Plantar fasciitis (Heel Pain)

Plantar fasciitis (Heel Pain)

Is the inflammation of the plantar fascia caused due to repetitive stress applied to it.

It is usually common in active individual, obese, runners or athletes, people who spend most of their day on foot.

The pain is usually characterized by piercing or searing type of heel pain that appears in the first few steps in the morning or after a period of inactivity.

Patient may present with tenderness around the medial calcaneal tuberosity at the plantar aponeurosis.

Pain increases when walking barefoot on toes or while climbing stairs.

Patho-physiology

As the term implies plantar fasciitis is the inflammation of the plantar fascia however in all the samples reviewed there is no evidence of inflammation histologically.

However research shows that plantar fascia is a degenerative condition, hence it is better to be  called “fasciosis” than fasciitis.¹

Biomechanics of the foot during gait

There are 6 phases of gait cycle : heel contact, weight acceptance, mid stance, push off , propulsion and toe off phase. Foot goes for supination during heel contact phase followed by pronation in weight acceptance phase, in order to maintain contact with the surface. From the mid stance to the toe off phase the foot goes for supination thus making the foot as a rigid lever which is necessary for the propulsion of the foot.

Plantar fascia plays a very important role in maintaining this arch during the gait cycle of the foot. Because if plantar fascia fails to work effectively the medial arch arch would disrupt and the force required to control supination and pronation would be altered. Hence plantar fascia plays a very important role in control of supination and pronation of the foot during gait cycle.

Evidence based therapy for plantar fasciitis

• Cryotherapy or NSAIDS – Not much effective in the treatment of plantar fascia, however it provides only temporary pain relief.
•  Taping – No studies have proved the effectiveness of taping.
•  Shoe inserts-  a study was done to compare the effectiveness of the custom made orthotics and prefabricated shoe inserts with stretching. It was found that prefabricated shoe inserts with stretching showed more effect than custom made orthotics.
•  Stretching – A study shows plantar fascia stretch alone more effective than combined stretch of calf muscle and Achilles tendon.
•  Night splints – limited evidence suggesting the effectiveness of night splints.
•  Extra-corporeal shock-wave therapy – No evidence supporting the effectiveness of Extra-corporeal shock wave therapy for reducing night pain and resting pain in short term.
• Corticosteroid injection – According to Cochraine review Steroid iontophersis injecton improved only short term outcomes.²

As mentioned earlier the arch of the foot is very important to maintain stability on the surface when walking or standing. Overpronation or underpronation can have direct influence on the effective working of plantar fascia.

Overpronated foot

Overpronation of the foot is caused due to muscle weakness, tightness in the heel cord and abnormal structure of the foot. Proximal muscles such as gluteus medius, gluteus minimus, tensor fascia latae or quadriceps can contribute to the pronation of the foot. These proximal muscles help in assisting lower extremity response during gait, hence weakness of these muscles will transmit greater shock to the supporting foot structures and decreased pronation control.

Heel cord assist in dorsiflexion of the foot during gait, hence tightness in the heel cord limits the ability to dorsiflex the ankle at heel strike phase of the gait thus making the foot to over pronate more at the midtarsal joints in order to make contact with the surface of the ground.

Structural deformities include excessive sub-talar or forefoot varus.

Treatments for overpronated foot include strengthening of the weak muscles, stretching of the calf muscles, and using appropriate shoes with sufficient toe box and firm ankle grip to control the movement of the ankle within the shoes. Insoles made of polyurethane and ethyl vinyl acetate also enhances shoe support.³

Underpronated foot (Supination)

Supinated foot which is caused due to factors such as increased muscle tightness, decreased mobility within the joints and decreased plantar fascia extensibility.

Highy arched or cavus foot will have limited joint mobility to distribute the force during weight acceptance phase. Hence when foot does not pronate during weight acceptance phase, it indirectly applies a lot of tension force to  the insertion of plantar fascia at the medial tubercle of calcaneum.

Treatment for supinated foot include Stretching of calf muscles, mobilization of joints and increase plantar fascia extensibility. Appropriate shoe wear with ethyl vinyl acetate midsole provides appropriate space for the rearfoot and forefoot to move , offers much shock absorption.

