying frog the patient goes into a full squat position and

maintains balance and full ground contact with the sole of the foot.

Elevation of the heel signifies a tight gastroc complex. This test can

be done with the training shoes on.

DIFFERENTIAL DIAGNOSIS:

S.No CHARACTER PLANTAR FASCITIS TARSAL TUNNEL

SYNDROME

1. Cause Overuse, excessive

weight bearing.

Trauma, space occupying

lesions, inflammation,

inversion, pronation,

valgus deformity.

2. Pain Plantar aspect of foot,

anterior calcaneus,

worse with walk and run.

Medial heel and medial

longitudinal arch.

3. 24hour behavior Worse in the morning Worse in the night

4. Electro diagnosis normal Prolonged motor and

sensory latencies.

5. Active movements Full ROM Full ROM

6. Passive

movements

Full ROM Pain on pronation

7. Resisted

isometrics

normal Foot intrinsics weak

8. Sensory deficits nil Possible

9. Reflexes normal Normal

PREVENTION:

with gentle foot exercises that strengthen the muscles in the arch of

the foot, such as

gentle toe curls,

marble pick ups,

tapping the big toe while holding the remaining four off the ground

and

continuing the regimen with [Trigger Point] massage balls

Begin with just a few of each exercise and gradually increase the

repetitions. Also, while returning to activity it is important to continue

the routine of stretching and ice.

Double check the footwear to make sure there’s proper arch support.

Commercial insoles or custom orthotics are good options to provide

necessary support.

TREATMENT

AIMS OF THE TREATMENT To reduce pain and inflammation.

To relieve strain from the fascia by stretching.

Patient education.

GOALS OF THE TREATMENTSHORT TERM GOALS:

(1)Relieve pain.

(2)Reduce swelling.

(3)Increase joint mobility.

(4)To strengthen muscles.

(5)Relieve tightness of TA

LONG TERM GOALS:(1)Patient education.

(2)Rehabilitation to improve ROM.

(3)Preventing and treating deformities.

MANAGEMENT

CONSERVATIVE MANAGEMENT:

Symptoms usually resolve more quickly when the time between the onset

of symptoms and the beginning of treatment is as short as possible. If

treatment is delayed, the complete resolution of symptoms may take 6-18

months or more. Treatment will typically begin

1. By correcting training errors which usually requires some degree of rest.

2. The use of ice after activities, and

3. An evaluation of the patient’s shoes and activities.

4. For pain, non steroidal anti-inflammatory drugs (e.g. aspirin, ibuprofen,

etc.) may be recommended.

DRUG THERAPY: Medical steroidal anti-inflammatory injections into the plantar fascia to

reduce pain Effectiveness of the steroids depends on the accuracy of

the injection and the patient's compliance with this period of reduced

activity.

It should be noted that 10 of 11 cases of spontaneous rupture of the

plantar fascia followed steroidal injections and an aggressive return to

activities.

SURGERYCRITERIA Before plantar fascia surgery i.e. fasciotomy is decided upon as a

treatment option there are certain criteria that should be met.

First, the condition should be serious enough to have lasted nine to

twelve months while trying other non-surgical treatment.

Stretches and other exercises designed to decrease symptoms of

plantar fascitis should also have been used during this period.

Athletes who suffer from this condition might also consider surgery

when performance becomes significantly impaired by heel pain and

related ailments.

Lastly, before participating in plantar fascia surgery it is crucial that you

are aware of the risks involved with the surgery. Although the procedure

is not generally serious, negative side effects can still occur.

COMPLICATIONS There are several complications that can inhibit full recovery following

plantar fascia surgery.

1. The arch of the heel can be reduced if the plantar fascia is released

too much.

2. Numbness in certain areas may occur following surgery if the nerves

around the fascia become damaged.

3. Infections can also develop which will need to be treated with

antibiotics.

4. Patients can also come out of surgery still feeling symptoms of

plantar fascitis and feeling pain around the heel.

5. Some times, malalignment leads to calcaneous spur formation.

METHOD OF SURGERY In most cases traditional plantar fascia release surgery involves open

surgery. In this procedure, the orthopedic surgeon cuts part of the

plantar fascia ligament, thereby relieving some tension that may have

accumulated.

To do this, the surgeon will begin by making an incision around the

heel pad. Incisions could then be made to the fascia ligament to

release strain.

Also, if a heel spur is present it may be removed along with any

damaged tissue.

Endoscopic surgery may also be used and it involves locating the

damaged portion of the fascia through instruments that are fed

through a small incision.

Following plantar fascia surgery, a cast or brace may be used to

reduce weight on the heel of the foot to allow the tissue to heal. It

may take a few weeks before weight bearing can be applied. In most

cases it will take at least three months to regain full activity of the

foot.

Like with any type of surgery, plantar fascia surgery certainly has its

risks. However, the majority of patients who undergo this procedure

enjoy a full recovery so it is important to decide with orthopedic

surgeon if the procedure is right for the patient.

PHYSIOTHERAPY MANAGEMENT1. Ice or cryotherapy after activity.

