118 Indian Journal of Physiotherapy and Occupational Therapy, April-June 2020, Vol. 14, No. 02 Treatment of Plantar Fasciitis: A Review Omeshree Nagrale Assistant Professor Department of Community Physiotherapy, R.V. College of Physiotherapy, Bangalore, India Abstract Plantar fasciitis is a disorder of the connective tissue which supports the arch of the foot. It results in pain in the heel and bottom of the foot that is usually most severe with the first steps of the day or following a period of rest. Pain is also frequently brought on by bending the foot and toes up towards the shin. The pain typically comes on gradually and it affects both feet in about one-third of cases. The researches review the literature pertaining to types of treatment and their efficacy. This article presents on overview on current knowledge on plantar fasciitis and focuses on etiology, diagnosis and treatment strategies, conservative treatment. Keywords: Plantar fasciitis, physical therapy. Introduction vs. shod walking.[3] During weight-bearing, the tibia loads the the foot “truss” and creates tension through Plantar fasciitis is the pain caused by degenerative the plantar fascia (windlass mechanism). The tension irritation at the insertion of the plantar fascia on the created in the plantar fascia adds critical stability to a medial process of the calcaneal tuberosity. The pain loaded foot with minimal muscle activity. Evidence of may be substantial, resulting in the alteration of daily the important stabilizing nature of the plantar fascia activities. Various terms have been used to describe is evidence when following cases post surgical releas plantar fasciitis, including jogger’s heel, tennis heel, which may lead to midfoot arthritis, rupture of the policeman’s heel and even gonorrheal heel. Although secondary stabilizers of the arch (e.g spring ligament), a misnomer, this condition is sometimes referred to as as well as other pathologies.[4][5][6] heel spurs by the general public. Epidermology: The average plantar heel pain Anatomy: The plantar fascia is comprised of white episode lasts longer than 6 months and it affects up to longitudinally organized fibrous connective tissue which 10-15% of the population. However, approximately originates on the periosteum of the medial calcaneal 90% of cases are treated successfully with conservative tubercle, where it is thinner but it extends into a thicker care.[7][8][9] Although this condition is seen in all central portion. The thicker central portion of the plantar ages, it is most commonly experienced during middle fascia then extends into five bands surrounding the flexor age. Females present with plantar heel slightly more tendons as it passes all 5 metatarsal heads. Pain in the commonly than males and occurs more frequently in an plantar fascia can be insertional and/or non-insertional athletic population such as running, accounting for up and may involve the larger central band, but may also to 8-10% of all running related injuries.[10] In the US include the medial and lateral band of the plantar fasica. alone, there are estimates that this disorder generates up The plantar fascia is best referred to as fascia because to 2 million patient visits per year and account for 1% of it’s relatively variable fiber orientation as opposed to of all visits to orthopedic clinics. Plantar heel pain is the the more linear fiber orientation of aponeurosis. The most common foot condition treated in physical therapy plantar fascia blends with the paratenon of the Achilles clinics and accounts for up to 40% of all patients being tendon, the intrinsic foot musculature and even the skin seen in podiatric clinics.[11] and subcutaneous tissue.[1][2] The thick viscoelastic multilobular fat pad is responsible for absorbing up to Characteristics/Clinical Presentation: 110% of body weight during walking and 250% during • Heel pain with first steps in the morning or after running and deforms most during barefoot walking long periods of non-weight bearing Indian Journal of Physiotherapy and Occupational Therapy, April-June 2020, Vol. 14, No. 02 119 • Tenderness to the anterior medial heel Surgery for plantar fasciitis should be considered only after all other forms of treatment have failed. With an • Limited dorsiflexion and tight achilles tendon endoscopic plantar fasciotomy, using the visual analog • A limp may be present or may have a preference to scale, the average post-operative pain was improved toe walking from 9.1 to 1.6. For the second group (ESWT), using the • Pain is usually worse when barefoot on hard surfaces visual analog scale the average post-operative pain was and with stair climbing improved from 9 to 2.1. Endoscopic plantar fasciotomy gives better results than extra-corporeal shock wave • Many patients may have had a sudden increase in therapy, but with liability of minor complications[12][13]. their activity level prior to the onset of symptoms Physical Therapy Management: The most common Differential Diagnosis: treatments include stretching of the gastroc/soleus/ Neurological: Abductor digiti quinti nerve plantar