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Etiology Pathophysiology Medical Management

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1 Etiology Pathophysiology Medical Management
Plantar Fasciitis Etiology Pathophysiology Medical Management Joshua Griffith 7/10/2014

2 Anatomy The plantar fascia is a thickened fibrous aponeurosis that originates from the medial tubercle of the calcaneus, runs forward to insert into the deep, short transverse ligaments of the metatarsal heads, dividing into 5 digital bands at the metatarsophalangeal joints and continuing forward to form the fibrous flexor sheathes on the plantar aspect of the toes. Small plantar nerves are invested in and around the plantar fascia, acting to register and mediate pain.

3 Anatomy The plantar fascia is made up of 3 distinct parts: the medial, central, and lateral bands. The central plantar fascia is the thickest and strongest section, and this segment is also the most likely to be involved with plantar fasciitis. In normal circumstances, the plantar fascia acts like a windlass mechanism to provide tension and support through the arch. It functions as a tension bridge in the foot, providing both static support and dynamic shock absorption.

4 What is Plantar Fasciitis?
Plantar fasciitis (PLAN-tur fas-e-I-tis) is one of the most common causes of heel pain. It involves pain and inflammation of a thick band of tissue, called the plantar fascia, that runs across the bottom of your foot and connects your heel bone to your toes. Plantar fasciitis commonly causes stabbing pain that usually occurs with your very first steps in the morning. Once your foot limbers up, the pain of plantar fasciitis normally decreases, but it may return after long periods of standing or after getting up from a seated position.

5 Etiology The cause of plantar fasciitis is often unclear and may be multifactorial. Because of the high incidence in runners, it is best postulated to be caused by repetitive microtrauma. Possible risk factors include obesity, occupations requiring prolonged standing and weight-bearing, and heel spurs. Other risk factors may be broadly classified as either extrinsic (training errors and equipment) or intrinsic (functional, structural, or degenerative). Extrinsic risk factors Training errors are among the major causes of plantar fasciitis. Athletes 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 the development of plantar fasciitis. Running indoors on poorly cushioned surfaces is also a risk factor.

6 Etiology Appropriate equipment is important. Athletes and others who spend prolonged time on their feet should wear an appropriate shoe type for their foot type and activity (see Treatment).Athletic shoes rapidly lose cushioning properties. Athletes who use shoe-sole repair materials are especially at risk if they do not change shoes often. Athletes who train in lightweight and minimally cushioned shoes (instead of heavier training flats) are also at higher risk of developing plantar fasciitis.

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

8 Etiology 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. As regards 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 this condition.[17] Weakness of the gastrocnemius, soleus, and intrinsic foot muscles is also considered a risk factor for plantar fasciitis. Aging and heel fat pad atrophy are 2 degenerative risk factors for plantar fasciitis

9 Symptoms Plantar fasciitis typically causes a stabbing pain in the bottom of your foot near the heel. The pain is usually worst with the first few steps after awakening, although it can also be triggered by long periods of standing or getting up from a seated position.

10 Causes Under normal circumstances, your plantar fascia acts like a shock-absorbing bowstring, supporting the arch in your foot. If tension on that bowstring becomes too great, it can create small tears in the fascia. Repetitive stretching and tearing can cause the fascia to become irritated or inflamed.

11 Risk Factor Factors that may increase your risk of developing plantar fasciitis include: Age. Plantar fasciitis is most common between the ages of 40 and 60. Certain types of exercise. Activities that place a lot of stress on your heel and attached tissue — such as long-distance running, ballet dancing and dance aerobics — can contribute to an earlier onset of plantar fasciitis. Faulty foot mechanics. Being flat-footed, having a high arch or even having an abnormal pattern of walking can adversely affect the way weight is distributed when you're standing and put added stress on the plantar fascia. Obesity. Excess pounds put extra stress on your plantar fascia. Occupations that keep you on your feet. Factory workers, teachers and others who spend most of their work hours walking or standing on hard surfaces can damage their plantar fascia.

12 Test and Diagnosis During the physical exam, your doctor checks for points of tenderness in your foot. The location of your pain can help determine its cause. Imaging tests Usually no tests are necessary. The diagnosis is made based on the history and physical examination. Occasionally your doctor may suggest an X-ray or magnetic resonance imaging (MRI) to make sure your pain isn't being caused by another problem, such as a stress fracture or a pinched nerve. Sometimes an X-ray shows a spur of bone projecting forward from the heel bone. In the past, these bone spurs were often blamed for heel pain and removed surgically. But many people who have bone spurs on their heels have no heel pain.

13 Medical Management Medications
Pain relievers such as ibuprofen (Advil, Motrin IB, others) and naproxen (Aleve) may ease the pain and inflammation associated with plantar fasciitis. Therapies Stretching and strengthening exercises or use of specialized devices may provide symptom relief. These include: Physical therapy. A physical therapist can instruct you in a series of exercises to stretch the plantar fascia and Achilles tendon and to strengthen lower leg muscles, which stabilize your ankle and heel. A therapist may also teach you to apply athletic taping to support the bottom of your foot. Night splints. Your physical therapist or doctor may recommend wearing a splint that stretches your calf and the arch of your foot while you sleep. This holds the plantar fascia and Achilles tendon in a lengthened position overnight and facilitates stretching. Orthotics. Your doctor may prescribe off-the-shelf heel cups, cushions or custom-fitted arch supports (orthotics) to help distribute pressure to your feet more evenly.

