Plantar Fasciitis

Hi this is aamir bhatti,

I have a patient at my clinic of acute plantar fasciitis.

Please put your suggestions regarding,

What to do with acute phase.
When to start stretcting and strengthening,
What other measures that i can do with the patient.

Thanks,

[somasimple]

Hi Aamir,

Such cases may respond very well to neural mobilizations (gliding). Neural mobs are very gentle stretchings made on toes (flexion/extension) slowly without pain and for 15/20 repeats.
Then you have to mobilize the ankle with the same constraints but maintaining the foot with the hand.

Recovery will happen in few sessions without stretching or strengthning.

[sdkashif]

Use following approach for treatment of Plantar fasciitis.

Use passive modalities to manage pain and inflammation. Ice application 15 to 20 minutes, ultrasound therapy, phonophoresis, iontophoreis microwave diathermy, Shortwave diathermy, LASER.

Try to reduce stress on plantar fascia by tapping, medial arch support, heel pad, strengthening and increasing edurance in the lower limb antigravity muscles, intrinsic foot muscles and alignment of back by strengthening the back flexors and extensors. Proper good posture training and assessing the gait to correct any discrepancy.

Massage of the plantar fascia, stretching exercises for plantar fascia and calf muscles.

Maintain strength, endurance and cardiovascular conditioning by aerobics like bicycling, rowing, aquatics.

Analysis of any perpetuating factor and a resolution plan to correct them. Mechanical disadvantage due to poor poture, poor working habits, any deviation in gait pattern must be corrected.

I think that these will be of help to you.

[somasimple]

Hi,

I'm a bit lost with your "extensive" approach!

You're using at the same time ice and heat and your advices promote also some contradictory techniques?

It is indeed a very extensive approach. Can I ask what medium you are using for phonophoresis/iontophoreis and would you do both or have you found one method better than the other. I have found the simplest and quickest way to provide relief is to use ultrasound, massage and building up the intrinsic muscles of the foot. Check the footware to ensure there is adequate arch support present. Taping is a good method to see if arch support is required. I also have found a lot of people get relief by rolling the traditional ribbed Coke bottle with the under their foot gives relief. I have not tried neural mobilisation as Bernard suggests but it also is a quick and easy technique to apply and results should be easily assessable.

[somasimple]

Hi Ozben,

I was some years ago inclined to use external tools as TENS and such things but I'm definitely convinced that my words (education) and my bare hands are ever more powerful than those ones.

I created a site about neuro-stimulation but I let it for a while now (www.algoless.com) because electrical stimulation do not really care but only alievate...

About this case, I will use before neuromobs some research about imbalances and lumbar problems and treat foot after have mobilized the whole limb. So my impression based on experience is that an whole approach is effective and a focused one may fail! Treating often such cases, I will say that progresses are made quickly in 2/3 sessions.

[sdkashif]

Hi physio colleagues!

Thanks for adding your valuable replies to a very good discussion. Have a look over these.

Modalities:

Ice

Heat preferably one of the deep heating methods like SWD, Microwave diathermy, ultrasound therapy.

Cold LASER

Iontophoresis, phonophoresis according to you clinical experience and expertise. Regarding phonophoresis, it depends what modality you chose. Well, definitely in the acute phase of inflammation you will have to use the low dosage. This is for the treatment of the site of inflammation in the plantar fascia.

Ionotophoresis choose an electrolyte salt according to your own choice and experience. My experience is to use the diclofenac sodium ointment. Use negative electrode to repel the negatively charged diclofenac within the tissue as sodium is the positively charged particle. There are varieties of electrolytic salts available according to the availability of different countries. You may choose one of them according to your expertise.

Phonophoresis

you may use any good ointment according to you experience.

For more information on iontophoresis and phonophoresis see the following site.

groups.msn.com/physiopak


Neural mobilization is one of the new emerging treatment.



