PLANTAR FASCIITIS PLANTAR FASCIITIS By Chris Murphy, MCSP

PRESENTATION The primary complaint in plantar fasciitis is pain at its origin on the medial tubercle on the calcaneum which can radiate along the plantar aponeurosis (see figure 1). This is most notable when weight bearing after rest, especially in the morning, symptoms often then ease but increase throughout the day and with increased or prolonged activity (2,5).

FUNCTION OF THE PLANTAR FASCIA The plantar fascia’s key role in foot func- tion is via the Windlass Effect (23) (see fig- ure 2). It attaches distally to the sesamoid bones and the base of the five proximal phalanges, and as the 1st metatarsal pha- langeal (MTP) joint extends with toe off, the calcaneus is drawn towards the toe shortening and supinating the foot. This provides a rigid base on which to push off. The plantar fascia is then tensioned again after heel strike as the arch lowers during pronation. Despite current controversy regarding a working model for foot func- tion, the importance of 1st ray function (1st metatarsal and medial cuneiform) and plantar fascia function is imperative (23).

AETIOLOGICAL FINDINGS The aetiology of plantar fasciitis is likely to be multifactoral and at present is poorly understood (6). Two recent reviews, one systematic (6) and one critical (4), noted a considerable paucity in the literature sup- porting the commonly proposed aetiologi- cal factors for chronic plantar heel pain (CPHP) and plantar fasciitis. In an athletic population no association was found for body mass index, height or weight (6). There was some evidence to suggest an

Plantar fasciitis is an extremely commonly encountered condition estimated to account for 5 to 14% of running injuries in the US (1). It must be remembered that there are multiple pathologies which could mimic true plantar fasciitis, and these will be discussed in the article. As a condition it affects both young and old, sporting and non-sporting populations and is not gender specific (2). Controversy surrounds suggested aetiological factors and treatment (3,4). Differential diag- nosis and histological findings will also be discussed, in conjunction with a sum- mary of the literature to date. Key examination factors will be highlighted and treatment suggestions made. Finally additional components of treatment will be noted and contextualised.

increased likelihood of developing CPHP with a progressive reduction in range of dorsiflexion. Those with less than 0 degrees dorsiflexion were 23 times more likely to have plantar pain (6). In addition a reduced range of 1st toe extension was noted in those with CPHP. While excessive pronation is commonly associated with plantar fasciitis (7), evidence supporting this as causal is limited (4).

DIFFERENTIAL DIAGNOSIS A key to effective rehabilitation in plantar fasciitis is accurate diagnosis. As such, a short discussion of other possible diag- noses is presented. No reference will be made to referred or systemic conditions which may mimic plantar heel pain.

The main alternative local diagnoses for chronic plantar heel pain are: 1. tibialis posterior syndrome 2. calcaneal/navicular stress fracture 3. fat pad injury 4. peripheral neurogenic pain relating to the tibial nerve 5. trigger point pain

Tibialis posterior syndrome Dysfunction of the tibialis posterior tendon is a common cause of plantar foot pain

(8,9). Symptoms include medial foot and ankle pain and pain in the medial arch. Palpation of the plantar fascia may be ten- der but needs to be compared to the asymptomatic side. Reduced inversion of the calcaneum during a heel raise is a sign of weakness of the tibialis posterior. The medial border of the calf is frequently ten- der and may reproduce plantar heel pain. See alternative texts for a comprehensive review of examination and treatment (8,9).

CALCANEAL/NAVICULAR STRESS FRACTURE Often related to increased activity, acute localised tenderness may be found over the origin of the plantar fascia but the reader is encouraged to explore the rest of the calcaneum and navicular. The calcaneum is frequently tender when squeezed simulta- neously medially and laterally and the navicular on direct palpation. A bone scan is the investigation of choice in both cases (7). Treatment is often immobilisation followed by mobilisation and graded rehabilitation.

Fat pad injury Onset of heel pain may be acute or insidi- ous and related to trauma or poor heel cushioning (7). Palpation of the entire fat

Plantar aponeurosis

Figure 1: A picture of the plantar fascia showing its origin and insertion (labelled)

14 Figure 2: The Windlass effect

Calcaneal fat pad Figure 3: Calcaneal fat pad www.sportex.net