Professional Documents
Culture Documents
Plantar Fasciitis
Plantar Fasciitis
HYDERABAD 500033.
A PROJECT REPORT ON
PLANTAR FASCITIS
PROJECT GUIDE:
MR.VIJAY KRISHNA
PROJECT BY
C.DEEPTHI
H.T.NO.07042010
This is to certify that the Project work entitled CERVICAL RIB is a bonafide work
carried out by C.DEEPTHI in partial fulfillment for the award of Degree of BACHELOR
OF PHYSIOTHERAPY of Dr. NTR UNIVERSITY OF HEALTH SCIENCES, Vijayawada
during the year August 2011.
Project Guide
Principal
MR.K.VIJAYA KRISHNA
Internal Examiner
External Examiner
ACKNOWLEDGEMENT
It is my immense pleasure to present this project work on PLANTAR FASCITIS
My greatful thanks to Mrs. Hannah Rajsekhar, principal of Apollo college of
physiotherapy, for providing me the base and background for pursuing this project.
I extend my sincere gratitude to my project guide Mr K.VIJAYA KRISHNA for her
valuable inputs, continuous support and perseverance in guiding me all through my
project.
I have learnt a lot from her through this project and she has inspired me to work harder.
I am thankful to my faculty for their timely advice and helpful suggestions.
I am thankful for my parents, family members, friends, and the librarian for
supporting me and without their blessings this project would not have been completed
successfully.
Special thanks to all my patients without whom the success of my project would have
been indefinite.
Above all I am extremely thankful to God for his grace and blessings.
This work is the reflection of the above personnels collective talent and their expertile in
the field of my project.
C.DEEPTHI
PLANTAR FASCIITIS
INDEX
1. INTRODUCTION.
2. ANATOMY OF PLANTAR FASCIA.
3. BIOMECHANICS.
4. SIGNS AND SYMPTOMS.
5. DIAGNOSIS.
6. PREVENTION.
7. TREATMENT PLAN.
8. PHYSIOTHERAPY MANAGEMENT.
9. ASSESSMENT.
10.CASE STUDIES.
11.LITERATURE REVIEW
12.CONCLUSION.
13.BIBILIOGRAPHY.
INTRODUCTION
The plantar fascia is a thick fibrous band that runs the length of the
sole of the foot.
The plantar fascia helps maintain the complex arch system of the
foot and plays a role in one's balance and the various phases of
gait.
Injury to this tissue, called plantar fasciitis, is one of the most
disabling running injuries and also one of the most difficult to
resolve.
Plantar fasciitis represents the fourth most common injury to the
lower limb and represents 8 -10% of all presenting injuries to sports
clinics.
Rehabilitation can be a long and frustrating process.
The use of preventive exercises and early recognition of danger
signals are critical in the avoidance of this injury.
Definition
FASCIA a band or sheath of connective tissue investing, supporting, or
binding together internal organs or parts of the body.
Plantar fasciitis
Plantar fascitis an inflammation (irritation and swelling with presence of
extra immune cells) of the thick tissue on the bottom of the foot that
causes heel pain and disability.
Plantar fascitis, which may cause the heel to hurt, feel hot or swell, is
inflammation of the plantar fascia, a thin layer of tough tissue supporting
the arch of the foot. Repeated microscopic tears of the plantar fascia
cause pain.
Typically with plantar fascitis, the pain is worse when first getting out of
bed, or is noticeable at the beginning of an activity and gets better as the
body warms up. Prolonged standing may cause pain, as well. In more
severe cases, the pain may worsen toward the end of the day.
INCIDENCE:
There is a greater incidence of plantar fascitis in males than females While
no direct cause could be found it could be argued that males are generally
heavier which, when combined with the greater speeds, increased ground
contact forces, and less flexibility, may explain the greater injury
predisposition.
RISK GROUPS
Professions involving prolonged standing like,
Traffic police
Teaching
Hill trekking
Doctors
Security guards etc
RISK FACTORS
Extrinsic risk factors
Training errors during sports are among the major causes of plantar
fascitis.
AGE
The exact incidence and prevalence by age of plantar fascitis is
unknown but the condition is seen in adults essentially of all ages
usually patients of aged 30 to 50 years are more prone to this condition.
MODIFICATIONS
wear an appropriate shoe type according to the foot type and activity
Sports shoes rapidly lose cushioning properties. Those who use shoesole repair materials are especially at risk if they do not change shoes
often.