Give attention to

The weak intrinsic muscles of foot due to the disuse atrophy and reduced power in the lower limb anti gravity muscles due to their less use.

Stretching and strengthening

Arch supports & Tapping

Intrinsic and extrinsic risk factors

The poor posture due to the pain and possible limping and deviation in the gait.

And also pathomechnics.

Treat the inflammation along with other predisposing factors are present.

Inflammatory arthropathies

[somasimple]

Hi sdkashif,
I'm sorry but you miss my point there.
I'm actually viewed certainly as a marginal PT but I do not really matter. But I'm still lost with your extensive and contradictory approach.
Plantar fascitis is not seen actually as an inflammatory state. There is many evidences and a simple examination do not show any heat or redness.
You're considering that I'm an “old age passive unrealistic and non-scientific” PT and the grand father will reply: “You're wrong guy, you leap too fast there!”
Neuro mobilizations may be made passively and actively. And I may add that I'm considered as a very “active” PT since I ever promote techniques and treatments where the patient is involved and understand the finality of it. I try to care, not simply to alleviate and wait to the next return of the patient.
You are promoting passive techniques that are evidently known as effective as placebo and I may conclude that you're the “passive” guy. I won't!
I do not really think that United States are on the top of the wave since the Best Knowledge come from Damasio (Portuguese), Flor (Deutschland), Wall/Melzack (GB/Canada), Butler (Australia), Rachamandran (India), Shacklock (Australia), Maitland (Australia), Moseley (Australia), Hodges (Australia), Coppieters (Holland)...

Thank you for all of you for such a wonderful response.

Well, i am using TENS, iontophoresis, infrared, proper shoewear with good arch support, and stretching and strengthening of intrinsic and calf muscles with my patient, Now the patient is much better in 10 sessions.

Thank for discussion.

Aamir Bhatti

[sdkashif]

Thanks for adding such a remarks. Accept my apologies if my reply seems so harsh. But oh my goodness! You are too harsh and aggressive replying me. I was just proposing an idea the most senior physios should try to review the current techniques used today. There is no idea to hitting some one.

Any way where will we place the electrotherapy portion of physiotherapy as physiotherapists spend a lot of time during their clinical training in the field of electrotherapy. And it will be very much frustrating for them to find that these modalities of electrotherapy are contradictory.

Let’s have a look over the possible causes of plantar fasciitis.

Repetitive micotrauma due to excessive stretch of plantar fascia leading to chronic inflammation of plantar fascia and degeneration of plantar fibres..

Seronegative spondylarthropathies

Over use injuries

Obesity

Biomechanical fault that causes abnormal pronation. For example, a patient with a flexible rear foot varus may at first appear to have a normal foot structure but, on weight-bearing, may display significant pronation. The talus will plantar flex and adduct as the patient stands, while the calcaneus everts.

Tibia vara, ankle equinus, rearfoot varus, forefoot varus, compensated forefoot valgus and limb length inequality, can cause an abnormal pronatory force.

Extrinsic factors of plantar fasciitis include training errors, improper footwear, and unyielding surfaces.

Intrinsic factors include pes cavus or pes planus, decreased plantar flexion strength, reduced flexibility of the plantar flexor muscles, excess pronation, and torsional malalignments.

So should we not try to manage these possible causes of plantar fasciitis?

[somasimple]

Hi, I wasn't at any time aggressive but took only your words and reformulated them to show their contents.

About electrotherapy: I forget its uses since I was in research for a manufacturer!
We were BTW talking about common plantar fascitis and not fortunately those special ones you cited.

Overuse may be cared by education, not US or any other modalities,
Weight problems by diet programs and normal activities, not really by PT.
Structural problems are structural problems that are out of the scope of the common plantar fascitis.
Many other ones are functional ones that are treated by us “actively” because they are only functional.

[sdkashif]

Dear Bernard, Hi!

