Plantar Fasciitis
Plantar Fasciitis Is a, cause of plantar foot pain which can occur on both sides and mimic the pain associated with distal sensory polyneuropathy. It can also present unilaterally mimicking S1 radiculopathy.
Symptoms: Plantar fascia is a band of thick connective tissue that originates on the calcaneus and fqns-out on the sole of the foot to connect to the base of the toes and support the arch of the foot. It is also related to the Achilles tendon, with connecting fibers between the two from the distal aspect of the Achilles tendon to the origin of the plantar fascia at the calcaneal tubercle. Poor foot biomechanics can cause increased tension of the fascia and pain. This can occur in patients with pes planus, past cavus, increased subtalar pronation, limited ankle dorsiflexion, decreased intrinsic foot muscle strength, and tight heel cords, all conditions that place stress on the plantar fascia. Therefore plantar fasciitis can coexist with many underlying neuromuscular conditions that are associated with foot deformity and weakness. Obesity, pregnancy, and prolonged standing are additional risk factors.
Patient s typically describes the worst pain as occurring with weightbearing after getting out of bed in the morning or after periods of inactivity. Pain can be gnawing, stabbing, or burning. History of pain when taking the first steps in the morning helps differentiate deconditioning from the pain experienced by patients with sensory polyneuropathy whose foot pain is characteristically worse at night when off the feet. In some patients, the pain may radiate to the dorsal lateral foot due to the patient offloading the pressure on the heel and walking on the outside of the foot creating an overuse condition of the lateral foot and ankle.
Diagnosis: The history and clinical examination are the mainstay of diagnosis. On physical examination there is tenderness to palpation of the medial plantar aspect of the heel bone. This area corresponds to the site of the plantar fascia insertion on the calcaneus. Palpation of the medial slip of the plantar fascia may also reveal tightness and discomfort, but the area of maximal tenderness corresponds to the medial tubercle of the calcaneus. Discomfort in the proximal plantar fascia can also be elicited by passive ankle and toe dorsiflexion.
Windlass Test - Physiopedia (physio-pedia.com)
Diagnostic imaging is rarely needed for the initial diagnosis. Ultrasound and MRI are reserved for cases that do not respond to treatment or to exclude other heel pathology. Plain x-ray of the foot can reveal a calcaneal heel spur in many individuals. The heel spur, however, is not pathognomonic of plantar fasciitis and distal to the cause of pain in this condition. Rather, the heel spur represents a byproduct of the chronic pulling of the the calcaneus and it can be present without symptoms of plantar fasciitis.
Treatment plantar fasciitis is a self-limited condition that usually improves within 1 year regardless of treatment conservative. Conservative treatment usually start with patient directed therapies. If these are not effective within a few weeks, management is advanced to include physician prescribed interventions. Initial position directed modalities include rest, activity modification, ice massage, oral analgesics, acetaminophen or NSAIDs, and stretching. Ice massage is performed by having the patient roll the arch of the foot over a frozen soda can or plastic bottle until numb. Treatment can be repeated multiple times a day. Stretching is performed both in bed before getting up in the morning and several times during the day. Before getting up, the patient is asked to stretch the Achilles tendon by dorsiflexing the foot and holding onto it for at least 30 seconds. This exercise was repeated 10 times and can be modified by using a large towel if limited flexibility prevents the patient from reaching the foot. While seated, the patient is also asked to stretch her plantar fascia by dorsiflexing the toes, holding the metatarsophalangeals and stretching the fascia in the arch region during the day, the patient may stretch by leaning against a wall and performing wall leans, alternating between knees bent knee extended while the heel is on the ground. Again he stretches held for a minimum of 30 seconds and repeated several times. Intrinsic foot and calf strengthening exercises can help as well.
If pain persists, physician prescribed treatment should be considered. These include shoe inserts, night splinting, physical therapy, and corticosteroid injections. Shoe inserts are commonly recommended for people with plantar fasciitis to even limiting overpronation of the foot and to unload the tensile portions of the plantar fascia. These include heel cups, prefabricated longitudinal arch supports, and custom-made full-length shoe insoles. Night splints can be used to prevent foot plantar flexion during sleep by keeping the foot and ankle in a neutral 90 degree position. Night splints have been shown to improve plantar fasciitis pain, but poor compliance because of sleep disturbance and foot discomfort has limited their long-term use. Multiple physical therapy modalities may be used, often in combination. Deep myofascial massage and iontophoresis can be performed by her physical therapist. In iontophoresis, electrical pulses are used to close absorption of topical medications into the soft tissues beneath the skin. A small study found iron to fluoresces opacity and residual dexamethasone to be helpful in plantar fasciitis. Corticosteroid injections have been found to be effective in the treatment of plantar fasciitis and may be part of the initial correction patients to desire an expedited return to normal activity. Possible risks associated with corticosteroid injections include fat pad atrophy and plantar fascia rupture. In recent years, platelet rich plasma injections have been proposed as an alternative treatment for plantar fasciitis and are currently being tested in clinical trials to determine the efficacy. Patients with recalcitrant plantar fasciitis can consider extracorporeal shockwave therapy or, as a last resort plantar fasciotomy. ESWT and sport to promote neovascularization and induced tissue repair technique is commonly used as it is noninvasive and has a good side effect profile although clinical trials are consulted and conflicted evidence.