Structural risk factors include pes planus, overpronation, pes cavus, leglength discrepancy, excessive lateral tibial torsion, and excessive
femoral ante version.
Pronation is a normal motion during walking and running, providing footto-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.
Aging and
Heel fat pad atrophy are two degenerative risk factors for plantar fascii.
The foot and ankle can be divided into the rear foot, midfoot, and
forefoot. The rear foot consists of four bones: the distal aspects of the
tibia and fibula (leg bones), the calcaneus (heel bone), and the talus.
The midfoot consists of five bones: the cuboid, the navicular, and three
cuneiforms. The forefoot consists of 19 bones: five metatarsal bones and
14 phalanges.
The plantar fascia originates from the medial calcaneal tuberosity and
divides into medial, central, and lateral bands that attach to the superior
surface of the abductor hallucis, flexor digitorum brevis, and abductor
digiti minimi muscles, respectively. The fascia then splits into five slips
that cross the metatarsophalangeal joints and insert onto the phalanges
of the digits.
The structure of the foot's MEDIAL LONGITUDINAL ARCH resembles
two rods: a rear rod consisting of the calcaneus and talus, and an
anterior rod consisting of the navicular, three cuneiforms, and the first
three metatarsals.
These rods are connected at their bases by the plantar fascia. When
force is applied to the apex of the Medial longitudinal arch, the arch
depresses, the two rods separate, and tension is distributed throughout
During initial contact, the heel contacts the ground surface. The
loading response occurs immediately after initial contact, ending
when the contra lateral foot lifts off of the ground surface.
Midstance starts when the contra lateral foot lifts off of the ground
surface.
The contra lateral leg is now in swing phase. The midstance phase
ends as tension on the gastrocnemius, soleus, and Achilles tendon
(triceps surae) of the stance leg causes the heel to lift.
Terminal stance phase begins when the heel lifts and ends when the
swing leg contacts the ground.
The plantar fascia and extrinsic and intrinsic musculature of the foot
play an active role in guiding the foot as it transitions from initial
contact to toe-off.
Efficient function of the plantar fascia and musculature of the foot
depends on the configuration of the rear foot and midfoot articulations
during the different sub phases of gait.
The rear foot comprises the talocrural and the subtalar joints. The
talocrural joint (ankle mortise) consists of the articulation of the distal
aspect of the tibia and fibula with the trochlea of the talus. It facilitates
two primary movements: dorsiflexion, pulling the toes up and back
toward the tibia, and plantar flexion, pointing the toes downward.
The subtalar joint(STJ) consists of the articulation of the undersurface
of the talus with the calcaneus. Movement of the subtalar joint is
pivotal in transforming the foot from a rigid lever during initial ground
contact to a mobile shock absorber during loading response and early
midstance, and back into a rigid lever as the foot prepares for toe-off.
The two primary movements that occur at the Sub talar joint are
pronation and supination. Pronation of the Sub talar joint normally
occurs during loading response and into early midstance. In Subtalar
joint pronation, the calcaneus turns outward (everts); the talus drops
downward distally and adducts toward the midline; and the talocrural
joint dorsiflexes.
During initial contact, the Sub talar joint is normally supinated. It
pronates from loading response to early midstance and then
resupinates later in midstance and into terminal stance.
In Subtalar joint supination, the calcaneus turns inward (inverts); the
talus moves upward proximally and abducts away from the midline;
and the talocrural joint plantar-flexes. Freedom of movement in the
midfoot depends on the position of the Sub talar joint.
The two main articulations of the midfoot are the talonavicular joint
and the calcaneocuboid joint. The midfoot revolves around two joint
axes: the longitudinal midtarsal joint angle and the oblique midtarsal
joint angle (OMJA). Movement of the midfoot around the longitudinal
midtarsal joint angle consists of inversion or eversion
Movement of the midfoot around the oblique midtarsal joint angle
consists of dorsiflexion and abduction, and plantar flexion and
adduction STJ pronation during loading response and into early
midstance causes the talonavicular joint to diverge and move distally
to the calcaneocuboid joint.
This reconfiguration unlocks the midfoot, allowing it to pronate around
the oblique midtarsal joint angle. Pronation of the midfoot around the
oblique midtarsal joint angle will stretch the plantar fascia slightly as
the Medial longitudinal arch is depressed, transforming the foot from
a rigid lever into a mobile adaptor that is better equipped to absorb
ground reaction forces. Shortly after early midstance, the SubTalar
Joint starts to resupinate and should resupinate back to neutral
before terminal stance.
aspect
of
the
plantar
fascia
to
wrap
around
the
metatarsophalangeal joint.