Thanks for adding your valuable reply. I need your valuable briefing in a little bit detail of neuromobilization in the case of plantar fasciitis here.

Please, also tell me about the evidence based findings and research of the role of neuromoblization with specific to Plantar fasciitis.

[somasimple]

Hi,

“Neuromobs” is a “young” technique and actively followed by David BUTLER, Michael SHACKLOCK and COPPIETERS. There is some valuable papers available already on PubMed.

If we consider a nerve as a sensitive structure (the only one sensitive, in fact), then an injury, a repeated stress or a limited motion created by an upper tightness, may changes the available length or some of the elastic properties of it. Releasing the tightness in limb, then elongating gently neural structures in flexion/extension at ankle and toes will give some “room” to the nerve and suppress pain.

Neural mobilization is soft method and it's because it is “soft” that it works. If you try to stretch then you compress nerve by muscle and lost effectiveness.

[sdkashif]

More information on plantar fasciitis that is needed to be shared is as under;

Causes:

Extrinsic risk factors

Training errors

Training errors are among the major causes of plantar fasciitis.

Patients usually have a history of an increase in distance, intensity, or duration of activity.

The addition of speed workouts, plyometrics, and hill workouts are particularly high-risk behaviors for development of plantar fasciitis.

Running indoors on poorly cushioned surfaces is also a risk factor.

Equipment

The patient shoes rapidly lose cushioning properties. Patients using shoe sole repair materials are especially at risk if they do not change shoes often enough.

Patients who train in lightweight and minimally cushioned shoes (instead of heavier training flats) are also at higher risk of developing plantar fasciitis. Athletes should be wearing an appropriate shoe type for their foot type and activity.

Intrinsic risk factors

Structural risk factors

Structural risk factors include pes planus, overpronation, pes cavus, leg-length discrepancy, excessive lateral tibial torsion, and excessive femoral anteversion.

Patients with pes planus (low-arched) or pes cavus (high-arched) feet have increased stress placed on the plantar fascia with foot strike.

Pronation is a normal motion during walking and running, providing foot-to-ground surface accommodation and impact absorption by allowing the foot to unlock and become a flexible structure. Overpronation, on the other hand, can lead to increased tension on the plantar fascia.

Leg-length discrepancy, excessive lateral tibial torsion, and excessive femoral anteversion can lead to an alteration of running biomechanics, which may increase plantar fascia stress.

Functional risk factors: Tightness in the gastrocnemius and soleus muscles and the Achilles tendon is considered a risk factor for plantar fasciitis. Reduced dorsiflexion has been shown to be an important risk factor for plantar fasciitis Weakness of the gastrocnemius, soleus, and intrinsic foot muscles is also considered a risk factor.

Degenerative risk factors: Aging and heel fat pad atrophy are 2 degenerative risk factors for plantar fasciitis

Physical Therapy:

Initial or Acute Phase:

The initial physical therapy program for plantar fasciitis stresses stretching of the calf and foot. The stretching program should include wall stretches with the knee both in the extended and flexed positions.

To perform a wall stretch, the athlete should stand 3 feet from a wall, placing the hands on the wall. Keeping the toes pointed straight and the heel on the ground, the athlete leans the hips toward the wall and holds this position for 30-40 seconds. Stretches targeted at the plantar fascia are particularly important.

Iontophoresis has been found in one study to increase the speed of resolution of plantar fasciitis, although it had no effect on long-term outcome.

Ice is the first-line anti-inflammatory treatment for plantar fasciitis. This treatment can be applied by ice massage, ice bath, or ice pack.


For ice massage, the patient freezes water in a small paper or Styrofoam cup and then rubs the ice over the painful heel, using circular motion and moderate pressure for 5-10 minutes.


For an ice bath, a shallow pad is filled with water and ice. The athlete soaks the heel for 10-15 minutes; to prevent cold injuries, the athlete should use neoprene toe covers or keep the toes out of the ice water.