2. Taping.

3. Stretching the plantar fascia in the morning.

4. Rest.

5. Arch Support (especially if there is a flat foot).

6. Losing weight if possible, especially in overweight women because

survey of 5,000 visitors shows overweight women are 6 times more

likely than overweight men to get plantar fasciitis. This is probably

because fat deposits lower on the body in women than in men. This

lowers the center of gravity which will cause excess tension in the

plantar fasciitis if there is not also greater flexibility in the calf

muscles.

7. Night splints.

8. Myofascial release.

PHASE – 1:

1. STRETCHING OF PLANTAR FASCIA:

Plantar fascia exercises are useful in treating and preventing various

types of heel pain. By doing plantar fascia exercises, patient can

greatly improve the strength and flexibility of foot which will reduce

pain from plantar fascitis and heel spurs, while also helping to prevent

further occurrences of heel pain ailments.

Stretching exercises should also be used to improve the overall

flexibility of the Achilles tendon as well since those who suffer from

plantar fascitis often have a tight Achilles tendon which can add

additional strain to the fascia ligament.

Plantar fascia exercises that target the calf muscles in addition to the

plantar fascia are also an excellent way to reduce heel pain.

Often times, muscles and ligaments in the calf can become tense. As

already mentioned, when this occurs additional strain is placed on the

plantar fascia.

Plantar fascia exercises are often taken for granted yet are an

excellent way to reduce the effects of plantar fascitis. Doing these

exercises before and after an exercise routine is also very important

in pain management.

Running or participating in any other type of physical activity can be

harmful when the muscles and ligaments throughout the foot and calf

are tight and are not properly warmed up.

Exercising on tight muscles can increase the risk of tearing tissue and

developing or worsening painful conditions such as heel spurs or

Achilles tendonitis

PLANTAR FASCIA EXERCISES:

Plantar Fascia Exercise #1

Stand about two to three feet from a wall.

Lean towards the wall, keeping your knees straight and your

heels flat on the ground.

When doing this exercise patient should be able to feel the

muscles in your calf and the Achilles tendon begin to tighten.

Hold this position for about 10 seconds and repeat this

exercise several times.

By doing this exercise, the calf muscles and Achilles tendon

can become more flexible and stronger in order to prevent

further injury and heel pain.

Plantar Fascia Exercise #2

Sit in a chair and have your knees bent at 90 degree angles.

While keeping the heels of the feet flat on the floor, raise the

foot upwards.

Like Plantar Fascia Exercise #1, patient should be able to feel

the calf area tighten up.

This should be repeated at least several times a day to

improve flexibility and strength.

Done 4-5 times a day , 5-10 Repititions.

Done before first steps in morning before standing after long period of rest.

While sitting grab all five toes and pull the toes back toward the knee.

Hold for 30 sec and repeat 5 times.

Plantar Fascia stretches against the wall.

Place the foot against the wall. Gently lean forward slowly and hold

for 30 sec. Repeat 3-5 times.

2. RUNNERS STRETCHES FOR THE ACHILLES TENDON :

A tight Achilles Tendon is often implicated as an causative factor in Plantar

Fascitis.

Achilles Tendon Stretching Exercises:

Soleus Runners Stretch

Slowly Stretch the Achilles Tendon by placing the affected leg back

and slowly bending the knee in to a flexed position. Hold for 30 sec

and repeat 5 times.

Achilles Stretching On Incline Board

Place the feet and hold for 30 sec , slowly leaning forward to stretch

the Achilles Tendon.

Gastrocnemius Runners Stretch:

Keep the knee straight and slowly stretch the affected leg for 30 sec.

Rest:

Discontinue Running and walking for exercise until asymptomatic for 6

week.

Weight loss.

Modification of hard surfaces.

STRENGTHENING OF FOOT MUSCLES

Almost 35% of patients cited strengthening programs as the most

helpful treatment.

To strengthen muscles, do towel curls and marble pick ups.

Place a towel on a smooth surface, place the foot on the towel,

and pull the towel toward the body by curling up the toes or,

Put a few marbles on the floor near a cup. Keep the heel on the

floor and use the toes to pick up the marbles and drop them in the

cup.

Another exercise is toe taps. Keep the heel on the floor and lift all

of the toes off the floor. Tap only the big toe to the floor while

keeping the outside four toes in the air. Next, keep the big toe in

the air and tap the other four toes to the floor.

3. SHOE WEAR MODIFICATIONS :

Wearing shoes that are too small may cause plantar fascitis. Shoes

with thicker, well-cushioned midsoles may help alleviate the problem.

Running shoes should be frequently replaced as they lose their shock

absorption capabilities.

Flared, stable heel to help control heel stability.

Firm heel counter to control the hind foot.

Soft cushioning of the heel, raising the heel 12-15 min higher than the

sole.

Well molded Achilles pad.

Avoid rigid leather shoes that increase stress on Achilles Tendon.

4. LOW DYE TAPING :

Plantar fascia taping is a common way to help relieve the symptoms

of plantar fascitis.

Plantar fascia taping is widely used to add support and reduce stress

on the plantar fascia ligament as both a way to relieve pain from

plantar fascitis, as well as a preventative measure against that and

other heel pain ailments.

Plantar fascia taping is a good way to stabilize the fascia ligament.

