Evidence Based Treatment for Plantar Fasciitis Review of Literature

March 2007 Keeping Bodies in Motion ® by Joshua Dubin, DC, CCSP, CSCS S PORTS T HERAPY Evidence Based Treatment for Plantar Fasciitis Review of Literature Fig. 1A Superficial Fig. 1B Plantar Fascia twelve steps the plantar fascia becomes ABSTRACT Plantar Muscles Plantar fasciitis, a repetitive strain of the Foot stretched and the pain gradually injury of the medial arch and heel, is one diminishes. However, symptoms may of the most common causes of foot pain. resurface as throbbing, a dull ache, or The function of the plantar fascia is a fatigue-like sensation in the medial twofold: statically, it stabilizes the medial arch of the foot after prolonged periods longitudinal arch; dynamically, it restores of standing, especially on unyielding the arch and aids in reconfiguring the cement surfaces.5,6,7,8 foot for efficient toe-off. When this tissue Medial The plantar fascia is a thick, becomes damaged, pain and/or weakness Band fibrous, relatively inelastic sheet of may develop in the area. Risk factors of connective tissue originating from the plantar fasciits include structural Abductor medial heel, where it then passes over abnormalities, overweight, age-related Hallucis Central the superficial musculature of the foot degenerative changes, occupations or Band and inserts onto the base of each toe activities that require prolonged standing Abductor Lateral (figures 1A and 1B). The plantar fascia Flexor Band and/or ambulation, and training errors. Digitorum Digitorum is the main stabilizer of the medial Literature indicates that plantar fasciitis Minimi Brevis longitudinal arch of the foot against may be successfully treated using a ground reactive forces, and is instrumental conservative approach. In recalcitrant cases of plantar in reconfiguring the foot into a rigid platform before toe-off.4,9,10 fasciitis, however, surgical treatment may be necessary to Under normal conditions, the plantar fascia performs this return the patient to normal activities of daily living or function appropriately without incurring injury. sport. This paper will review the anatomy and kinematics Some risk factors of plantar fasciitis include faulty of the foot and ankle, outline common causes of plantar mechanics of the foot due to structural abnormalities, fasciitis, and describe viable treatment and prevention options. age-related degenerative changes, overweight, training errors, and occupations involving prolonged standing; INTRODUCTION those falling into this category include teachers, construction workers, cooks, nurses, military personnel, and athletes Plantar fasciitis is a common occupational or sport-related training for long distance running events.7,8,11,12,13,14 In the repetitive strain injury. Approximately 2 million people in presence of these risk factors, excessive tensile forces may the US are treated annually for plantar fasciitis.1,2,3,4 The cause micro-tears in the plantar fascia. Repetitive trauma chief initial complaint is typically a sharp pain in the to the plantar fascia exceeding the fascia’s ability to recover inner aspect of the heel and arch of the foot with the first may lead to degenerative changes and an increased risk few steps in the morning or after long periods of non-weight of injury.5,15,16 Implementation of a conservative treatment bearing. Usually, after walking approximately ten to and preventative protocol has been shown to be effective in resolving or reducing the symptoms associated with fascia assumes a dynamic role in reconfiguring both the plantar fasciitis.17,18 MLA and the rearfoot in preparation for toe-off.22,23 An understanding of the anatomy and kinematics of the foot and ankle, the static and dynamic function of the BIOMECHANICS OF THE FOOT AND ANKLE plantar fascia during ambulation, and knowledge of the contributing risk factors associated with plantar fasciitis DURING AMBULATION aid in developing a proper treatment and preventative A runner’s gait can be separated into two phases: the protocol for this condition. stance phase and the swing phase. During the stance phase, the foot contacts and adapts to the ground surface; during the swing phase, the leg accelerates forward and ANATOMY OF THE PLANTAR FASCIA AND prepares for ground contact. The stance phase consists of THE MEDIAL LONGITUDINAL ARCH OF THE the following four sub-phases: initial contact, loading response, midstance, and terminal stance. During initial FOOT Fig. 2 Bones of the Foot and Ankle The foot and ankle can contact, the heel contacts the ground surface. The loading response occurs immediately after initial contact, ending be divided into the rearfoot, Fibula Calcaneus when the contralateral foot lifts off of the ground surface. midfoot, and forefoot. The Tibia rearfoot consists of four The midstance phase starts when the contralateral foot bones: the distal aspect of Rearfoot Talus lifts off of the ground surface; the contralateral leg is now the tibia and fibula (leg Midfoot Navicular the swing leg. The midstance