An ice pack can be made by placing crushed ice in a plastic bag wrapped in a towel. The use of crushed ice allows the ice pack to be molded to the foot and increase the contact area; a good alternative is a bag of prepackaged frozen corn kernels wrapped in a towel. Ice packs usually are placed for 15-20 minutes. Icing should be performed after completing exercise, stretching, and strengthening.


Recovery phase:

Physical Therapy: A strengthening program emphasizing foot intrinsic muscle strengthening is added in the next phase of physical therapy. Exercises include towel curls, marble pick-ups, and toe taps.

For a towel curl, the patient sits with the foot lying flat on the end of a towel placed on a smooth surface. The patient pulls the towel toward the body by curling up the towel with the toes while keeping the heel on the floor. As the patient improves, add weight to the far end of the towel to increase the difficulty of this exercise.

To do marble pick-ups, the patient places a few marbles on the floor near a cup, picks them up with the toes, and drops them in the cup while keeping the heel on the floor. For a greater challenge, the athlete may try to pick up coins instead of marbles.

To do toe taps, the patient lifts all toes off the floor; while keeping the heel on the floor and the outside 4 toes in the air, repetitively taps just the big toe to the floor. Next, the patient reverses the process and repetitively taps the outside 4 toes to the floor while keeping the big toe in the air .

Medical Issues/Complications: Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used to treat plantar fasciitis. While there is controversy as to whether or not NSAIDs actually assist in the physiologic healing process, they can be useful as an adjunct to control pain while treating the plantar fasciitis with stretching, strengthening, and relative rest.

Surgical Intervention: For cases that do not respond to conservative treatment, a surgical release of the plantar fascia may be considered. Overall, surgical release has a 70-90% success rate in treating patients with plantar fasciitis: open, endoscopic, or radiofrequency lesioning techniques may be used.

Potential complications include flattening of the longitudinal arch and heel hypoesthesia, as well as the potential complications that are associated with plantar fascia rupture. Longitudinal arch strain appears to account for over 50% of the chronic complications.

Other Treatment:This may include corticosteroid injections and/or night splints.

Corticosteroids: In cases of recalcitrant plantar fasciitis, corticosteroid injection may be considered. Other causes of heel pain should be considered, and a plain radiograph of the foot or calcaneus always should be obtained before injecting steroids. A corticosteroid injection may be given through a plantar or a medial approach with or without ultrasound guidance. Studies have reported success rates of 70% or better. Potential risks include plantar fascia rupture, which was found in almost 10% of patients after plantar fascia injection in one series and fat pad atrophy. Long-term sequelae were found in approximately 50% the patients with plantar fascia rupture.

Night splints: Most people naturally sleep with their feet in a plantar-flexed position, which causes the plantar fascia to be shortened. Night splints are designed to keep the ankle in a neutral position during sleep, essentially passively stretching the calf and the plantar fascia for a prolonged period. Theoretically, the night splint allows the plantar fascia to heal in the elongated position, which in turn decreases the tension with the first step in the morning. A night splint can be molded either from plaster or fiberglass casting material, or a prefabricated and commercially produced plastic brace can be used. Studies have shown that approximately 80% of patients using night splints improved. The splints are especially useful in individuals who have had symptoms of plantar fasciitis for longer than 12 months.

Maintenance Phase:

Physical Therapy: To minimize the chances of reoccurrence, athletes should continue on a maintenance program of daily stretching and/or strengthening at least 2-3 times per week.

Other Treatment:

This may include orthotic devices and arch supports.

Patients with low arches have increased stress placed on the plantar fascia with foot strike and decreased ability to absorb the forces that are generated by foot strike. Mechanical corrections for pes planus include taping of the arches, over-the-counter (OTC) arch supports, and custom orthotic devices. Studies have found significant benefit to these treatments when used in appropriate patients.

