Treatment of plantar fasciitis targets several fronts

[Guest guest]

April 2007 Biomechanics Magazine

Treatment of plantar fasciitis targets several fronts

By: Josh Dubin, DC, CSCS

http://www.biomech.com/showArticle.jhtml?articleID=198900237

The study, science, and application of gait rehabilitation

technology is a growing, evolving field. No longer constrained by

traditional terminology, gait technology incorporates force plates,

devices, three-dimensional analysis, biomechanics, and

multidisciplinary collaboration.

In this section, Josh Dubin completes his series on plantar

fasciitis with a focus on treatment and prevention strategies. Ian

Engelman considers how to best help patients with drop foot, using

both devices and technology.

- R.

Plantar fasciitis is a term used to denote inflammation of the

plantar fascia. However, recent studies indicate that plantar

fasciitis may instead be a noninflammatory degenerative process.

Sonographic studies have revealed a correlation between marked (4 mm

or greater) degenerative thickening of the plantar fascia and

plantar fasciitis. The normal thickness of the plantar fascia

averages approximately 2 mm. Based on these findings, plantar

fasciitis may more aptly be termed plantar fasciosis.1-11

Babcock et al surmised several mechanisms that may cause plantar

fasciitis pain: Repeated trauma or chronic pressure from a thickened

plantar fascia may irritate pain fibers; chronic pressure of

thickened fascia against digital vessels may cause ischemic pain;

the effect of local pain neurotransmitters/chemicals, such as

substance P and glutamate, may be enhanced; and inflammation may

cause a secondary increase in nociceptor sensitivity.12

A practitioner can discover risk factors for and diagnose plantar

fasciitis by obtaining a detailed history and conducting a physical

examination. A history should include initial onset of injury;

current symptoms; occupation; recent weight gain; if in training,

progression of the frequency, intensity, and duration of weekly

runs; whether training routes incorporated hills; age of running

shoes; and training goals.

Palpation may reveal tenderness over the medial calcaneal tuberosity

and the medial longitudinal arch (MLA). These findings are

exacerbated by maintaining digital pressure over the tender aspect

of the MLA and then recreating the windlass mechanism

(see, " Biomechanics contribute to plantar fasciitis treatment, "

March, page 39) by dorsiflexing the big toe to approximately 65

degrees .13

Practitioner observation of the MLA of the barefoot weight-bearing

patient may reveal a pes planus or pes cavus foot structure. A pes

plano valgus foot may have callus formation over the second, third,

and fourth metatarsophalangeal joints (MTPs) due to ill-timed

pronation and a low-gear toe-off.

Reference lines should be drawn on the central aspect of the lower

leg and the heel. With the patient prone, the subtalar joint (STJ)

neutral position can be found by palpating the front of the talus

with one hand and inverting and everting the rearfoot with the other

hand. The STJ neutral angle can be measured with the arms of the

goniometer positioned over the heel and leg bisection lines.

Inversion of the heel line, compared with the leg line, indicates

rearfoot varus. Goniometer measurements are repeated with the

patient standing on an elevated box. The weight-bearing measurement

is compared with the STJ neutral measurement to evaluate for

excessive pronation of the STJ in compensation for rearfoot varus or

pes planus valgus, or for the limited pronation common in pes cavus

rigidus. The STJ should pronate approximately 4 degrees as the foot

adapts to the ground terrain.14 Range of motion of the talocrural

joint should be conducted with the patient prone, the STJ held in

the neutral position, and the leg fully extended. If the talocrural

joint is restricted in dorsiflexion, measurements should be repeated

with the leg flexed to differentiate between gastrocnemius and

soleus musculature restrictions.