When the foot is taped properly, the fascia's movement becomes

limited. Often times, athletes may tape their feet during certain times

to help prevent strain during exercise. By limiting the fascia's

movement, it becomes a way to keep the ligament from moving

abnormally or stretching excessively and thus preventing tears from

developing in the tissue.

Apply taping in the morning to give the feet support throughout the

day, or apply it prior to exercise to keep it from stretching excessively.

5. ICE MASSAGE :

Ice to the area of inflammation for Anti- inflammatory effect.

Use Ice wrap for -7 min.

PHASE – 2:

If phase-1 measures fail to relive symptoms after several months, phase

treatement is used.

ORTHOTICS:

orthotics physically re-stretch the fascia ligament while moving and

also provides acupressure and structural support in the areas of the

foot that require the most attention in order to help reverse the

condition.

When used in combination with effective orthotic, exercises can

significantly improve the injury that the patient may be suffering from

and also provide long term prevention against reoccurrences.

Orthotics is the most expensive option as a plaster cast is made of

the individual’s feet to correct specific biomechanical factors. One

study found that 27% of patients cited orthotics as the most helpful

treatment of plantar fascitis.

Feet that pronate (arches roll in) have a prolonged mid-stance phase

of ground contact and may cause excessive internal rotation of the

tibia.

As has been established, the excessive pronation can compromise

the plantar fascia while the excessive rotation may injure the knee.

These faults can lead to hip and low back pain because they allow

the affected leg to drop unevenly, stressing the supporting muscles

and ligaments of the hips and low back.

Orthotics, by forming a solid foundation for the foot, can prevent

excessive pronation and therefore check excessive or aberrant

movement further up the kinetic chain of the leg.

Physicians who routinely use orthotics (podiatrists and chiropractors)

can cast two different types of orthotics

1. Biomechanical/ functional or

2. Accommodative orthotics.

Patient with very high or very low arches may benefit from arthtic

inserts.

A less rigid, accommodative insert is applicanle to a more requires

more cushion and less hind foot control.

A padded but rigid insert is indicated for a more unstable foot with

compensatory pronation (pes planus or low arch) which requires

more control.

NIGHT SPLINTS:

Night splints, which are removable braces, allow passive stretching of

the calf and plantar fascia during sleep, and minimize stress on the

inflamed area.

A 5- degree dossiflexion night splint is bebeficial.

Splint holds the plantar fascia in a continuously tensed state.

Use of Night splint is to minimize the change of tension in the fascia

that occurs with each days new activities.

MODALITIES :

Iontophoresis.

Ultrasounds.

Deep friction massage.

Foot bath technique.

RANGE OF MOTION:  Use of an "eight board" or wobble board will increase the range of

motion of the ankle, increase proprioception and strengthen the small

intrinsic muscles of the foot.

The eight board is easy to construct and should be used daily. Incline

boards are also useful for stretch of the gastroc

complex. Once pain in the plantar fascia has

subsided this stretch can be used both

mornings and evenings.

  A return to running should be considered only after there is a three to

four week period of no pain. Exercises and preventative exercises should

continue to be done.

PHASE – 3:

Patients in whom phase 1 and 2 measures have failed may be

candidates for surgical intervention.

But there is high compilation rate from the surgery.

Indicate the surgery after the failure of phase 1 and 2 Rx for 18

months.

Never use Endoscopic release because of the increased compilation

rate compared with that of open release because inability to identify

the nerve to the abductor digiti minimi

RUPTURE OF THE PLANTAR FASCIA :

TREATMENT :

PHASE – 1 : (0-14) Days

Immediate non- weight bearing with crutches.

Light compression wrap changed several times a day for 2-3 days.

Non- weight bearing. Light, fiber glass cast on day 3, worn for 1-2 week

depending on resolution of pain.

Non steroidal Anti- imflammatory drugs for 2-3 week.

Gentle active toe extension and flexion exercises while still in cast.

PHASE – 2 : (2-3 Weeks)

Removal of fiber glass cast

Use of 1/8 inch felt pad placed from heel to heads of metatarsals and

lightly wrapped with bandage.

Weight bearing is progressed from as tolerated in boot with crutches to

weight bearing in boot only

Exercises are begun as pain allows

Swimming.

Stationary bicycling with no resistance.

Gentle Achilles stretches with towel looped around foot.

PHASE – 3 : (3-8 Weeks)

Active ankle strengthening exercises are progressed.

High impact exercises are help until patient has been completely

asymptomatic for 2-3 week.

Use of a custom arthritic layered with an overlying soft substance is

often helpful for eventual athletic participation.

HOME PROGRAME

PLANTAR FASCIA STRETCHING EXERCISES

1. Long Sitting Stretch

1) Sit on the floor with your legs stretched out in front of you

2) Loop a towel around the top of your affected foot

3) Pull the towel towards you until a stretch is felt across the bottom of your

foot

4) Hold for 30 seconds then relax - repeat 10 times

2. Achilles Stretch

1) Stand facing a wall and place your hands straight out on the wall

2) Step back with your affected foot keeping it flat on the floor

3) Move the other leg forward and slowly lean in toward the wall

4) Stop when you feel a stretch through the calf

5) Hold for 30 seconds then relax - repeat 10 times

3. Stair Stretch

1) Stand on a step on the balls for your feet

2) Hold the rail for balance

3) Slowly lower the heel of the injured foot until a stretch is felt

4) Hold for 30 seconds then relax - repeat 10 times

4. Can roll Stretch

1) Roll the injured foot (without a shoe on) back and forth from the tip of the

toes to the heel over a can.