These coordinated movements that occur during terminal stance
have been termed a windlass mechanism.
During this motion, tension on the distal aspect of the plantar fascia
is transmitted to its proximal attachment on the medial aspect of the
heel, causing the calcaneus to invert and the medial arch to rise as
the forefoot pulls back toward the rear foot.
have
tendinous
attachment
sites
near
the
Medial
longitudinal arch.
The former two muscles are active in resisting pronation from
midstance to toe-off, and the tibialis posterior decelerates pronation
from loading response to early midstance.
Under normal circumstances, the plantar fascia, plantar ligaments,
osseous architecture, and extrinsic and intrinsic muscles of the foot
and leg are able to absorb ground reaction forces without incurring
injury.
However, structural abnormalities may lead to faulty biomechanics of
the rear foot and midfoot. These abnormalities may cause excessive
and rapid pronation of the STJ during loading response and into early
midstance, or ill-timed pronation that continues into terminal stance.
This may lead to an increased strain on the plantar fascia and other
supporting structures of the foot, predisposing a person to developing
plantar fascitis. Structural abnormalities associated with excess,
prolonged, or ill-timed pronation may include ankle equinus, rear foot
varus, forefoot varus, pesplano valgus, and pes cavus.
lateral rotator force, the hind foot will supinate and the planter fascia
will be unloaded.
With the in reduction in the tension in the planter fascia the range of
available toe hyperextension will increase.
Finally, increasing tension in tie-rod independent of loading the foot
will draw the two struts of the truss together, shortening and raising
the triangle.
This phenomenon can occur when the Metatarso phalangea joints
are extended.
Whether the are extending with distal lever free or the toes are being
extended as the heel raises in the weight bearing, the fascia is pulled
tighter and the arch can be raised simply through an increase in
passive tension in the aponeurosis.
Through the mechanism of planter aponeurosis, the Metatarso
phalangeal joints act interdependently with the joints of hind foot and
may contribute the supination of foot through the effect of Metatarso
phalangeal joint extension on the plantar aponeurosis.
Muscle activity appears to contribute little support
to
the
PATHO MECHANICS
The development of plantar fascitis is thought to have a mechanical
origin
Excessive stretch of plantar fascia can result in micro trauma of the
plantar fascia at its insertion on the medial calcaneal tuberosity or
along the course of the fascia.This micro trauma, if repetitive can
result in chronic inflammation and degeneration of the plantar fascia
fibers.
Repetitive micro trauma at the plantar fascia may cause significant
plantar pain particularly with the first few steps after sleep other
periods of inactivity or prolonged walking especially stair climbing.
Vascular and metabolic disturbances, the formation of free radicals,
hyperthermia and genetic factors have also been linked to
degenerative change in connective tissues .
CLINICAL FEATURES
Pain and stiffness are worse with rising in the morning or after prolonged
ambulation and may be exacerbated with climbing stairs.
DIAGNOSIS
Diagnosis can be made by careful examination and by the evidence
of clinical features, but in possible cases, it can be evidenced by poor
dorsiflexion (lifting the forefoot off the ground) or inability to perform
the "flying frog" position.
In the flying frog the patient goes into a full squat position and
maintains balance and full ground contact with the sole of the foot.
Elevation of the heel signifies a tight gastroc complex. This test can
be done with the training shoes on.
DIFFERENTIAL DIAGNOSIS:
S.No
CHARACTER
PLANTAR FASCITIS
TARSAL
TUNNEL
SYNDROME
1.
Cause
Overuse,
weight bearing.
lesions,
inflammation,
inversion,
pronation,
valgus deformity.
2.
Pain
24hour behavior
4.
Electro diagnosis
normal
Prolonged
motor
5.
sensory latencies.
Full ROM
6.
Passive
Full ROM
Pain on pronation
7.
movements
Resisted
normal
8.
isometrics
Sensory deficits
nil
Possible
9.
Reflexes
normal
Normal
PREVENTION:
with gentle foot exercises that strengthen the muscles in the arch of
the foot, such as
gentle toe curls,
marble pick ups,
tapping the big toe while holding the remaining four off the ground
and
continuing the regimen with [Trigger Point] massage balls
and
Begin with just a few of each exercise and gradually increase the
repetitions. Also, while returning to activity it is important to continue
the routine of stretching and ice.
Double check the footwear to make sure theres proper arch support.