Forefoot varus measurements can be conducted with the patient prone

and the rearfoot placed in STJ neutral. One straight edge of the

goniometer is lined up across the MTPs and the other edge of the

goniometer is placed perpendicular to the calcaneal bisection

line.14-16

Radiographic examination or a bone scan may aid in ruling out

differential diagnoses of calcaneal stress fracture, plantar fascia

rupture, osteomyelitis, or Ewing's sarcoma. Studies indicate that

calcaneal spurs are coincidental radiographic findings and are not

relevant.5,14,15,17

Treating plantar fasciitis

Conservative treatment for plantar fasciitis should focus on

decreasing pain, promoting healing, restoring range of motion and

strength, correcting training errors, limiting biomechanical

deviations caused by structural abnormalities, and maximizing good

nutrition.18 In my experience and based on a review of the

literature the following treatment protocol is suggested:

Manual adjustments to the ankle and foot to free up joint motion of

the talocrural, subtalar, and midtarsal joint articulations;10,11

and

Deep tissue procedures, such as the Graston Technique (manual

therapy that employs specially designed devices) and Active Release

Technique (a patented manual therapy technique), to break up scar

tissue and restore soft tissue motion.

I have found the myofascial technique using the Graston tool to be

particularly helpful to break up adhesions at the origin of the

plantar fascia on the medial calcaneal tubercle (Figure 1).

Considerable clinical evidence supports the effectiveness of deep

tissue procedures in treating strain/sprain injuries.19-21

Myofascial techniques have been shown to stimulate fibroblast

proliferation, leading to collagen synthesis that may promote

healing of plantar fasciitis by replacing degenerated tissue with a

stronger and more functional tissue.1,22

A home exercise program for myofascial release therapy can be taught

to the patient. If the plantar fasciitis is in the right foot, the

seated patient will cross the right leg over the left knee. With the

right hand he or she will then grab the bases of the first, second,

and third proximal phalanges and shorten the plantar fascia by

flexing the toes at the MTPs. The left hand will apply digital

pressure over the medial or central band of the plantar fascia. The

patient will then extend the toes at the MTPs with the right hand

while applying a distal-to-proximal traction with the left hand23

(Figure 2). This maneuver can be repeated as necessary. The patient

may also be taught how to roll a golf ball, laundry ball with nubs,

or frozen plastic bottle under the MLA to stimulate the plantar

fascia.

A strength training program for the extrinsic and intrinsic

musculature of the foot should be implemented. Standing and seated

calf raises strengthen the gastrocnemius, the soleus, and the

intrinsic musculature of the foot. Towel gripping exercises with the

toes may be another alternative in strengthening the intrinsic

musculature on the bottom the foot. The tibialis anterior and

extensor musculature of the foot aid in decelerating foot slap;

these muscles can be strengthened with cable-resisted exercises or a

dorsiflexion-assisted resistive device (DARD). Cable-resisted

eversion exercises of the foot strengthen the peroneal

musculature.3,15,24,25

Triceps surae stretching with the knee extended and bent can be done

on a slant board, with a pro-stretch device, or on a flat floor. The

self-myofascial release technique can also stretch the plantar

fascia. Stretching of the triceps surae and plantar fascia have been

shown to improve range of motion of the talocrural joint in

dorsiflexion and to help in treating plantar fasciitis.3,23,24

A prefabricated night splint should incorporate approximately 5

degrees of dorsiflexion of the talocrural joint and extension of the

first digit. The splint passively stretches the fascia overnight and

is helpful in alleviating morning heel pain caused by shortening of

the fascia.2,15,23,26 However, except for committed athletes,

compliance with the night splint generally has been poor because it

is bulky.27

A heel lift of one-quarter to three-quarters of an inch can be used

temporarily to limit compensatory pronation caused by ankle equinus.