14 Medical Management Surgical or other procedures
When more-conservative measures aren't working, your doctor might recommend: Steroid shots. Injecting a type of steroid medication into the tender area can provide temporary pain relief. Multiple injections aren't recommended because they can weaken your plantar fascia and possibly cause it to rupture, as well as shrink the fat pad covering your heel bone. Extracorporeal shock wave therapy. In this procedure, sound waves are directed at the area of heel pain to stimulate healing. It's usually used for chronic plantar fasciitis that hasn't responded to more-conservative treatments. This procedure may cause bruises, swelling, pain, numbness or tingling and has not been shown to be consistently effective. Surgery. Few people need surgery to detach the plantar fascia from the heel bone. It's generally an option only when the pain is severe and all else fails. Side effects include a weakening of the arch in your foot.

15 Medical Management The aims of plantar fasciitis rehabilitation are to decrease pain and inflammation, improve flexibility and strength then gradually return to full fitness. Any biomechanical problems of the foot must also be looked at to avoid plantar fasciitis recurring in the future.

16 Pathophysiology Biomechanical dysfunction of the foot is the most common etiology of plantar fasciitis; however, infectious, neoplastic, arthritic, neurologic, traumatic, and other systemic conditions can prove causative. The pathology is traditionally believed to be secondary to the development of microtrauma (microtears), with resulting damage at the calcaneal-fascial interface secondary to repetitive stressing of the arch with weight bearing.[8, 9, 10] Excessive stretching of the plantar fascia can result in microtrauma of this structure either along its course or where it inserts onto the medial calcaneal tuberosity. This microtrauma, if repetitive, can result in chronic degeneration of the plantar fascia fibers. The loading of the degenerative and healing tissue at the plantar fascia may cause significant plantar pain, particularly with the first few steps after sleep or other periods of inactivity.

17 Pathophysiology The term fasciitis may, in fact, be something of a misnomer, because the disease is actually a degenerative process that occurs with or without inflammatory changes, which may include fibroblastic proliferation. This has been proven from biopsies of fascia from people undergoing surgery for plantar fascia release. Studies have introduced the etiologic concept of fasciosis as the inciting pathology. Fasciosis, like tendinosis, is defined as a chronic degenerative condition that is characterized histologically by fibroblastic hypertrophy, absence of inflammatory cells, disorganized collagen, and chaotic vascular hyperplasia with zones of avascularity.[11, 12, 13, 14]

18 Pathophysiology These changes suggest a noninflammatory condition and dysfunctional vasculature. With reduced vascularity and a compromise in nutritional blood flow through the impaired fascia, it becomes difficult for cells to synthesize the extracellular matrix necessary for repairing and remodeling.[15] Biomechanics of running During running, the vertical forces in the foot at foot strike may reach 2-3 times an individual’s body weight.[16] The plantar fascia and longitudinal arch are also part of the foot’s shock absorption mechanism. During the heel-off phase of gait, tension increases on the plantar fascia, which acts as a storage of potential energy. During toe-off, the plantar fascia passively contracts, converting the potential energy into kinetic energy and imparting greater foot acceleration

19 Lifestyle and Home Remedies
To reduce the pain of plantar fasciitis, try these self-care tips: Maintain a healthy weight.This minimizes the stress on your plantar fascia. Choose supportive shoes. Avoid high heels. Buy shoes with a low to moderate heel, good arch support and shock absorbency. Don't go barefoot, especially on hard surfaces. Don't wear worn-out athletic shoes. Replace your old athletic shoes before they stop supporting and cushioning your feet. If you're a runner, buy new shoes after about 500 miles of use. Change your sport. Try a low-impact sport, such as swimming or bicycling, instead of walking or jogging. Apply ice. Hold a cloth-covered ice pack over the area of pain for 15 to 20 minutes three or four times a day or after activity. Or try ice massage. Freeze a water-filled paper cup and roll it over the site of discomfort for about five to seven minutes. Regular ice massage can help reduce pain and inflammation. Stretch your arches. Simple home exercises can stretch your plantar fascia, Achilles tendon and calf muscles.

20 Patient Education Patients should be informed that improvement often takes many weeks or months and requires considerable effort to maintain a heel-cord stretching program or to wear a night splint. They should also be taught proper performance of a home exercise program involving stretching the plantar fascia. The following recommendations are appropriate: Wear shoes with adequate arch support and cushioned heels; discard old running shoes and wear new ones; rotate work shoes daily Avoid long periods of standing Lose weight

21 Patient Education Stretch the plantar fascia and warm up the lower extremity before participating in exercise For increased flexibility, stretch the plantar fascia and the calf after exercise Do not exercise on hard surfaces Avoid walking barefooted on hard surfaces Avoid high-impact sports that require a great deal of jumping (eg, aerobics and volleyball) Apply ice for 20 minutes after repetitive impact-loading activities and at the end of the day Limit repetitive impact-loading activities such as running to every other day, and consider rest or cross-training for nonrunning days

22 References

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