Commercial insoles or custom orthotics are good options to provide
necessary support.
TREATMENT
AIMS OF THE TREATMENT
To reduce pain and inflammation.
To relieve strain from the fascia by stretching.
Patient education.
MANAGEMENT
CONSERVATIVE MANAGEMENT:
Symptoms usually resolve more quickly when the time between the onset
of symptoms and the beginning of treatment is as short as possible. If
treatment is delayed, the complete resolution of symptoms may take 6-18
months or more. Treatment will typically begin
1. By correcting training errors which usually requires some degree of rest.
2. The use of ice after activities, and
3. An evaluation of the patients shoes and activities.
4. For pain, non steroidal anti-inflammatory drugs (e.g. aspirin, ibuprofen,
etc.) may be recommended.
DRUG THERAPY:
Medical steroidal anti-inflammatory injections into the plantar fascia to
reduce pain Effectiveness of the steroids depends on the accuracy of
the injection and the patient's compliance with this period of reduced
activity.
It should be noted that 10 of 11 cases of spontaneous rupture of the
plantar fascia followed steroidal injections and an aggressive return to
activities.
SURGERY
CRITERIA
Athletes who suffer from this condition might also consider surgery
when performance becomes significantly impaired by heel pain and
related ailments.
COMPLICATIONS
There are several complications that can inhibit full recovery following
plantar fascia surgery.
1. The arch of the heel can be reduced if the plantar fascia is released
too much.
2. Numbness in certain areas may occur following surgery if the nerves
around the fascia become damaged.
3. Infections can also develop which will need to be treated with
antibiotics.
4. Patients can also come out of surgery still feeling symptoms of
plantar fascitis and feeling pain around the heel.
5. Some times, malalignment leads to calcaneous spur formation.
METHOD OF SURGERY
PHYSIOTHERAPY MANAGEMENT
1. Ice or cryotherapy after activity.
2. Taping.
3. Stretching the plantar fascia in the morning.
4. Rest.
5. Arch Support (especially if there is a flat foot).
6. Losing weight if possible, especially in overweight women because
survey of 5,000 visitors shows overweight women are 6 times more
likely than overweight men to get plantar fasciitis. This is probably
because fat deposits lower on the body in women than in men. This
lowers the center of gravity which will cause excess tension in the
plantar fasciitis if there is not also greater flexibility in the calf
muscles.
7. Night splints.
8. Myofascial release.
PHASE 1:
1. STRETCHING OF PLANTAR FASCIA:
plantar fascitis often have a tight Achilles tendon which can add
additional strain to the fascia ligament.
Plantar fascia exercises that target the calf muscles in addition to the
plantar fascia are also an excellent way to reduce heel pain.
Often times, muscles and ligaments in the calf can become tense. As
already mentioned, when this occurs additional strain is placed on the
plantar fascia.
Plantar fascia exercises are often taken for granted yet are an
excellent way to reduce the effects of plantar fascitis. Doing these
exercises before and after an exercise routine is also very important
in pain management.
Running or participating in any other type of physical activity can be
harmful when the muscles and ligaments throughout the foot and calf
are tight and are not properly warmed up.
Exercising on tight muscles can increase the risk of tearing tissue and
developing or worsening painful conditions such as heel spurs or
Achilles tendonitis
Lean towards the wall, keeping your knees straight and your
heels flat on the ground.
While keeping the heels of the feet flat on the floor, raise the
foot upwards.
Like Plantar Fascia Exercise #1, patient should be able to feel
the calf area tighten up.
Place the feet and hold for 30 sec , slowly leaning forward to stretch
the Achilles Tendon.
Gastrocnemius Runners Stretch:
Keep the knee straight and slowly stretch the affected leg for 30 sec.
Rest:
Discontinue Running and walking for exercise until asymptomatic for 6
week.
Weight loss.
Modification of hard surfaces.
Put a few marbles on the floor near a cup. Keep the heel on the
floor and use the toes to pick up the marbles and drop them in the
cup.
Another exercise is toe taps. Keep the heel on the floor and lift all
of the toes off the floor. Tap only the big toe to the floor while
keeping the outside four toes in the air. Next, keep the big toe in
the air and tap the other four toes to the floor.
3. SHOE WEAR MODIFICATIONS :
Wearing shoes that are too small may cause plantar fascitis. Shoes
with thicker, well-cushioned midsoles may help alleviate the problem.