Silicone heel pad can further enhance shock absorption.³

By Dr. Liana Thomas (PT)

Reference –

1. Plantar fasciitis  A degenerative process without Inflammation (Harvey Lemont et al.)
2. Plantar fasciitis (Charles Cole, Craig Seto et al.)
3. Plantar faciitis and the Windlass mechanism : A Biomechanical Link to clinical practice (Lori   A. Bolgia et al. )

SUCCESS STORY OF FLAT FEET WITH POSTERIOR TIBIAL TENDON DYSFUNCTION

CASE STUDY: FLAT FEET WITH POSTERIOR TIBIALTENDON DYSFUNCTION (PTTD)

41 year old female complaints pain & swelling at inner side of left ankle since a year. Pain was gradually increased. Initially it use to hurt on prolong standing & walking eventually pain got worst. Now not even able walk few steps also.

On Examination:

• Swelling was present around left navicular area
• Grade III tenderness at the navicular area

Biomechanical Assessment:
Static-

• Clawing of toes left side
• Medial Arch- Flat Bilaterlly (Flat Feet)
• Transvrse arch reduced
• Subtalar joint- Overpronation bilatrally more on lfert side
   
• Navicular drop- Present bilaterally
• Navicular drift- Present bilaterally
• Calcaneum (Posterior view)- Eversion bilaterally more on left side
• Knee- Valgus

Gait Assessment:

• Gait Pattern- Poor heel to pattern
• Heel Strike- Medial heel strike
• Stance Phase- Overpronation at the sub-talar joint bilaterally
• Limp on left side

Treatment & Advice:
Advice-

Bio-Advance

• Complete rest for one week with cold pack 4 time a day over affected area for 20 min. each time.

Orthotic correction to improve lower limb biomechnical alignment-

• Advised to wear sport shoes (Even indoor) with firm heel counter (Stable Shoes) few days as concidering her pain & sevirity of flat feet.
• Prescribed Bio-Advanced medium density orthotic insole in her shoes & also to reduce stress on Tibialis posterior muscle tendon.

1st Follow up after two week

• Demarkeble changes seen. More than 50% of pain was reduced.
• Added correction in orthotics to further enhance arch support.
• Advised to continue with cold pack. 

2 nd Follow up after one month

Strive

• This time 90% pain reduced.
• Now slight discomfirt only after long stand or walk.
• Adviced Strive orthotic footwear for short distance (Near by) & continue the sports shoes for out door.
• Exercises for strengthening tibialis posterior muscle.

3rd Follow up after 2 months
No pain & Adviced to continue with orthotics

Feedback of Patient's husband

Feedback

HOW PODIATRY: AN INNOVATIVE SOLUTION TO ANKLE, FOOT AND LOWER LIMB PROBLEMS

Podiatry must definitely be a new word for many people among us. But before we get into the details of Podiatry, let's answer the question that why is there a need to gain knowledge about foot or problem related to it ??? As we have commonly known that while constructing any structure it is essential for the basement to be strong and sturdy. Taking this fact into consideration, we infer that when it comes to the Human body, the Foot is that important base which is needed to perform the human functions of mobility and stability. There are 26 bones, 33 Joints, 107 Ligament & 19 Muscles which are intricately connected to each other to complete the anatomy of foot.  Hence, if the alignment of the base i.e. the foot is affected it will have repercussion that will affect our postural alignment. But unfortunately, most often, this amazing structure is neglected & not given the care & attention it needs.

Standing and walking are integral part of our daily routine. However, people do not give heed to foot problems until it hampers their standing or walking routine severely. This is the fundamental reason foot problems are not easily treated and hence are ignored. However, ignorance is not always bliss. Since our feet & the ability to move is what demarcates the difference between INDEPENDENCE & DEPENDENCE.

Podiatrist is a doctor who specialized in treating conditions related to foot, ankle and lower limb. Consequently, the medical science of diagnosis and treatment of foot, ankle and lower limb related problems called Podiatry. Although still an alien term, Podiatry has been in practice since early 1900s in America, Australia & Europe.

FOOT SCREENING

Now that we are acquainted to & agree on the importance of foot. Let’s get an insight on some common signs which will help you to identify any foot related problem and screen yourself. So you can check for yourself for following signs.

Other Toes

Great Toe Deviation (Bunion)

Flat Feet

Corn & Callus

Heel

Shoe Wear Out

LOW BACK PAIN AND KNEE PAIN

 

The human musculoskeletal system can be considered facsimile to a chain link. If the position of any one end is changed or if anyone links, is broken, then it will damage the entire chain link.  Thus, altered foot alignment can result in knee pain & back pain. Therefore, there is an interconnectivity between the foot, knee and spine.

