Plantar Fascial Injury
Plantar fascial injury is one of the, if not the most seen musculoskeletal injury by podiatrists. It is commonly described by patients as chronic condition which has built up gradually and has now hit a breaking point of which needs to be addressed.
Frequently named Plantar Fasciitis, which indicates an inflammation of the plantar fascia. The chronic nature of the condition and the subsequent studies of the tissue histology suggest that this is not the case and as such Plantar Fasciosis is the more appropriate terminology, given the degenerative findings within the tissue. However, purely for the case of easy reading for our readers who are not medically inclined. Throughout this article plantar fascial injury will be called plantar fasciitis – ENJOY!
The plantar fascia is a flat sheet of thickened, poorly vascularised and poorly innovated, deep fibrous connective tissue of the foot which can measure between 2.2 and 5.4milimetres (Cardina, Chhem, Beauregard, Aubin, & Pelletier, 1996). The broad white longitudinal fibres originated at the medial tuberosity of the calcaneus and insert at the proximal head of the phalanges. Anteriorly, at the metatarsal-phalangeal joints latitudinal connective tissue fibres reinforce the supportive nature of the plantar aponeurosis creating the Transverse Arch of the foot. Similarly, a medial and lateral longitudinal band of connective tissue further support the respective arches while protecting deeper structures of the foot (Brukner, 2013).
The plantar fascia is able to support up to twenty-five percent of the load experienced by the medial longitudinal arch. During dynamic gait the plantar aponeurosis may only elongate up to two percent of its relaxed size however, the stretch tension and isometric contraction which occurs in association with the windlass mechanism acts like a spring moment during propulsion. The windlass mechanism occurs when the first phalangeal dorsiflexes and the metatarsal plantarflexes – stretching the plantar aponeurosis and lifting the medial longitudinal arch height through shortening the distance between the bones of the foot (Michaud, 2011).
Although clinical diagnosis of plantar fasciitis can be made with reasonable certainty through routine assessment, sometimes medical imaging may be deemed appropriate to rule out other potential diagnosis. The common signs and symptoms of plantar fasciitis result in a gradual onset of pain which causes a dull ache or throbbing after long periods of standing or actively moving on cement flooring. A tell-tale sign of the condition is the unmistakable “first step pain” in the morning or after short periods of rest (Dubin & Joshua, 2007)
Biomechanical influences and training error are two of the most common reasons for the development of such a condition. Ankle equinus (restricted ankle joint ROM) as a result of hard or soft tissue can influence the onset of plantar fascial pain by increasing tension within the plantar fascia and achillies tendon causing repetitive trauma. Additionally, the restricted joint ROM can lead to an increase in pronatory forces, lengthening the plantar fascia and leading to micro-trauma.
A sudden increase in training load can lead to not only an increase in frequency of these movements but additional fatigue of the tissues in question, furthering the development of pain (Dubin & Joshua, 2007)
It is stated by (Buchbinder, 2004) that the causes of plantar fasciitis are multifactorial in nature and therefore treatment/management modalities are required to be multifactorial as well. The following treatment modalities are commonly used in the management of plantar fasciitis.
Tissue Specific Stretching
It was found in a prospective randomized study conducted by (DiGiovanni, Nawoczenski, lintal, Murray, Wilding, & Baumhauer, 2003)that tissue specific plantar fascia stretching showed significantly better results when compared to a generalized calves and achillies tendon based stretching regime. Most notable were the decreases in worst pain measured via VAS score with a p-value = 0.02 and first step function and pain with a p-value =0.006. From these results it can be inferred that the use of non-weight bearing stretching exercises specific to the plantar aspect of the foot creates greater pain reduction than a standard weight-bearing achillies tendon stretching program. These findings were further supported in a Ramdomized Study (DiGiovanni B. , et al., 2003)and Clinical Trial with two year follow up by (DiGiovanni B. , et al., 2003) who found that a program of non-weight bearing stretches specific to the foot produced superior results to weight bearing achillies tendon stretching for symptoms of plantar fasciitis.
Strength Training Program
Developing both extrinsic and intrinsic muscle activation, control and strength is important for the aiding of pain reduction and future prevention of such injuries. As mentioned above, common causes of plantar fasciitis are fatigue and tissue stress due to an increased workload. It then makes sense that re-establishing the mind-muscle connection and adequate preparation of these tissues be addressed during the management process.
Extracorporeal Shock Wave Therapy
Chew, Leong, Lin, Lim and Tan established in a 2013 randomized trial that both plasma injection and extracorporeal shockwave therapy combined with conventional treatment created more improved outcomes for patient pain and function when compared with conventional treatment as a standalone. However, no significant difference was found between ESWT and plasma injection (Chew, Leong, Lin, Lim, & Tan, 2013).
In a 2014 randomized control study by (Suleymanoglu, Esmaeilzadeh, Sen, Diracoglu, Yaliman, & Eskiyurt, 2014)comparing radial shock wave therapy and low level laser therapy for chronic plantar fasciitis it was concluded that both RSWT and LLLT were significantly effective in the decrease of thickened plantar fascia immediately after the 3-month assessment p<0.001. The specific modalities mentioned here are not included in the above table due to practitioner cost, invasive nature and the point that this measure was used after a 6 months non response period to conservative interventions.