As range of motion of the talocrural joint improves with therapy,

the heel lifts can eventually be removed.14,24,26

Shoes and training

Running shoes should be changed every 300 to 500 miles. A sneaker

loses approximately 50% of its ability to absorb ground reaction

forces after that.3,24,28

Patients should be educated and encouraged to purchase the proper

running shoe. A pes cavus foot structure may benefit from a

cushioned sneaker; the liner can be removed and replaced with a

cushioned liner. The rearfoot varus, pes planus valgus, and forefoot

varus foot structure may benefit from a motion control sneaker.29

When appropriate, arch supports may be useful. A semirigid orthosis

with a medial arch support no higher than 5/8-inch can help limit

excess pronation.6,14,16,24,26,30,31 Low-Dye taping of the foot has

been shown to be effective in limiting pronation.11,32,33

Runners also need recommendations for appropriate training limits.

For marathon runners, an initial training base of four miles at 65%

to 75% of maximum heart rate should be established. Later, a

progressive training schedule should be followed that allows the

supporting structures of the foot to adapt so they can withstand

increasing stress loads. Long training runs, usually done on

weekends, should be limited to a pace that requires 65% to 75% of

maximum heart rate to improve aerobic capacity.

During the week, a shorter four to eight-mile interval run at 85% to

90% of maximum heart rate is recommended to improve anaerobic

capacity. Hill training should be added gradually because of the

increased load placed on the lower extremities. The average marathon

training schedule consists of three shorter runs during the week,

and one longer run on the weekend. Total mileage should not be

increased by more than 10% per week.24,34,35

Runner patients may also consider modifying their training with

swimming, bicycling, and the elliptical machine.1,15,24

A viscoelastic heel cup or small cushioned doughnut can be placed

over the medial calcaneal tubercle to reduce ground reaction forces

acting on the proximal aspect of the plantar fascia.26

Adjustments to the everyday environment of patients with plantar

fasciitis may also help relieve some of their pain. For example, a

cushioned mat can be placed over a hard working surface, reducing

ground reaction forces for professionals who stand for prolonged

time periods over a fixed spot.

Other opportunities to help reduce or relieve some of the pain

include nutritional advice, modalities, and drugs. A dietitian can

calculate burn rate from daily exercise and develop an appropriate

daily meal plan for healthy weight loss or maintenance. Ultrasound

and electric muscle stimulation combination therapy can help restore

normal muscle tone, aid in the healing process, and reduce

pain.11,36 Iontophoresis with dexamethasone is also a useful

modality to decrease inflammation.37

Inflammation can be reduced by taking nonsteroidal anti-inflammatory

drugs, per prescription, and applying a cold pack to the MLA for 20

minutes on, one hour off, repeated throughout the day.

Histological findings in plantar fasciitis have indicated

degenerative changes with no inflammatory precursors.3 The healing

potential of NSAIDs, ice therapy, and iontophoresis for the

treatment of plantar fasciitis, therefore, may be limited.

A short leg walking cast worn for approximately six weeks may limit

the ground reaction tensile forces acting on the fascia, thereby

limiting repetitive strain and promoting healing.26

Cortisone injections or surgical management may need to be

considered if conservative measures are not successful in

alleviating or allowing the patient to comfortably manage symptoms.

Corticosteroid injections are useful in relieving pain due to

inflammatory changes. However, they should be administered

judiciously because multiple injections may cause a plantar fascia

rupture.2,3,18

Conclusion

Plantar fasciitis is one of the most common causes of inferior heel

pain. Structural abnormalities, overuse, weakness, excess weight,

and training errors all contribute to risk of this condition.

Repetitive, excessive loads placed on the plantar fascia may lead to

degenerative changes that decrease its ability to absorb ground

reaction forces, and to reapproximate the MLA and resupinate the STJ

in preparation for toe-off. In many cases, conservative care has

been found to be successful in alleviating or controlling symptoms

related to plantar fasciitis. If conservative care is not effective,

a cortisone injection may be useful in decreasing pain symptoms. In

recalcitrant cases of plantar fasciitis, endoscopic conservative

surgery is a viable option.

C. Dubin, DC, CSCS, is the owner of Dubin Chiropractic in

Quincy, MA, and a member of the Team USA Triathlon/Duathlon

International Triathlon Union medical staff since 1996.

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