2) Repeat ten times in both directions.

ASSESSMENT

SUBJECTIVE ASSESSMENT NAME:

AGE:

SEX:

OCCUPATION:

CHIEF COMPLAINTS:

PAIN AREA OF SYMPTOMS:

TYPE OF PAIN:

AGGREVATING FACTORS:

RELIEVING FACTORS:

INTENSITY OF PAIN: by V.A.S scale

Min--------------------------l---------------------------Max

DURATION OF PAIN:

SEVERITY:

IRRITABILITY:

24 HOUR BEHAVIOUR:

HISTORY 1. PRESENT HISTORY:

MODE OF ONSET:

DURATION OF ONSET:

2. PAST HISTORY:

3. GENERAL CONDITIONS:

4. MEDICAL HISTORY:

5. SURGICAL HISTORY:

OBJECTIVE ASSESSMENT

PHYSICAL EXAMINATIONOBSERVATION SWELLING

CONTRACTURE

DEFORMITY

POSTURE

ARCHES OF FOOT

HALLUX VALGUS

PALPATION TENDERNESS

WARMTH

OEDEMA

EXAMINATIONRANGE OF MOTION

AROM

PROM

MMT

INVESTIGATIONS

DIFFERENTIAL DIAGNOSIS

DIAGNOSIS

AIMS OF TREATMENT

SHORT TERM GOALS:

LONG TERM GOALS:

TREATMENT PLAN

PROGNOSIS:

HOME PROGRAMME:

CASE STUDY 1

SUBJECTIVE ASSESSMENT NAME: XYZ

AGE: 22 yrs

SEX: female

OCCUPATION: Student

CHIEF COMPLAINTS: Pain in the heel of the right leg, often severe in the

mornings while getting up from bed.

PAIN AREA OF SYMPTOMS: Pain in the heel area

TYPE OF PAIN: Pulling pain

AGGREVATING FACTORS: Prolonged standing and walking, unilateral

standing on right leg.

RELIEVING FACTORS: reduced with activity.

INTENSITY OF PAIN: unable to perform functional activities after the onset

of pain (8 on V.A.S scale) Min-------------------------------!-----------Max

DURATION OF PAIN: 5 to 10 mins

SEVERITY: moderately severe

IRRITABILITY: very irritable

24 HOUR BEHAVIOUR: worse in the nights,relieved by the activity

HISTORY 1. PRESENT HISTORY:

MODE OF ONSET: Fall from height

DURATION OF ONSET : pain observed after discontinuing the pain killers

i.e. after 2 days

2. PAST HISTORY: The patient had a fall from tree, landed up on feet. Swelling

observed in left foot immediately after injury.

3. GENERAL CONDITIONS: normal.

4. MEDICAL HISTORY: pain killers taken after the injury.

5. FAMILY HISTORY: No family history.

6. SURGICAL HISTORY: No surgical history.

7. PERSONAL HISTORY: no history of HTN, DM etc

OBJECTIVE ASSESSMENTPHYSICAL EXAMINATION OBSERVATION

SWELLING—Present, seen immediately after injury.

CONTRACTURE--Absent

DEFORMITY-- Absent

POSTURE-- Limping

ARCHES OF FOOT-- Normal

HALLUX VALGUS—Absent

GAIT: antalgic gait

PALPATION

TENDERNESS: Present over the sole of the foot, marked on heel.

WARMTH: Present

OEDEMA: noticed soon after the injury over the whole feet.

EXAMINATION

RANGE OF MOTION

AROM PROM

RIGHT LEFT RIGHT LEFT

DORSIFLEXION 0-15 deg 0-20 deg 0-20 deg 0-20 deg

PLANTARFLEXION 0-45 deg 0-45 deg 0-45 deg 0-45 deg

EVERSION 0-20 deg 0-20 deg 0-20 deg 0-20 deg

INVERSION 0-25 deg 0-35 deg 0-35 deg 0-35 deg

MMT:

RIGHT LEFT

DORSIFLEXORS 3/5 4+/5

PLANTARFLEXORS 3+/5 4+/5

EVERTARS 4/5 4/5

INVERTARS 4/5 4/5

INVESTIGATIONS:

X-RAY-- No signs of Fracture.

No calcium deposits noted.

DIFFERENTIAL DIAGNOSIS: Differentially diagnosed with tarsal tunnel

syndrome.

DIAGNOSIS: plantar fascitis of right foot.

AIMS OF TREATMENT

SHORT TERM GOALS:

Relieve pain.

Reduce swelling.

Increase joint mobility.

To strengthen muscles.

Relieve tightness of TA.

LONG TERM GOALS:

Patient education.

Rehabilitation to improve ROM

Preventing and treating deformities.

TREATMENT PLAN:

Position of the patient: in supine lying

0 to 2 weeks:

Slow icing given to relieve the pain, also to relax the tight fascia

Slow sustained stretching of calf muscle, holding for 30 sec to 2 min for 3

to 5 times / day

2 – 4 weeks:

Slow icing continued for 10 min.

