REHABILITATION
pad is vital (see figure 3). Treat as a local soft tissue injury and address aggravating activities and contributing factors.
Peripheral neurogenic pain relating to the tibial nerve Peripheral neurogenic pain relates to pain caused by trauma or compression of the peripheral nerves. A critical zone for com- pression of the tibial nerve exists at the medial side of the calcaneum at the tarsal tunnel (10). This soon divides and detailed descriptions of the critital zones for the medial and lateral plantar nerves are given by Meyer (10). The medial calcaneal nerve pierces the flexor retinaculum medially and needs to be eliminated through palpation. Compression of any of these can cause heel or plantar foot pain. Palpation of these nerves is possible in conjunction with appropriate neurodynamics tests for the posterior tibial nerve (11). Conservative treatment includes activity modification, addressing biomechanical factors, soft tis- sue mobilisations at critical zones and neural mobilisations (10). Surgery may need to be considered in recalcitrant cases.
Trigger points Trigger points are focal, hyperirritable
points located in a taut band of skeletal muscle. They produce local pain and may refer in a given pattern (12). Trigger points which may mimic plantar fasciitis can be found in the gastrocnemius, soleus and flexor accessories (13). Treatments are numerous and include acupressure, myofascial release or acupuncture (14).
While this list is not exhaustive it provides a vital outline of other diagnoses which need to be considered when assessing an individual with plantar heel pain.
HISTOLOGICAL FINDINGS The name plantar fasciitis suggests pain as a result of inflammation. However, similar to recent histological findings in the achilles tendon (15), no evidence of inflammation has been found during surgi- cal exploration (16). Furthermore previous evidence demonstrating inflammation is questioned (16) as can be management guidelines (17). A key anti-inflammatory treatment is corticosteroid injections which have been strongly associated with plantar fascia ruptures (18). Acebedo and Betts (18) found that 88% of those with a ruptured plantar fascia had received corti- costeroid injections. Based on this
BOX 1: EXAMINATION AND TREATMENT
Subjective examination - a summary of key points 1. History of onset 2. Aggravating and easing factors 3. Current and previous training levels including duration, frequency and terrain 4. Full history and examination of footwear used 5. Completed body chart to highlighted associated sites of possible referral 6. Full medical history to rule out systemic disease/nutritional deficiencies 7. Previous history of injury and treatment 8. Current training aims/competitive commitments
The physical examination serves to highlight the current state of the tissue and intrin- sic and task performance factors which may have lead to the development of symptoms.
Physical examination 1. Plantar fascia accessory movement (19) 2. Ankle range of movement, especially dorsiflexion (6) 3. Differential diagnosis of masquerading conditions previously discussed 4. Examination of local nerve mobility and entrapment via straight leg raises/slump with sensitising manoeuvres and palpation (10) 5. Local foot biomechanics and 1st ray movement and function (during their chosen activity) 6. Proximal pelvic and lower limb strength and control (ideally using video analysis) 7. Technique during task performance
Each of these will now be discussed as they form a key part of treatment if found to be positive or faulty.
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premise, current rehabilitation regimes directed towards an inflammatory process need to be viewed critically.
REHABILITATION To align with convention the term plantar fasciitis will continue to be used. However the author is aware this is likely to change as complimentary findings are published to support the degenerative aetiology, and the term plantar fasciosis may well become the accepted description. A rehabilitation programme needs to take into account both intrinsic and extrinsic factors which may have contributed to degradation of the plantar fascia. To date, the theory of degeneration is in its infancy and research is incomplete, hence the suggestions made regarding treatment rely on current para- digms, experience and research. The aim of the examination is to establish informa- tion in all the clinical reasoning categories suggested by Jones (23). A complete picture as to why symptoms have occurred based on intrinsic and extrinsic factors and task performance can then be determined and a treatment rationale established (19).
PHYSICAL EXAMINATION Plantar fascia accessory movement Physiological-specific soft tissue mobilisa- tions proposed by Hunter (19) are used to examine tissue for its ability to physiolog- ically lengthen in all directions under manual pressure. The plantar fascia is tensioned by forces applied in a medial, lateral, posteroanterior, superior and inferior direction (see figure 4). This is repeated with the 1st toe extended (see figure 5) which further tensions the plan- tar fascia. Comparison is always made to ‘normal’ and the contralateral limb.
This highlights symptomatic areas in the tissue. These can then be ‘stressed’ through graded sustained pressure with slow oscillations mobilising the site of restriction or pain reproduction. The aim of applied pressures is to promote tissue adaptation to load and a normal healing process (19). It is suggested that pain is used to guide the magnitude of force application as no normal values have yet been established. Duration of forces appli- cation is suggested to be 30-60 seconds, 5 times and repeated at least three times a day. As symptoms decrease with simple pressure, treatment is progressed and additional stresses are added prior to force
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