PLANTAR FASCIITIS

Figure 4: Demonstration of application of pressure to the plantar fascia

Figure 5: Application of pressure while maintain- ing 1st toe extension

Figure 6: Use of a tubi grip to maintain toe extension

Figure 7: Creating a stretch

application eg. 1st toe extension, ankle dorsiflexion. The position can then become functional and mobilisations applied in a weight bearing position. Home mobilisa- tions can be performed by the patient using a rolling pin or an ice tube (water frozen in a beaker). These can be pro- gressed using an elastic bandage or band to maintain toe extension (see figure 6). Patients find these useful before rising in the morning to alleviate the initial pain on weight bearing.

Ankle range of movement, especially dorsiflexion It is important to ensure no pronation of the foot occurs as you reach end of range as this will give a false value. Moderate soft tissue resistance is to be expected. Flex the knee to differentiate between gastrocne- mius and soleus. If restricted, local soft tissue mobilisations can be applied and home stretching using a board elevated to a maximum of 15 degrees (Figure 7). Elevate the board until a moderate stretch is felt and maintain this for 2 minutes. It is important to instruct the patient to maintain their arch and not to ‘cheat’ and fall into pronation. This can be done will brushing their teeth.

Differential diagnosis of masquerading conditions previously discussed Appropriate palpation will assist in elimi- nating the aforementioned conditions. It must be remembered that pathologies can co exist and re-examination and reassess- ment is vital at every stage of the treat- ment process.

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Figure 8: Extension of the 1st MTP

Examination of local nerve mobility and entrapment via straight leg raises/slump test with sensitising manoeuvres and palpation. These will assist in highlighting the tibial nerve as a source of symptoms or a contributing factor. Restrictions can then be mobilised locally at neural interfaces (11) or through functional movements such as the slump with dorsiflexion of the foot (10). Symptoms are reproduced, held for 4 seconds and then released, this is repeated 10 times twice a day (10). Reassessment is vital to establish improvement and if nec- essary frequency and intensity can be increased or decreased.

Local foot biomechanics and 1st ray movement and function (during their chosen activity) The extensibility of the 1st MTP joint needs to be established in both a non weight bearing and weight bearing position (see figures 8 and 9). Ideally this should be at least 65 degrees. Restrictions may cause altered biomechanics during gait and run- ning altering loading on the plantar fascia. Reasons for restrictions may relate to local biomechanics impeding 1st ray function or soft tissue restrictions. Consultation with a podiatrist is recommended.

Proximal pelvic and lower limb strength and control (ideally using video analysis) Examination of length and strength of the key muscle groups affecting lower limb alignment is vital. These groups include the gluteus maximus, the gluteus medius, the tensor fascia latae, the hamstrings, the rec- tus femoris, the gastrocnemius, the soleus,

Figure 9: Extension of the 1st MTP in standing

the tibialis posterior and the long toe flex- ors. Length tests and strength test are ade- quately described elsewhere (24). These also need to be considered during func- tional tasks and after repeated perfor- mance of the task as fatigue may be an issue. Strength training needs be lower repetitions and higher resistance (6-8RM) repeated 2-3 times a week. Endurance lev- els required will vary depending on the chosen activity.

Technique during task performance Examination of technique of task being performed is vital. Faulty technique may lead to altered alignment of the lower limb and excessive loading on the plantar fas- cia. Advice from a coach or trainer may prove invaluable to adjust technique or tai- lor exercises to be most appropriate and ultimately effective.

OTHER TREATMENT MODALITIES Taping Taping may also prove useful in the short term to offload the plantar fascia. Low dye taping has proven to be effective in reduc- ing symptoms both whilst applied and post removal (25). Long term use may be impractical and adjustments in foot wear and possibly orthotics may provide better ongoing solutions.

Foot wear modification Good quality foot wear is essential during athletic activity, poor foot wear may pro- vide inadequate support and may have some impact on presentation. Consultation with a podiatrist may be necessary to iden-

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