phase ends as the tension bones), the calcaneus (heel on the gastrocnemius, soleus, and achilles tendon (triceps bone), and the talus. The Cuboid surae) of the stance leg causes the heel to lift off of the midfoot consists of five Forefoot ground surface. The terminal stance phase begins when bones: the cuboid, navicular, Cuneiforms the heel lifts off of the ground and ends when the swing 19,20,24 and three cuneiforms. The leg contacts the ground. (figure 5). The plantar fascia forefoot consists of nineteen Fig. 5 bones: five metatarsal bones The Stance and fourteen phalanges Phases of (figure 2). The plantar Running fascia originates from the Gait medial calcaneal tuberosity, dividing into a medial, central, and lateral band that attaches to the superior surface of the abductor hallucis, flexor digitorum brevis, and abductor digiti minimi musculature, respectively. The fascia then splits into five slips that cross the metatarsophalangeal Terminal Midstance Loading Initial Contact Stance Response joints and inserts onto the phalanges of digits # 1-5.1,8,19,20 The foot has a visible medial Fig. 3A Diagram illustrating the Medial longitudinal arch (MLA) and extrinsic and intrinsic musculature of the foot play an Longitudinal Arch. The Calcaneus and that aids in distributing the active role in guiding the foot as it transitions from initial Talus represent the posterior rod; the force attributed to weight contact to toe-off. Efficient function of the plantar fascia Navicular, Cuneiforms, and the first three and musculature of the foot depends on the configuration Metatarsals represent the anterior rod. bearing. The MLA of the The Plantar Fascia connects the bases foot resembles two rods: a of the rearfoot and midfoot articulations during the different 8,25,26 of the two rods. rear rod consisting of the sub-phases of gait. calcaneus and talus, and The rearfoot is comprised of two joints; the talocrural an anterior rod consisting joint and the subtalar joint. The talocrural joint (ankle of the navicular, three mortise) consists of the articulation of the distal aspect of the cuneiforms, and the first tibia and fibula with the trochlea of the talus. The talocrural three metatarsals. These joint allows for two primary movements: dorsiflexion, rods are connected at their approximating the tibia to the toes, and plantar flexion, 8,19,29,27 base by the plantar fascia. pointing the toes downward (figures 6A, 6B). Fig. 3B Diagram illustrating flattening When force is applied to The subtalar joint of the Medial Longitudinal Arch, causing consists of the articulation Fig. 6A Dorsiflexion of the Talocrural separation of the bases of the anterior the apex of the MLA, the Joint (the talocrural and posterior rods, placing an arch depresses, the two of the undersurface of the joint is indicated by increased strain on the Plantar Fascia rods separate, and tension talus with the calcaneus a red line) is distributed throughout (figures 7A, 7B). Movement the plantar fascia8,21 (figures of the subtalar joint is 3A, 3B). The main ligaments pivotal in transforming the that aid in supporting the foot from a rigid lever during initial ground contact MLA are the long and short Fig. 6B Plantar plantar ligaments and the to a mobile shock absorber Flexion of the calcaneonavicular ligament during loading response Talocrural Joint Fig. 4 Ligaments that aid in supporting (spring ligament) (figure 4). and early midstance, and the Medial Longitudinal Arch – Plantar back into a rigid lever as View of the Foot During static stance the Calcaneonavicular the foot prepares for toe-off. Ligament MLA is supported by the plantar fascia, the ligaments, The two primary movements and the osseous architecture that occur at the subtalar of the foot.1,8,20 During late joint (STJ) are pronation and supination. Pronation Short Plantar Long Plantar ambulation, the plantar Ligament Ligament Fig. 7A Medial View of the Subtalar Joint Fig. 10A (the subtalar joint is of the STJ normally occurs the lateral column of the foot, including The indicated by a red line) during loading response the calcaneocuboid joint, allowing the Peroneus and into early midstance. muscles and fascia of the leg and foot Longus STJ pronation consists of to function more efficiently in guiding Muscle the following movements: the foot into toe-off.8,19,20 the calcaneus turns outward The peroneus longus and the Fig. 7B Lateral View of (eversion); the talus drops plantar fascia are actively involved in the Subtalar Joint downward, distally, and preparing the foot for toe-off. The adducts towards the midline; tendon of the peroneus longus muscle Subtalar Joint and the talocrural joint passes over the outer and plantar dorsiflexes (figure 7C). aspect of the calcaneocuboid joint and Fig. 10B During initial contact the attaches to the undersurface of the Plantar View of the Foot STJ is normally supinated; base of the first metatarsal (figures and the it pronates from loading 10A, 10B). During late midstance the Peroneus Fig.

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