Arch taping can be used as definitive treatment or as a trial to determine whether the expense of arch supports or orthotics is worthwhile. Taping may be more cost-effective for acute onset of plantar fasciitis, whereas OTC arch supports and orthotics may be more cost-effective for chronic or recurrent cases of plantar fasciitis and for prevention of injuries (arches must be retaped for each practice or game).

OTC arch supports usually last a full season; custom orthotic devices should last many seasons. OTC arch supports are especially useful in athletes with acute plantar fasciitis and mild pes planus, particularly adolescents whose rapid foot growth may require one or more new pairs of arch supports per season.

Custom orthotic devices are designed to control biomechanical risk factors such as pes planus, valgus heel alignment, and leg-length discrepancies. Athletes treated with orthotic devices usually require semi-rigid three-quarter to full-length orthotic devices with longitudinal arch support to control overpronation and metatarsal head motion, especially of the first metatarsal head .The main disadvantage of use of orthotic devices is the cost.

Summary of Treatment:

Initial or Acute Phase:

Stretching of Calf and foot

Iontophoresis

Ice application in form of Ice massage, ice bath and Ice cube Massage.

Recovery Phase:

A strengthening program emphasizing foot intrinsic muscle strengthening. Exercises include towel curls, marble pick-ups, and toe taps.

Nonsteroidal anti-inflammatory drugs useful as an adjunct to control pain while treating the plantar fasciitis with stretching, strengthening, and relative rest.

Surgical release of the plantar fascia.

In cases of recalcitrant plantar fasciitis, corticosteroid injections.

Night splints designed to keep the ankle in a neutral position during sleep, essentially passively stretching the calf and the plantar fascia for a prolonged period.

Maintenance Phase:

A maintenance program of daily stretching and/or strengthening at least 2-3 times per week.

Orthotic devices and arch supports.

[alophysio]

Hi,

I have to agree with Bernard (somasimple) on this thread...

Firstly, my personal preference is to ditch the electrotherapy - where is the evidence for it?

Secondly, addressing the biomechanical causes is the best thing to do.

Thirdly, plantar fasciitis is a misnomer. It is similar to Achilles Tendinitis and Lateral Epiconylitis. There have been studies which show that there are not many inflammatory markers present but increased neurotransmitter (?) markers which increase the sensitivity. Researchers therefore believe that the problem is a tendinopathy, not inflammation. Correction of the underlying, often repetitive causes are the best bet.

Fourthly, although i am from Australia, I really do believe that the best physios are from Australia, Netherlands, Canada and selected parts of the USA. Australia is the land of motor control, brought core-stability research to the fore and continues to break new ground through the work of O'Sullivan, Hodges, Jull, etc. Canada benefits from the enormous contribution of Diane Lee. Just look at the research...

Lastly, my 2 cents worth...
1. I screen my patients to exclude all the joints to the T/S since tension along any of the fascial systems can affect the nerves and and structures of and to the foot (I once fixed a chronic ankle pain by treating the instability in the T/S - didn't touch the ankle once and the pain disappeared in 1-2 sessions!).
2. My patients have to learn to prevent excessive pronation - a wobble board exercise with one-leg standing works the muscles that help support your longtiduinal arch. Also "toe crawls" are excellent - the patient moves forward inches at a time by dragging themselves forward with toe flexion - try it for 2m - it is not that easy if you are weak!
3. They have to use a dowel stick, rolling pin, etc to self-massage the plantar fascia since I have found that it does provide relief in so many patients (especially after doing their exercises).
4. Taping for the arch - fig 6 or low-dye works best - to ease the load and settle the pain.
5. Stay away from the electro!!! If the patient wants to use heat or ice - i don't care, let them do it but i don't think it will help except to cover up their pain. All the other gadgets are, in my humble opinion, a waste of time (mine and theirs)...

Sdkashif, where do you get your reference material from? I am used to references when quoting other people's work (i am assuming that the info you provide is not entirely your own...)