ORTHOTICS:
orthotics physically re-stretch the fascia ligament while moving and
also provides acupressure and structural support in the areas of the
foot that require the most attention in order to help reverse the
condition.
When used in combination with effective orthotic, exercises can
significantly improve the injury that the patient may be suffering from
and also provide long term prevention against reoccurrences.
Orthotics is the most expensive option as a plaster cast is made of
the individuals feet to correct specific biomechanical factors. One
study found that 27% of patients cited orthotics as the most helpful
treatment of plantar fascitis.
Feet that pronate (arches roll in) have a prolonged mid-stance phase
of ground contact and may cause excessive internal rotation of the
tibia.
These faults can lead to hip and low back pain because they allow
the affected leg to drop unevenly, stressing the supporting muscles
and ligaments of the hips and low back.
Orthotics, by forming a solid foundation for the foot, can prevent
excessive pronation and therefore check excessive or aberrant
movement further up the kinetic chain of the leg.
Physicians who routinely use orthotics (podiatrists and chiropractors)
can cast two different types of orthotics
1. Biomechanical/ functional or
2. Accommodative orthotics.
Patient with very high or very low arches may benefit from arthtic
inserts.
A less rigid, accommodative insert is applicanle to a more requires
more cushion and less hind foot control.
A padded but rigid insert is indicated for a more unstable foot with
compensatory pronation (pes planus or low arch) which requires
more control.
NIGHT SPLINTS:
Night splints, which are removable braces, allow passive stretching of
the calf and plantar fascia during sleep, and minimize stress on the
inflamed area.
A 5- degree dossiflexion night splint is bebeficial.
Splint holds the plantar fascia in a continuously tensed state.
Use of Night splint is to minimize the change of tension in the fascia
that occurs with each days new activities.
MODALITIES :
Iontophoresis.
Ultrasounds.
Deep friction massage.
Foot bath technique.
RANGE OF MOTION:
stretch of the gastroc complex. Once pain in the plantar fascia has
subsided this stretch can be used both mornings and evenings.
A return to running should be considered only after there is a three to
four week period of no pain. Exercises and preventative exercises should
continue to be done.
PHASE 3:
Patients in whom phase 1 and 2 measures have failed may be
candidates for surgical intervention.
But there is high compilation rate from the surgery.
Indicate the surgery after the failure of phase 1 and 2 Rx for 18
months.
Never use Endoscopic release because of the increased compilation
rate compared with that of open release because inability to identify
the nerve to the abductor digiti minimi
RUPTURE OF THE PLANTAR FASCIA :
TREATMENT :
PHASE 1 : (0-14) Days
Light compression wrap changed several times a day for 2-3 days.
Non- weight bearing. Light, fiber glass cast on day 3, worn for 1-2 week
depending on resolution of pain.
Gentle active toe extension and flexion exercises while still in cast.
PHASE 2 : (2-3 Weeks)
Use of 1/8 inch felt pad placed from heel to heads of metatarsals and
lightly wrapped with bandage.
High impact exercises are help until patient has been completely
asymptomatic for 2-3 week.
HOME PROGRAME
PLANTAR FASCIA STRETCHING EXERCISES
1. Long Sitting Stretch
1) Sit on the floor with your legs stretched out in front of you
2) Loop a towel around the top of your affected foot
3) Pull the towel towards you until a stretch is felt across the bottom of your
foot
4) Hold for 30 seconds then relax - repeat 10 times
2. Achilles Stretch
1) Stand facing a wall and place your hands straight out on the wall
2) Step back with your affected foot keeping it flat on the floor
3) Move the other leg forward and slowly lean in toward the wall
