Plantar fasciitis is defined as an inflammation of the plantar fascia and perifascial structures. There is many possible causative factors but in general it is caused by repeated trauma or overload to the plantar fascia. We will look closer at some of the factors that may predispose for this repetetive trauma to the plantar fascia and discuss various treatment options available. There is not a high level of agreement among health professionals when it comes to the most effective treatment of plantar fasciitis. This is one of the reasons it is an interesting subject to look into. It is also a relatively common disorder which may occur in synergy with other problems of the lower limbs. We will first describe in detail the clinical features of Plantar fasciitis then some predisposing factors and finally a description and discussion of the treatment options available , both in physiotherapy and other. Clinical Features of Plantar Fasciitis

Incidence:

• Affecting 10% of the population (USA)

• most common in middleaged women and male runners

• one of the most common complaints relating to the foot.

Risk Factors

• Obesity

• running

• tight Achilles tendon

• high arch (pes cavus)

• low arch (pes planus)

Signs and Symptoms

• Heel pain in the morning or after rest

• Heel pain during weight bearing

• Inflammation and swelling along the medial longitudinal arch of the foot

• Pain often localized to medial tubercle

• of calcaneus

• Dull aching pain

Etiology

Plantar fasciitis is often attributed to faulty biomechanics leading to excessive pronation or supination and with it a low or a high medial longitudinal arch.

The Windlass Mechanism

Stretch tension from the plantar fascia prevents spreading of calcaneus and metatarsals and maintains the longitudinal arch. This is the essence of the windlass mechanism. A windlass means tightening of a rope or cable. Dorsiflexion during the propulsive phase of gait winds the plantar fascia around the head of the metatarsal. This shortens the distance between the calcaneus and metatarsals and elevates the medial longitudinal arch. The shortening that results from hallux dorsiflexion is the basis of the windlass mechanism principle. And it is this principle which explains why overpronation may lead to plantar fasciitis. Both supination and pronation means increased tension in the plantar fascia and it is the balance between supination and pronation during gait that determines the the level of tension put on the plantar fascia1. This is because the windlass mechanism functions by maintaining a normal medial longitudinal arch during the stance phase of gait and this is important for sufficient shockabsorption. It also act as a spring during push off while still maintaining the arch. If this balance is interrupted faulty biomechanics is the result which in turn may lead to plantar fasciitis.

The biomechanical predisposing factors

Pes Planus and excessive pronation

Factors that contribute to excessive pronation include muscle weakness, gastrocnemius tightness, and structural foot deformities. Excessive pronation can cause weakness in the posterior tibialis muscle and elongation of the plantar fascia. Tibialis posterior is an important muscle because it decreases the tension put on the plantar fascia during weight acceptance by eccentrically lenghtening. Gastrocnemius tightness may lead to overpronation as a compensatory mechanism due to lack of dorsiflexion during gait. Structural deformities like forefoot or subtalar varus may contribute to plantar fasciitis in a similar compensating way.

Pes Cavus and excessive supination

Patients with a cavus foot have a decreased distance between the calcaneus and metatarsal heads. This may be due to several factors including muscle tigthness , decreased elasticity or tightness of plantar fascia and limited joint mobility. These factors leads to excessive supination and as a result a higher medial longitudinal arch (pes cavus). Limited pronation also leads to decreased ability for shock absorption. Tightness of the achilles tendon is also a common finding with pes cavus and excessive supination this means that dorsiflexion during gait puts more tension on the foot then under normal circumstances.

Treatment options for Plantar fasciitis

When treating plantar fasciitis it is important to avoid activities that provokes symptoms and put a lot of stress on the plantar fascia. Such as sudden increase in activity level or hard surfaces. Foot-wear should also be sufficiently shock absorbing to relieve the plantar fascia.