Offloading Devices and Taping
There is a wide range of prefabricated and custom made offloading devices available to patients who are seeing allied health professionals. When comparing full-length silicone insoles versus ultrasound-guided corticosteroid injection for the management of plantar fasciitis through means of randomized clinical trials, it was found that after one month of treatment both groups had significant improvement of both pain and function related to their foot pain, however those involved in the injection group were found to have statistically significant differences (p<0.005) in VAS, ultra-sonographic thickness of plantar fascia, foot and ankle outcome score for daily living activities and sport and recreation function. However, conclusively it was advised that silicone insoles were used as a first line treatment given the minimally non-invasive nature (Yucel, et al., 2013).
A randomized controlled trial of calcaneal taping, sham taping and plantar fascia stretching in 2006 found a significant difference between calcaneal taping and stretching of the plantar fascia/ sham taping/control in the category of VAS pain (p<0.006) , (p<0.001) and (p<0.001) respectively. Stretching was found to have statistical significance over the control group (p=0.026). It was concluded that calcaneal taping was shown to be more effective as an intervention for plantar heel pain (Hyland, Webber- Gaffney, Cohen, & Lichtman, 2006).
In the event of kinesiology taping for the short term treatment of plantar fasciitis it was found that no significant difference was seen in the either group using kinesiology taping with traditional physical therapy or just traditional physical therapy (Tsai, Chang, & Lee, 2010).
When exploring more invasive treatments plantar fasciotomy with the use of endoscopic or radiofrequency lesioning techniques have been found to be around 70-90% effective, however with any surgical intervention comes risk, in this case both flattening of the medial longitudinal arch and heel hypoesthesia (Davies, Weiss, & Saxby, 1999).
So concludes our article on plantar fascial injury, I hope it has been informative. If you have any question or suggestion, please feel free to comment and I will get back to you as soon as possible.
Until next time,
Brukner, P. (2013). Bruker and Khan’s Clinical Sports Medicine. North Ryde: McGraw-Hill Education Pty Ltd.
Buchbinder, R. (2004, May 20). The New England Journal of Medicine. Plantar Fasciitis. Massachusetts, United States of America.
Cardina, l. E., Chhem, R., Beauregard, C., Aubin, B., & Pelletier, M. (1996). Plantar fasciitis: sonographic evaluation. Radiology, 257- 259.
Chew, K., Leong, D., Lin, C., Lim, K., & Tan, B. (2013). Comparison of Autologous Conditioned Plasma Injection, Extracorporeal Shockwave Therapy and Conventional Treatment for Plantar Fasciitis: A Randomized Trial. PM and R, 1035 – 1043.
Davies, M., Weiss, G., & Saxby, T. (1999). Plantar Fasciitis: How Successful is Surgical Intervention? Foot and Ankle International, 803 – 807.
Department of Physical Therapy, U. o. (2006). Plantar Fascia-Specific Stretching Exercise Improves Outcomes in Patients with Chronic Plantar Fasciitis. The Journal of Bone and Joint Surgery.
DiGiovanni, B., Nawoczenski, D., Lintal, M., Moore, E., Murray, J., Wilding, G., & Baumhauer, J. (2003). Tissue – Specific Plantar Fascia Stretching Exercise Enhances Outcomes In Patients with Chronic Heel Pain. The Journal of Bone and Joint Surgery.
DiGiovanni, B., Nawoczenski, D., lintal, M., Murray, J., Wilding, G., & Baumhauer, J. (2003). Tissue-Specific Plantar Fascia-Stretching Exercise Enhances Outcomes in Patients with Chronic Heel Pain. Journal of Bone and Joint Surgery, 1270-1277.
Dubin, & Joshua. (2007). Evidence Based Treatment for Plantar Fasciitis. Sports Therapy.
Hyland, M., Webber- Gaffney, A., Cohen, L., & Lichtman, P. (2006). Randomized Controlled Trial of Calcaneal Taping, Sham Taping and Plantar Fascia Stretching for the Short-Term Management of Plantar Heel Pain. Journal of Orthopaedic and Sports Physical Therapy, 364 – 371.
Michaud, T. (2011). Human Locomotion: the Conservative Management of Gait-Related Disorders. Newton: Newton Biomechanics.
Suleymanoglu, T., Esmaeilzadeh, S., Sen, E., Diracoglu, D., Yaliman, A., & Eskiyurt, N. (2014). The Effects of Radial Shockwave Therapy and Low Level Laser Therapy in the Treatment of Chronic Plantar Fasciitis: A Random Controlled Study. Annals of the Rheumatic Disease.
Tsai, C., Chang, W., & Lee, J. (2010). Effects of Short Term Treatment with Kinesiotaping for Plantar Fasciitis. Journal of Musculoskeletal Pain, 71 – 80.
Wang, C.-J., Wang, F.-S., Yang, K., Weng, L.-H., & Ko, J.-Y. (2006). Long-Term Results of Extracorporeal Shockwave Treatment for Plantar Fasciitis. The American Journal of Sports Medicine, 592 – 596.
Yucel, U., Kucuksen, S., Cingoz, H., Anliacik, E., Ozbek, O., Salli, A., & Ugurlu, H. (2013). Full-Length Silicone Insoles Versus Ultrasound-Guided Cortisone Injection in the Management of Plantar Fasciitis: A Randomized Clinical Trial. Prosthetics and Orthotics International, 471 – 476.