Stretches given individually to gastrocnemius and soleus.

Ultra sound given over the medial aspect of the right heel.

Intensity – 0.6w/ cm-2

Duration – 8 min.

4 – 7 weeks:

Taught the self stretching techniques before getting down from bed.

Ankle mobilizations done to improve the range of dorsiflexion and

inversion.

Stretches continued with increased hold time.

Self stretching exercises taught.

Strengthening exercises like pebble board exercise, sand exercise

encouraged.

Ultra sound given with reduced intensity and duration.

Feet wear modification done.

7 – 8 weeks:

Ultra sound discontinued.

Active R.O.M exercises encouraged.

Strengthening exercises continued.

Encouraged Self stretching exercises before and after the intense activity.

Taught the patient about the protection and prevention techniques.

PROGNOSIS:

Pain reduced on V.A.S scale to 3.

Able to do unilateral stance on the affected leg.

Reduced pain during the first few steps after prolonged rest.

HOME PROGRAMME:

1. Stretching exercises to relieve tightness of plantar fasciitis

2. Joint ROM exercises.

3. Preventive measures.

CASE STUDY 2

SUBJECTIVE ASSESSMENT NAME: ABCD

AGE: 40 yrs

SEX: Female

OCCUPATION: Teacher

CHIEF COMPLAINTS: pain over the heel of the left foot

PAIN AREA OF SYMPTOMS: pain over the inner border of the heel.

TYPE OF PAIN: pin pointing pain over the heel

AGGREVATING FACTORS: pain worse in the mornings and after

prolonged rest.

RELIEVING FACTORS: relieved as the day progresses.

INTENSITY OF PAIN: able to continue doing work even with pain, but with

discomfort, pain on V.A.S scale is 5.

Min--------------------------!----------------------------Max

DURATION OF PAIN: during the first few steps after prolonged rest.

SEVERITY: moderately severe.

IRRITABILITY: moderately irritable.

24 HOUR BEHAVIOUR: worse in the mornings, relieved with activity.

HISTORY

1. PRESENT HISTORY:

MODE OF ONSET: gradual.

DURATION OF ONSET: less than 1 min of weight bearing on

the affected leg.

2. PAST HISTORY: No specific past history. Applied pain relieving balm after

the onset.

3. GENERAL CONDITIONS: normal.

4. MEDICAL HISTORY: patient took paracetomol for pain relief.

5. SURGICAL HISTORY: no surgical intervention underwent.

OBJECTIVE ASSESSMENTPHYSICAL EXAMINATIONOBSERVATION

SWELLING: no swelling noticed.

CONTRACTURE: absent

DEFORMITY: absent

POSTURE: unequal weight bearing over the medial border of the left foot due

to pain.

ARCHES OF FOOT: reduced arches or pes planus noticed

HALLUX VALGUS: absent.

PALPATION

TENDERNESS: present over the medial aspect of the left foot.

WARMTH: slight increase in temperature all over the sole of the foot.

OEDEMA: absent.

EXAMINATIONRANGE OF MOTION:

AROM PROM

RIGHT LEFT RIGHT LEFT

DORSIFLEXION 0-20 deg 0-15 deg 0-20 deg 0-20 deg

PLANTARFLEXION 0-45 deg 0-45 deg 0-45 deg 0-45 deg

EVERSION 0-20 deg 0-20 deg 0-20 deg 0-20 deg

INVERSION 0-35 deg 0-25 deg 0-35 deg 0-35 deg

M.M.T:

RIGHT LEFT

DORSIFLEXORS 4+/5 3+/5

PLANTARFLEXORS 4+/5 4/5

EVERTARS 4/5 4/5

INVERTARS 4/5 4/5

INVESTIGATIONS: x- ray adviced.

DIFFERENTIAL DIAGNOSIS: differentially diagnosed with tarsal tunnel

syndrome.

DIAGNOSIS: plantar fascitis of left foot.

AIMS OF TREATMENT

SHORT TERM GOALS:

Relieve pain.

Reduce swelling.

Increase joint mobility.

To strengthen muscles.

Relieve tightness of TA.

LONG TERM GOALS:

Patient education.

Rehabilitation to improve ROM

Preventing and treating deformities

TREATMENT PLAN:

1 – 2 weeks:

Cryotherapy initiated over the sole of the left foot.

Slow sustained stretches of calf muscle, holding for 3 min, 5 times/ day

Foot wear analysed and adviced for a change of foot wear.

2 – 3 weeks:

Icing continued for 10 min.

Stretching of gastro soleus continued.

Ultra sound initiated for pain relief.

Intensity: 0.5W/cm-2

Duration: 5 min.

3 – 5 weeks:

Reduced ultra sound duration and intensity due to increased pain.

Intensity – 0.4W/cm-2

Duration – 3 min.

Cold therapy for 10 min.

Stretching of calf muscles 5 times /day.

Made the patient aware of the unequal weight bearing on both the

borders of feet.

5 to 6 weeks:

Ultra sound continued with the same intensity and duration.

Slow icing for 10 min.

Sustained, slow stretching of calf, 5 times a day.