Extracorpeoral Shockwave Therapy

Extracorporeal Shockwave Therapy is proven successful for treatment of insertion tendinopathies. EST has been recommended for treatment of PF patients that do not respond to conservative treatment. However it has not been proven to be valid form of treatment for plantar fasciitis. A randomized clinical trial done in nine hospitals and one outpatient clinic in Germany involving 272 patients found no clinically significant difference between EST and placebo.

Corticosteroid injection

Corticosteroid injection is one of the most common treatments of chronic tendon lesions. These conditions are similar to PF and corticosteroids has been suggested as treatment for PF. Yet there exists no clinical evidence for the effiency of corticosteroids in treating neither chronic tendon lesions or PF. This is believed to be either due to lack of good randomised controlled trials or actual lack of effiency of the treatment. Accuracy is an important consideration while injecting corticosteroids both when it comes to location of injection and dosage.

Night splints

Plantar Fasciitis splints or “night” splints sometimes are worn at night during sleep or during rest after activity. Often the most severe pain and inflammation of plantar fasciitis is experienced in the morning, which could cause the first few steps to be excruciating. The position the feet and ankles are held in as we sleep promotes cramping of the fascia and calf muscles. When feet are pointed under the weight of the blankets the plantar fascia muscle is contracted (shortened). Those first steps in the morning are painful because the muscle which as been contracted all night is suddenly stretched and pulled.

There is conflicting opinions and evidence supporting the effectiveness of wearing night splints for the treatment of pf. Some articles have reported an 88% improvement in patients using the night splints in combination with conventional treatments such as calf stretching, heel cushions and ibuprofen. However; contrary to this evidence a randomised trial compared the use of night splints versus conservative treatment in 116 patients for 3 months. No statistically significant improvement was found between the two groups.

Orthotic foot supports

Orthotic foot supports is a common intervention for plantar fasciitis. In the case of overpronation they are designed to alter the Biomechanical function, stabilising and realigning the foot into into a more optimal position. This helps to prevent the feet from rolling inwards, supporting the arch from flattening. These devices have shown promising results in some people however; there is not a lot of clinical evidence available to support this.

Exercise therapy

In the case of overpronation

Rehabilitation should focus on restoring normal muscle strength, improving muscle flexibility, and normalizing bio-mechanical influences. The program should strengthen the posterior tibialis, ankle plantar flexors, and peroneus longus muscles as well as the proximal hip and knee musculature. Calf stretching starting in a non-weight-bearing position and progressing into weight-bearing should also be incorporated. This will increase ankle dorsiflexion regardless of foot position. Therefore it will result in less strain on the plantar fascia.

In the case of underpronation (supination)

Rehabilitation should focus on improving plantar fascia extensibility, normalizing joint mobility, improving muscle flexibility, and supporting the longitudinal arch. Extensibility and joint mobility will improve the condition by allowing for a more normal level of pronation and will aid in shock absorption during gait.

Discussion

While there are many different interventions and theories offered for both the biomechanical causes of plantar fasciitis and the best treatment strategy available, all supported with convincing clinical evidence, there is little agreement between the different medical disciplines on the most effective practice and each claim positive results from their methods.

Plantar fasciitis is a condition that may have multiple causative factors and it is important to understand these factors in order to treat specifically. Especially when it comes to exercise therapy the need for specificity is great. The reason there is not much agreement we believe is because of the many possible factors involved and therefore it does not exist a single intervention that is effective for all cases.

Conclusion

While all this conflicting evidence exists surrounding this particular pathology, we have found from our research that the most common treatment methods such as exercise therapy, night splinting, calf stretches, orthodic supports and medication all offer positive results and can be considered as effective treatment methods in most cases. However as always there is a percentage of the population unresponsive to conventional therapies and therefore leaving the subject open to debate and further research. So, in our opinion the most effective treatment strategy would be a combination of treatments based on an individual case basis. What works for one patient wont necessarily  work for another and therefore one should consider multiple treatment approaches based on the unique knowledge of the individual patient.

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