4) Stop when you feel a stretch through the calf
5) Hold for 30 seconds then relax - repeat 10 times
3. Stair Stretch
1) Stand on a step on the balls for your feet
2) Hold the rail for balance
3) Slowly lower the heel of the injured foot until a stretch is felt
4) Hold for 30 seconds then relax - repeat 10 times
ASSESSMENT
SUBJECTIVE ASSESSMENT
NAME:
AGE:
SEX:
OCCUPATION:
CHIEF COMPLAINTS:
PAIN
AREA OF SYMPTOMS:
TYPE OF PAIN:
AGGREVATING FACTORS:
RELIEVING FACTORS:
INTENSITY OF PAIN: by V.A.S scale
Min--------------------------l---------------------------Max
DURATION OF PAIN:
SEVERITY:
IRRITABILITY:
24 HOUR BEHAVIOUR:
HISTORY
1. PRESENT HISTORY:
MODE OF ONSET:
DURATION OF ONSET:
2. PAST HISTORY:
3. GENERAL CONDITIONS:
4. MEDICAL HISTORY:
5. SURGICAL HISTORY:
OBJECTIVE ASSESSMENT
PHYSICAL EXAMINATION
OBSERVATION
SWELLING
CONTRACTURE
DEFORMITY
POSTURE
ARCHES OF FOOT
HALLUX VALGUS
PALPATION
TENDERNESS
WARMTH
OEDEMA
EXAMINATION
RANGE OF MOTION
AROM
PROM
MMT
INVESTIGATIONS
DIFFERENTIAL DIAGNOSIS
DIAGNOSIS
AIMS OF TREATMENT
SHORT TERM GOALS:
LONG TERM GOALS:
TREATMENT PLAN
PROGNOSIS:
HOME PROGRAMME:
CASE STUDY 1
SUBJECTIVE ASSESSMENT
NAME: XYZ
AGE: 22 yrs
SEX: female
OCCUPATION: Student
CHIEF COMPLAINTS:
PAIN
Min-------------------------------!-----------Max
HISTORY
1. PRESENT HISTORY:
MODE OF ONSET: Fall from height
DURATION OF ONSET : pain observed after discontinuing the pain killers
i.e. after 2 days
2. PAST HISTORY: The patient had a fall from tree, landed up on feet. Swelling
observed in left foot immediately after injury.
3. GENERAL CONDITIONS: normal.
4. MEDICAL HISTORY: pain killers taken after the injury.
5. FAMILY HISTORY: No family history.
6. SURGICAL HISTORY: No surgical history.
7. PERSONAL HISTORY: no history of HTN, DM etc
OBJECTIVE ASSESSMENT
PHYSICAL EXAMINATION
OBSERVATION
PALPATION
TENDERNESS: Present over the sole of the foot, marked on heel.
WARMTH: Present
OEDEMA: noticed soon after the injury over the whole feet.
EXAMINATION
RANGE OF MOTION
DORSIFLEXION
PLANTARFLEXION
EVERSION
INVERSION
AROM
RIGHT
0-15 deg
0-45 deg
0-20 deg
0-25 deg
LEFT
0-20 deg
0-45 deg
0-20 deg
0-35 deg
PROM
RIGHT
0-20 deg
0-45 deg
0-20 deg
0-35 deg
MMT:
DORSIFLEXORS
PLANTARFLEXORS
EVERTARS
INVERTARS
INVESTIGATIONS:
RIGHT
3/5
3+/5
4/5
4/5
LEFT
4+/5
4+/5
4/5
4/5
LEFT
0-20 deg
0-45 deg
0-20 deg
0-35 deg
AIMS OF TREATMENT
SHORT TERM GOALS:
Relieve pain.
Reduce swelling.
Increase joint mobility.
To strengthen muscles.
Relieve tightness of TA.
LONG TERM GOALS:
Patient education.
Rehabilitation to improve ROM
Preventing and treating deformities.
TREATMENT PLAN:
4 7 weeks:
Taught the self stretching techniques before getting down from bed.
Ankle mobilizations done to improve the range of dorsiflexion and
inversion.
Stretches continued with increased hold time.
Self stretching exercises taught.
Strengthening exercises like pebble board exercise, sand exercise
encouraged.
Ultra sound given with reduced intensity and duration.
Feet wear modification done.
7 8 weeks:
Ultra sound discontinued.
Active R.O.M exercises encouraged.
Strengthening exercises continued.
Encouraged Self stretching exercises before and after the intense activity.
Taught the patient about the protection and prevention techniques.
PROGNOSIS:
Pain reduced on V.A.S scale to 3.
CASE STUDY 2
SUBJECTIVE ASSESSMENT
NAME: ABCD
AGE: 40 yrs
SEX: Female
OCCUPATION: Teacher
CHIEF COMPLAINTS: pain over the heel of the left foot
PAIN
AREA OF SYMPTOMS: pain over the inner border of the heel.
TYPE OF PAIN: pin pointing pain over the heel
AGGREVATING FACTORS: pain worse in the mornings and after prolonged
rest.
RELIEVING FACTORS: relieved as the day progresses.
INTENSITY OF PAIN: able to continue doing work even with pain, but with
discomfort, pain on V.A.S scale is 5.
Min--------------------------!----------------------------Max
DURATION OF PAIN: during the first few steps after prolonged rest.
SEVERITY: moderately severe.
