Plantar Fasciitis: Function, Assessment & Rehabilitation

Introduction

Plantar fasciitis is a chronic injury which causes pain and inflammation at the origin of the plantar fascia on the plantar surface of the heel. The pain is exacerbated in the mornings after getting up or after long rest periods. Plantar fasciitis is frequently seen in athletic populations, but it is also observed in the sedentary population. Chronic inflammation and may also cause calcification at the origin of the plantar fascia and bony traction spur formation. Ten percent of the population experience plantar heel pain at some point during their lifetime and plantar fasciitis accounts for approximately 1% of all outpatient visits to orthopaedic clinics. (Crawford, 2005; Lee et al., 2007).

Functional Anatomy

The plantar fascia is a broad band of fibrous tissue that normally measures 3mm-3.8 mm in thickness which runs along the bottom surface of the foot, from the heel to the toes. It forms the medial longitudinal arch of the foot. It comprises of three bundles: central, lateral, and medial. It is the principle static and dynamic stabiliser of the longitudinal arches of the foot. It also acts as a shock absorber and helps to protect the underlying soft tissues.

During the toe off portion of gait cycle, the windlass effect on the plantar fascia of the plantar fascia tightening this raises the longitudinal arches to rise. This helps generate a more rigid foot for propulsion. During heel strike the plantar fascia relaxes, flattening the arch. This allows the foot to absorb shock and accommodate irregularities in the walking surface.

(Puttaswamaiah and Chandran, 2007).

 

 

Subjective

Pain is most frequently described as sharp rather than dull and is especially prominent first thing in the morning when the patients place their feet on the ground for the first time.

People frequently report that walking helps initially, and they often try to stretch the longitudinal arch to try and break down what they feel are painful adhesions. Although walking helps initially, the pain reoccurs with further exertion.

 

Objective

Biomechanical analysis of the lower limb, assessing the kinetic chain during functional movements (squat, single leg squat, running technique etc)

Excessive pronation of the foot during gait (pes planus)

Reduced ROM with ankle Dorsiflexion

Tight triceps surae (Gastrocnemius/Soleus)

Pain on passive Dorsiflexion of ankle

Pain on palpation of plantar fascia at calcaneal origin.

Abductor Hallucis tightness.

Navicular drop lower on affected side

Positive windlass test

 

Differential Diagnosis

Achilles tendinopathy

Complete rupture of the plantar fascia.

Subcalcaneal bursitis.

Medial calcaneal nerve entrapment (tibial nerve).

Tarsal tunnel syndrome.

Rupture fat pad Sever’s disease.

Calcaneal stress fracture.

 

Treatment

Massage, trigger point therapy to triceps surae, plantar fascia

Specific stretching should be to the gastrocnemius/soleus complex, the hamstrings and the
plantar fascia itself for 3-5 times a week, 2-3 reps for 30 secs hold (De Maio et al., 1993; Pfeffer, 1997)

Strengthening of the triceps surae, tibialis posterior and anterior abductor hallucis (to reduce navicular drop and pronation), intrinsic muscles of the foot and the medial loingitudinal arch of the foot (Guijosa et al., 2006)

Resisted inversion, eversion of the ankle

Modified heel lifts

Short foot exercise

Toe flare out

Eccentric heel drops

Orthotics can help reduce excessive pronation and foot instability however for patients to become less reliant on orthotic inserts using supportive taping and exercise to improve foot biomechanics during functional activities may be more effective and place more emphasis on the patient to strengthen their intrinsic foot muscles, supports and ankle stability.

(Guijosa, 2006;  Bartold, 2004; Jung et al., 2011)

Orthotics can help reduce pain, improve lower limb functioning and increase foot instability in patients with plantar fasciitis (Lee et al., 2008)

Conclusion

Plantar fasciitis can be a cause of heel pain for recreational athletes, long distance runners and sportsmen and women in general. It can also affect the sedentary and obese. It its most likely caused by overuse or ineffeicient biomechanics of people during functional movements. Hopefully above I have shown its function, diagnosis and treatment methods to help rehabilitate and improve on the injury.

Any comments on peoples own experience on treating or dealing with this injury would be greatly appreciated

 

References

Bartold, S.J. (2004). The plantar fascia as a source of pain—biomechanics, presentation and treatment Journal of Bodywork and Movement Therapies, 8 (3), 214-226.

Guijosa, A.L., Muñoz, I.,  de La Fuente, M and Cura-Ituarte. P. (2007) Fascitis plantar: revisión del tratamiento basado en la evidencia. Reumatología Clínica, 3 (4), 159–165.
Puttaswamaiah, R. and Chandran, P. (2007) Degenerative plantar fasciitis: A review of current concepts, The Foot,17(1), 3-9.

Yong Lee, S., McKeon, P. and Hertel, J. (2009)Does the use of orthoses improve self-reported pain and function measures in patients with plantar fasciitis? A meta-analysis
Physical Therapy in Sport,10 (1)12-18.

2 Comments

  1. great blog. so clear & concise. thanks.

  2. Except in traumatic cases (contusion to plantar calcaneus) virtually every case of plantar fascitis (pf) I see is accompanied by weakness of the foot invertors, particularly tibialis posterior. If this muscle is not functioning optimally and with adequate strength, there is increased loading on the medial longitudinal arch with resultant strain/sprain (depending on if you view the pf as inert or dynamic) of the pf. If this is not addressed, it leaves the patient exposed to chronic or recurrent pf.
    Trigger point release of tib post will often yield immediate strength “gains” (actually just the return of functional strength to an inhibited muscle) of 50% or >. In very resistant or chronic cases I may use a variation of serial “Low Dye” taping to unload the pf during wt. bearing for a period of a week or 10 days to permit the affected tissue some rest. I have posted a series of progressive tib post strengthening exercise on Youtube to assist in the rehab from weak to return to sport levels of strength.

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