fascia, orthotics, ultrasound, iontophoresis, night entrapment, lumbar spine disorders, problems with splints and joint mobilization/manipulation. medial calcaneal branch of the posterior tibial nerve, Strength Training. Similar to tendinopathy tarsal tunnel syndrome. management, high-load strength training appears to be Soft tissue: Achilles Tendinopathy, fat pad atrophy, effective in the treatment of plantar fasciitis. High-load heel contusion, plantar fascia rupture, posterior tibial strength training may aid in a quicker reduction in pain [14] tendonitis, retrocalcaneal bursitis and improvements in function. Skeletal: Sever’s disease, calcaneal stress fracture, Stretching consists of the patient crossing the infections, inflammatory arthropathies, subtalar arthritis affected leg over the contralateral leg and using the fingers across to the base of the toes to apply pressure into Miscellaneous: Metabolic disorders, osteomalacia, toe extension until a stretch can be felt along the plantar Paget’s disease, sickle cell disease, tumors (rare), fascia. Achilles tendon stretching can be performed in vascular insufficiency,Rheumatoid arthritis a standing position with the affected leg placed behind the contralateral leg with the toes pointed forward. The Diagnostic Procedure: Plantar fasciitis is a clinical front knee was then bent, keeping the back knee straight diagnosis. It is based on patient history and physical and heel on the ground. The back knee could then be in a exam. Patients can have local point tenderness along the flexed position for more of a soleus stretch[15]. medial tuberosity of the os calcis, pain on the first steps or after training. Plantar fascia pain is especially evident Mobilizations and manipulations have also been upon dorsiflexion of the patients pedal phalanges, which shown to decrease pain and relieve symptoms in some further stretches the plantar fascia. Therefore, any activity cases. Posterior talocrural joint mobs and subtalar joint that would increase stretch of the plantar fascia, such as distraction manipulation have been performed with the walking barefoot without any arch support, climbing hypomobile talocrural joint. Patients in 6 different cases stairs, or toe walking can worsen the pain. The clinical demonstrated complete pain relief and full return to examination will take under consideration a patient’s activities with an average of 2-6 treatments per case[16]. medical history, physical activity, foot pain symptoms and more. The doctor may decide to use Imaging studies A recent study evaluated the effect of ankle, subtalar like radiographs, diagnostic ultrasound and MRI. and midfoot joint mobilizations on pain and function in patients with PF. The researchers hypothesized that Medical Management: When conservative mobilization of this joints, in addition to conventional measures fail, surgical plantar fasciotomy with or physical therapy, would significantly improve pain and without heel spur removal may be employed. There is function on patients with PF, as opposed to conventional a method, through an open procedure, percutaneously treatment only. The mobilization in conjunction with or most common endoscopically, that releases the conventional therapy did not improve pain and function plantar fascia. This is an effective treatment, without more than conventional treatment alone in patients with the need for removal of a calcaneal spur, when present. PF. Ankle and midfoot joint mobilization aimed at There is a professional consensus, 70-90% of heel pain improving DF rang om motion is not more effective than patients can be managed by non-operative measures. ultrasound and stretching alone in treatment of PF. The 120 Indian Journal of Physiotherapy and Occupational Therapy, April-June 2020, Vol. 14, No. 02 association between limited DF and PF most probably Reference is based on calf muscle shortening and not on ankle or 1. Carlson RE, Fleming LL, Hutton WC. foot joint mobilization. Therefore, treatment should be The biomechanical relationship between focused on soft tissue techniques rather than on foot and the tendoachilles, plantar fascia and ankle joint mobilization.[17] metatarsophalangeal joint dorsiflexion angle. Foot Posterior-night splints maintain ankle dorsiflexion ankle Int/Am Orthop Foot Ankle Soc [and] Swiss and toe extension, allowing for a constant stretch on the Foot Ankle Soc. 2000;21(1):18–25. plantar fascia. Some evidence reports night splints to 2. Stecco C, Corradin M, Macchi V, et al. Plantar fascia be beneficial but in a review by Cole et al he reported anatomy and its relationship with Achilles tendon that there was limited evidence to support the use of and paratenon. J Anat. 2013;223(August):1–12. night splints to treat patients with pain lasting longer doi:10.1111/joa.12111. than six months and patients treated with custom made 3. Gefen A, Megido-Ravid M, Itzchak Y. In vivo night splints improved more than prefabricated night biomechanical behavior of the human heel pad [18] splints . during the stance phase of gait. J Biomech. Six treatments of acetic acid iontophoresis 2001;34:1661–1665.