IRRITABILITY: moderately irritable.
24 HOUR BEHAVIOUR: worse in the mornings, relieved with activity.
HISTORY
1. PRESENT HISTORY:
MODE OF ONSET: gradual.
DURATION OF ONSET: less than 1 min of weight bearing on
the affected leg.
2. PAST HISTORY: No specific past history. Applied pain relieving balm after
the onset.
3. GENERAL CONDITIONS: normal.
4. MEDICAL HISTORY: patient took paracetomol for pain relief.
5. SURGICAL HISTORY: no surgical intervention underwent.
OBJECTIVE ASSESSMENT
PHYSICAL EXAMINATION
OBSERVATION
to pain.
ARCHES OF FOOT: reduced arches or pes planus noticed
HALLUX VALGUS: absent.
PALPATION
EXAMINATION
RANGE OF MOTION:
DORSIFLEXION
PLANTARFLEXION
EVERSION
INVERSION
M.M.T:
DORSIFLEXORS
PLANTARFLEXORS
EVERTARS
INVERTARS
AROM
RIGHT
0-20 deg
0-45 deg
0-20 deg
0-35 deg
RIGHT
4+/5
4+/5
4/5
4/5
LEFT
0-15 deg
0-45 deg
0-20 deg
0-25 deg
PROM
RIGHT
0-20 deg
0-45 deg
0-20 deg
0-35 deg
LEFT
0-20 deg
0-45 deg
0-20 deg
0-35 deg
LEFT
3+/5
4/5
4/5
4/5
syndrome.
DIAGNOSIS: plantar fascitis of left foot.
AIMS OF TREATMENT
SHORT TERM GOALS:
Relieve pain.
Reduce swelling.
Increase joint mobility.
To strengthen muscles.
Relieve tightness of TA.
LONG TERM GOALS:
Patient education.
CASE STUDY 3
SUBJECTIVE ASSESSMENT
NAME: xxx
AGE: 41 yrs
SEX: female
OCCUPATION: house wife
CHIEF COMPLAINTS: pain in the heel of the right foot.unable to walk in the
morning soon after getting up from the bed.
PAIN
AREA OF SYMPTOMS: pain in the heel of the right foot, close to the lateral
border.
TYPE OF PAIN: pulling type of pain, some times pinpointing, unable to
describe exactly.
AGGREVATING FACTORS:
walking.
RELIEVING FACTORS: relieved with activity at the end of the day.
INTENSITY OF PAIN: able to continue with pain,5 on V.A.S scale.
Min-----------------!----------------Max
DURATION OF PAIN: 3 to 5 min after the onset of pain.
SEVERITY: moderately severe.
IRRITABILITY: irritable.
24 HOUR BEHAVIOUR: worse in the mornings.
HISTORY
1)
OBJECTIVE ASSESSMENT
PHYSICAL EXAMINATION
OBSERVATION
SWELLING: absent
CONTRACTURE: absent
DEFORMITY: hallux valgus present.
POSTURE: unequal weight distribution on both the legs due to pain.
ARCHES OF FOOT: prominent pes planus.
HALLUX VALGUS: present
PALPATION
TENDERNESS: present over the heel of the right foot close to the lateral
aspect.
WARMTH: present.
OEDEMA: absent.
EXAMINATION
RANGE OF MOTION:
DORSIFLEXION
PLANTARFLEXION
EVERSION
INVERSION
AROM
RIGHT
0-15 deg
0-45 deg
0-20 deg
0-35 deg
LEFT
0-21 deg
0-45 deg
0-20 deg
0-35 deg
PROM
RIGHT
0-20 deg
0-45 deg
0-20 deg
0-35 deg
M.M.T:
DORSIFLEXION
PLANTARFLEXION
EVERSION
INVERSION
RIGHT
3/5
3+/5
4/5
4/5
LEFT
3+/5
3+/5
4/5
4/5
INVESTIGATIONS: x- ray
DIFFERENTIAL DIAGNOSIS: did with tarsal tunnel syndrome.
DIAGNOSIS: plantar fasciitis of the right foot.
AIMS OF TREATMENT
SHORT TERM GOALS:
Relieve pain.
Reduce swelling.
Increase joint mobility.
To strengthen muscles.
LEFT
0-23 deg
0-45 deg
0-20 deg
0-35 deg
PROGNOSIS:
GOOD prognosis with
Consistent reduction of pain on V.A.S scale to 2.
Patient is comfortable in making steps after prolonged rest.