6 – 7 weeks:

Slow icing done for 10 min.

Continued ultrasound with less intensity along with voveron gel.

Stopped stretching.

AROM exercises of ankle joint performed.

7 – 8 weeks:

Slow icing continued for 10 min.

Gentle kneading at the site of pain.

Use of night splint for 6 to 8 hrs at the time of sleep.

Kneading by using topical cream.

Slow icing

Ultra sound with intensity 0.5 A, duration of 4 min.

AROM exercises continued.

PROGNOSIS:

There is considerable reduction in pain on V.A.S. scale to 3.

Patient is able to walk for a long distance.

Decreased morning pain after getting up from bed.

Patient is able to perform unilateral stance on the effected leg.

HOME PROGRAMME:

Self stretching exercises taught.

AROM exercises encouraged.

Preventive measures.

CASE STUDY 3

SUBJECTIVE ASSESSMENT NAME: xxx

AGE: 41 yrs

SEX: female

OCCUPATION: house wife

CHIEF COMPLAINTS: pain in the heel of the right foot.unable to walk in the

morning soon after getting up from the bed.

PAIN AREA OF SYMPTOMS: pain in the heel of the right foot, close to the lateral

border.

TYPE OF PAIN: pulling type of pain, some times pinpointing, unable to

describe exactly.

AGGREVATING FACTORS: walking after prolonged rest, prolonged

walking.

RELIEVING FACTORS: relieved with activity at the end of the day.

INTENSITY OF PAIN: able to continue with pain,5 on V.A.S scale.

Min-----------------!----------------Max

DURATION OF PAIN: 3 to 5 min after the onset of pain.

SEVERITY: moderately severe.

IRRITABILITY: irritable.

24 HOUR BEHAVIOUR: worse in the mornings.

HISTORY1) PRESENT HISTORY: patient applies topical ointment when ever has

pain.

2) MODE OF ONSET: gradual

3) DURATION OF ONSET: relieves with in 5 min of onset.

4) PAST HISTORY: previously had the same pain 4 months before, patient took

overon tablet but had temporary relief, took ultra sound treatment in a clinic

nearby. Pain reduced but recurred after 1 month. She applied topical balms on

the area of pain but could not carry on her work with pain.

5) GENERAL CONDITIONS: patient has back pain and knee pain, she also had

ankle pain 5 yrs back.

6) MEDICAL HISTORY

Cortico- steroid injection below the ankle 5 yrs back.

Voveron pain killers

Estrogen supplements taken after hysterectomy.

7). SURGICAL HISTORY: hysterectomy done 8 yrs back.

OBJECTIVE ASSESSMENTPHYSICAL EXAMINATIONOBSERVATION

SWELLING: absent

CONTRACTURE: absent

DEFORMITY: hallux valgus present.

POSTURE: unequal weight distribution on both the legs due to pain.

ARCHES OF FOOT: prominent pes planus.

HALLUX VALGUS: present

PALPATION

TENDERNESS: present over the heel of the right foot close to the lateral

aspect.

WARMTH: present.

OEDEMA: absent.

EXAMINATIONRANGE OF MOTION:

AROM PROM

RIGHT LEFT RIGHT LEFT

DORSIFLEXION 0-15 deg 0-21 deg 0-20 deg 0-23 deg

PLANTARFLEXION 0-45 deg 0-45 deg 0-45 deg 0-45 deg

EVERSION 0-20 deg 0-20 deg 0-20 deg 0-20 deg

INVERSION 0-35 deg 0-35 deg 0-35 deg 0-35 deg

M.M.T:

RIGHT LEFT

DORSIFLEXION 3/5 3+/5

PLANTARFLEXION 3+/5 3+/5

EVERSION 4/5 4/5

INVERSION 4/5 4/5

INVESTIGATIONS: x- ray

DIFFERENTIAL DIAGNOSIS: did with tarsal tunnel syndrome.

DIAGNOSIS: plantar fasciitis of the right foot.

AIMS OF TREATMENT

SHORT TERM GOALS:

Relieve pain.

Reduce swelling.

Increase joint mobility.

To strengthen muscles.

Relieve tightness of TA.

LONG TERM GOALS:

Patient education.

Rehabilitation to improve ROM

Preventing and treating deformities

TREATMENT PLAN:

1 – 2 weeks:

Icing to the plantar fascia, over the sole of the foot for 10 mins.

Ultra sound to reduce pain.

Intensity: 0.7W/cm-2

Duration: 6 mins.

Stretching of both hamstring and calf muscles.

Hold time: 2 min.

Number of stretches: 5 times/day.

Observed foot wear and adviced for foot wear modification, as there was

unequal weight bearing on the borders of foot.

2 – 3 weeks:

Iceing continued for 10 mins.

Ultra sound with reduced intensity and duration.

Intensity: 0.4 W/cm-2

Duration: 5 mins.

Self stretches taught in,

1. Sitting

2. Standing and

3. Long sitting

Advised for night splint for 6 – 8 hrs /day.

AROM exercises in bucket of water.

3 – 5 weeks:

Foot wear modified with silicon insoles in the shoes with elevated medial

arch of the foot, patient was advised to use although out the day while

walking.

Ankle strengthening exercises in high sitting with the help of thera band.