Reduced discomfort and tightness during ankle toe movements.
Increased ROM of ankle joint.
LITERATURE REVIEW
1. Tissue-Specific Plantar Fascia-Stretching Exercise Enhances
Outcomes in Patients with Chronic Heel Pain
Abstract
workday on their feet had an odds ratio of 3.6 (95% confidence interval, 1.3 to
10.1) when compared with the referent group of those who did not.
Conclusions: The risk of plantar fasciitis increases as the range of ankle
dorsiflexion decreases. Individuals who spend the majority of their workday on
their feet and those whose body-mass index is >30 kg/m 2 are also at increased risk
for the development of plantar fasciitis. Reduced ankle dorsiflexion, obesity, and
fasciitis and to evaluate the effectiveness of arch taping in controlling heel pain
during ambulation.
Background: Plantar heel pain as a consequence of plantar fascial strain, a
condition frequently diagnosed as plantar fasciitis, can significantly interfere with
functional ambulation. Biomechanical causes of plantar fasciitis have been related
to micro failure of plantar facial tissue followed by incomplete repair resulting
from abnormal histological responses. Arch taping has been suggested as a viable
treatment option for patients with this diagnosis but few studies have documented
its clinical effectiveness in reducing pain. Methods and measures: Two female
subjects diagnosed with plantar fasciitis with a history of chronic heel pain
participated in the clinical evaluation. Time to onset of pain was recorded during
ambulation with and without arch taping on several days.
Results: Visual and statistical analysis using the Two Standard Deviation Band
method showed improvement at the P<0.05 significance level in walking time for
both subjects with arch taping. Conclusions: Biomechanical and histological
factors need to be considered for successful management of plantar fasciitis. The
arch taping technique applied in these two cases was effective in controlling pain
during ambulation and could be considered as a viable treatment option for other
individuals with similar clinical presentations. Slower healing time of dense
connective tissue such as plantar fascia needs to be protected for longer periods of
time to ensure resolution of plantar fasciitis.
Background Plantar fasciitis is one of the most common foot complaints. It is often
treated with foot orthoses; however, studies of the effects of orthoses are generally
of poor quality, and to our knowledge, no trials have investigated long-term
effectiveness. The aim of this trial was to evaluate the short- and long-term
effectiveness of foot orthoses in the treatment of plantar fasciitis.
Methods: A pragmatic, participant-blinded, randomized trial was conducted from
April 1999 to July 2001. The duration of follow-up for each participant was 12
months. One hundred and thirty-five participants with plantar fasciitis from the
local community were recruited to a university-based clinic and were randomly
allocated to receive a sham orthosis (soft, thin foam), a prefabricated orthosis (firm
foam), or a customized orthosis (semirigid plastic).
Results: After 3 months of treatment, estimates of effects on pain and function
favored the prefabricated and customized orthoses over the sham orthoses,
although only the effects on function were statistically significant. Compared with
sham orthoses, the mean pain score (scale, 0-100) was 8.7 points better for the
prefabricated orthoses (95% confidence interval, 0.1 to 17.6; P = .05) and 7.4
points better for the customized orthoses (95% confidence interval, 1.4 to 16.2; P
= .10). Compared with sham orthoses, the mean function score (scale, 0-100) was
8.4 points better for the prefabricated orthoses (95% confidence interval, 1.0-15.8;
P = .03) and 7.5 points better for the customized orthoses (95% confidence
interval, 0.3-14.7; P = .04). There were no significant effects on primary outcomes.
customized and prefabricated orthoses used in this trial have similar effectiveness
in the treatment of plantar fasciitis.
CONCLUSION
The foot must sustain tremendous forces during ambulation. Any and all
measures taken to improve the shock absorptive qualities, intrinsic strength
and proprioceptive balance of the foot will eventually reduce the pain.
Injury to the plantar fascia can be difficult to resolve and will require a
prolonged recovery period. Halfhearted or sporadic attention to rehabilitation
of this injury will produce minimal results.
BIBILIOGRAPHY
1. Essentials of orthopedics and applied Physiotherapy Jayanth joshi.
2. Orthopedic physical assessment David j. Magee.
3. Joint structure and function Cynthia Norkins.
4. Human Anatomy B.D.Chowrasya.
5. Grays anatomy Gray.
REFERENCE WEBSITES
1. www.emedicine.com
2. http://www.heelpain.com
3. http://plantarfascitistips.com
4. medline journals.
5. http://www.wikihow.com
6. http://www.medindia.net