5 sets each of dorsi flexion, plantar flexion, inversion, eversion.

5 – 8 weeks:

Reduced the width of the insole as the patient complained of discomfort.

Discontinued night splint.

Self stretching of hamstring and calf muscles continued.

AROM exercises encouraged.

Strengthening exercises for both ankle continued.

PROGNOSIS:

GOOD prognosis with

Consistent reduction of pain on V.A.S scale to 2.

Patient is comfortable in making steps after prolonged rest.

Reduced discomfort and tightness during ankle toe movements.

Increased ROM of ankle joint.

Increased strength of foot muscles.

Adviced to continue use of silicon insole in shoes.

HOME PROGRAMME:

Encouraged to do AROM exercises

Self stretching exercises made to continue.

Strengthening exercises for ankle encouraged.

Preventive measures

LITERATURE REVIEW

1. Tissue-Specific Plantar Fascia-Stretching Exercise Enhances

Outcomes in Patients with Chronic Heel Pain Abstract

Background: Approximately 10% of patients with plantar fasciitis have

development of persistent and often disabling symptoms. A poor response to

treatment may be due, in part, to inappropriate and nonspecific stretching

techniques. We hypothesized that patients with chronic plantar fasciitis who are

managed with the structure-specific plantar fascia-stretching program for eight

weeks have a better functional outcome than do patients managed with a standard

Achilles tendon-stretching protocol.

Methods: One hundred and one patients who had chronic proximal plantar fasciitis

for duration of at least ten months were randomized into one of two treatment

groups. The mean age was forty-six years. All patients received prefabricated soft

insoles and a three-week course of celecoxib, and they also viewed an educational

video on plantar fasciitis. The patients received instructions for either a plantar

fascia tissue-stretching program (Group A) or an Achilles tendon-stretching

program (Group B). All patients completed the pain subscale of the Foot Function

Index and a subject-relevant outcome survey that incorporated generic and

condition-specific outcome measures related to pain, function, and satisfaction with

treatment outcome. The patients were reevaluated after eight weeks.

Results: Eighty-two patients returned for follow-up evaluation. With the exception

of the duration of symptoms (p < 0.01), covariates for baseline measures revealed

no significant differences between the groups. The pain subscale scores of the Foot

Function Index showed significantly better results for the patients managed with the

plantar fascia-stretching program with respect to item 1 (worst pain; p = 0.02) and

item 2 (first steps in the morning; p = 0.006). Analysis of the response rates to the

outcome measures also revealed significant differences with respect to pain,

activity limitations, and patient satisfaction, with greater improvement seen in the

group managed with the plantar fascia-stretching program.

Conclusions: A program of non-weight-bearing stretching exercises specific to the

plantar fascia is superior to the standard program of weight-bearing Achilles

tendon-stretching exercises for the treatment of symptoms of proximal plantar

fasciitis. These findings provide an alternative option to the present standard of

care in the non operative treatment of patients with chronic, disabling plantar heel

pain. The Journal of Bone and Joint Surgery (American).

2. Risk Factors for Plantar Fasciitis: A Matched Case-Control Study

The Journal of Bone and Joint Surgery (American) 85:872-877 (2003)

Abstract

Background: Plantar fasciitis is one of the more common soft-tissue disorders of

the foot, yet little is known about its etiology. The purpose of the present study was

to use an epidemiological design to determine whether risk factors for plantar

fasciitis could be identified. Specifically, we examined the risk factors of limited

ankle dorsiflexion with the knee extended, obesity, and time spent weight-bearing.

Methods: We used a matched case-control design, with two controls for each

patient. The matching criteria were age and gender. We identified fifty consecutive

patients with unilateral plantar fasciitis who met the inclusion criteria. The data that

were collected included height, weight, whether the subject spent the majority of

the workday weight-bearing, and whether the subject was a jogger or runner. We

used a reliable goniometric method to measure passive ankle dorsiflexion

bilaterally. The main outcome measure was the adjusted odds ratio of plantar

fasciitis associated with varying degrees of limitation of ankle dorsiflexion,

different levels of body mass, and the subjects' reports on weight-bearing.

Results: Individuals with 0° of dorsiflexion had an odds ratio of 23.3 (95%

confidence interval, 4.3 to 124.4) when compared with the referent group of

individuals who had >10° of ankle dorsiflexion. Individuals who had a body-mass

index of >30 kg/m 2 had an odds ratio of 5.6 (95% confidence interval, 1.9 to 16.6)

when compared with the referent group of individuals who had a body-mass index

of 25 kg/m 2 . Individuals who reported that they spent the majority of their

workday on their feet had an odds ratio of 3.6 (95% confidence interval, 1.3 to

10.1) when compared with the referent group of those who did not.

Conclusions: The risk of plantar fasciitis increases as the range of ankle

dorsiflexion decreases. Individuals who spend the majority of their workday on

their feet and those whose body-mass index is >30 kg/m 2 are also at increased risk

for the development of plantar fasciitis. Reduced ankle dorsiflexion, obesity, and

work-related weight-bearing appear to be independent risk factors for plantar

fasciitis. Reduced ankle dorsiflexion appears to be the most important risk factor.

3.Effectiveness of Foot Orthoses to Treat Plantar Fasciitis

Karl B. Landorf, PhD; Anne-Maree Keenan, MAppSc; Robert D. Herbert, PhD

Archives of Internal Medicine 2006;166(12), June 26:1305-1310.

Abstract

Study design: Alternating single-subject A-B and A-B-A designs. Objective: To

discuss biomechanical and histological issues related to the development of plantar

fasciitis and to evaluate the effectiveness of arch taping in controlling heel pain

during ambulation.

Background: Plantar heel pain as a consequence of plantar fascial strain, a

condition frequently diagnosed as plantar fasciitis, can significantly interfere with

functional ambulation. Biomechanical causes of plantar fasciitis have been related

to micro failure of plantar facial tissue followed by incomplete repair resulting

from abnormal histological responses. Arch taping has been suggested as a viable

treatment option for patients with this diagnosis but few studies have documented

its clinical effectiveness in reducing pain. Methods and measures: Two female

subjects diagnosed with plantar fasciitis with a history of chronic heel pain

participated in the clinical evaluation. Time to onset of pain was recorded during

ambulation with and without arch taping on several days.

Results: Visual and statistical analysis using the Two Standard Deviation Band

method showed improvement at the P<0.05 significance level in walking time for

both subjects with arch taping. Conclusions: Biomechanical and histological

factors need to be considered for successful management of plantar fasciitis. The

arch taping technique applied in these two cases was effective in controlling pain

during ambulation and could be considered as a viable treatment option for other

individuals with similar clinical presentations. Slower healing time of dense

connective tissue such as plantar fascia needs to be protected for longer periods of

time to ensure resolution of plantar fasciitis.

Background Plantar fasciitis is one of the most common foot complaints. It is often

treated with foot orthoses; however, studies of the effects of orthoses are generally

of poor quality, and to our knowledge, no trials have investigated long-term

effectiveness. The aim of this trial was to evaluate the short- and long-term

effectiveness of foot orthoses in the treatment of plantar fasciitis.

Methods: A pragmatic, participant-blinded, randomized trial was conducted from

April 1999 to July 2001. The duration of follow-up for each participant was 12

months. One hundred and thirty-five participants with plantar fasciitis from the

local community were recruited to a university-based clinic and were randomly

allocated to receive a sham orthosis (soft, thin foam), a prefabricated orthosis (firm

foam), or a customized orthosis (semirigid plastic).

Results: After 3 months of treatment, estimates of effects on pain and function

favored the prefabricated and customized orthoses over the sham orthoses,

although only the effects on function were statistically significant. Compared with

sham orthoses, the mean pain score (scale, 0-100) was 8.7 points better for the

prefabricated orthoses (95% confidence interval, –0.1 to 17.6; P = .05) and 7.4

points better for the customized orthoses (95% confidence interval, –1.4 to 16.2; P

= .10). Compared with sham orthoses, the mean function score (scale, 0-100) was

8.4 points better for the prefabricated orthoses (95% confidence interval, 1.0-15.8;

P = .03) and 7.5 points better for the customized orthoses (95% confidence

interval, 0.3-14.7; P = .04). There were no significant effects on primary outcomes.

At the 12 month review.

Conclusions: Foot orthoses produce small short-term benefits in function and may

also produce small reductions in pain for people with plantar fasciitis, but they do

not have long-term beneficial effects compared with a sham device. The

customized and prefabricated orthoses used in this trial have similar effectiveness

in the treatment of plantar fasciitis.

CONCLUSION

The foot must sustain tremendous forces during ambulation. Any and all

measures taken to improve the shock absorptive qualities, intrinsic strength

and proprioceptive balance of the foot will eventually reduce the pain.

Injury to the plantar fascia can be difficult to resolve and will require a

prolonged recovery period. Halfhearted or sporadic attention to rehabilitation

of this injury will produce minimal results.

Proves that Physiotherapy interventions for patients suffering from plantar

fasciitis have shown lot of improvement and pain reduction.

There is remarkable improvement in reducing the morning stiffness, pain

and pain after prolonged rest.

Physiotherapy treatment has reduced complications like immobility and

dependence by strengthening the muscle s and improving the joint mobility.

Rehab programme has improved their work endurance more than expected

and boosted their self confidence towards life and gave them better way of

dealing their problem.

Good evidence that physiotherapy management is both effective and safer

than many other pharmaceutical alterations.

BIBILIOGRAPHY

1. Essentials of orthopedics and applied Physiotherapy – Jayanth joshi.

2. Orthopedic physical assessment – David j. Magee.

3. Joint structure and function – Cynthia Norkins.

4. Human Anatomy – B.D.Chowrasya.

5. Gray’s anatomy – Gray.

6. Therapeutic exercises, foundations and techniques – Corolyn Kisner.

7. Tidy’s physiotherapy.

8. Cash orthopedics.

9. Essential orthopedics – Maheshwari.

10. Sunder’s manual of physical therapy practice.

11.Orthopedic rehabilitation—Brotzman and wilk

REFERENCE WEBSITES

1. www.emedicine.com

2. http://www.heelpain.com

3. http://plantarfascitistips.com

4. medline journals.

5. http://www.wikihow.com

6. http://www.medindia.net