DIABETES

 

Diabetes is a multi system metabolic disorder which even has its implications on the normal functioning of foot. However, the treatment of foot complications related to diabetes is an entirely different domain (elaborated in previous article)

    It causes two major problems in feet

• Poor blood flow (PVD)
• Damaged nerves (Diabetic Neuropathy)

WHAT DO YOU DO NOW?

In case you have incurred any of the above enlisted problems, who do you approach for the same. The answer is a Podiatrist.

HOW DOES IT WORK?

Before starting the treatment it is essential to identify the root cause, which can only be known after a thorough assessment. This assessment involves the following-

•       Understanding the patient’s complaints & lifestyle.

•       Visual inspection of FEET- Skin Condition, Colour, Corn/Callus/Ulcer

•       Foot Alignment & Posture.

•       Gait Analysis.

•       Foot sensation.

•       Measure foot size- Length & width.

•       Inspection of the patient’s footwear.

THE INNOVATIVE SOLUTION

Once you understand the main reason of the problem, Podiatry line of treatment includes following-

1. Shoes: Appropriate shoes as per patients problem &  lifestyle demand, Doctor will guide you about sports shoe specifications, size & other details.
2. Prescribe corrective Orthotics:

The main solution is corrective Orthotics (also known as insoles). Use of such orthotics helps re-align the body in a corrected posture & thus provides a long-term solution without any side effects.

COMMON FOOT RELATED CONDITIONS WHERE PODIATRY CAN HELP:

Flat Feet Plantarfascitis/Calcaneal spur(Heel Pain) Calcaneal Apophyasitis High Arch Bunion Metatarsalgia Morton’s Neuroma Hammer toes

Ankle sprain Achilles Tendinitis Posterior Tibialis Tendon Dysfuncion Knee pain Back Pain, Leg length Discrapancy Accessory Navicular Bone Corn & Calluses Diabetic Neuropathy

Metatarsalgia

METATARSALGIA

 Metatarsalgia is described as excessive pain which occurs over the toes & forefoot.
Most commonly, the first metatarsal head is affected- the ball of the foot just behind the big toe. In the foot there are small toe nerves between the metatarsal bones. When the head of one metatarsal bone is pressed against another, the small nerve is caught between them & start to become inflamed, thus causing metatarsalgia.

These can cause metatarsalgia or Contribute:

• Ill fitting footwears- Footwears that is tight around the toes or has high heels that can add pressure on the ball of the foot as it is forced into tight space.
• Overweight- Overweight people may suffer this pain as the excess weight can strain on the foot.
• Age- As a person ages several degenerative changes occur in the body, one such is reduced shock absorption. Metatarsalgia can subsequently develop as the foot has less protection from the strain of impact & load.
• High Impact Exercise- People who run or play high impact sport are at risk of metatarsalgia. When we running our feet absorb large amounts of force.
  

• Shapes of the foot & toes- Having a high arch in your foot or a second toe longer than the big toe can add to the pressure on the metatarsals.
• Stress fractures- These are small breaks in the toe bones or metatarsals. They can cause pain when weight is put on the foot- the individual compensates by changing the way they put weight on his/her foot.

Medical conditions that can cause Metatarsalgia:

• Bunion- this is a painful swollen bump that occurs at the base of the big toe.
• Rheumatoid Arthritis- swelled joints in the foot can cause metatarsalgia.
• Morton's Neuroma- is entrapment & irritation of the inter digital nerve which passes between 3rd & 4th metatarsal bones.
• Diabetes- the small nerves in the foot can become irritated, thus causing metatarsalgia. 

Common symptoms of metatarsalgia:

• A burning pain
• Sharp aching
• Pain in the ball of the foot.
• Pain increases when walk bare feet.
• Pain that worsens when standing or moving around but decreases at rest.

Treatment:

• Apply ice pack to the area approximately 15-20 minutes 2-3 times a day. Wrap ice in something to protect your skin from direct contact to ice.
• Avoid high impact sports & exercise that puts pressure on the feet. Try something lighter on the feet i.e. Cycling or swimming.
• Try to keep pressure off the feet, when resting try putting your feet up.
• Be sure to exercise your ankle & keep stretching the Achilles tendon.
• Use fitted insoles (Orthotics) as these will reallocate pressure or reduce pressure, improve foot function & guard the ball your foot.
• Change to better fitting flat headed shoes.

Success Story of Metatarsalgia Click here- http://vcarerehab.blogspot.com/2018/03/success-story-of-metatarsalgia.html

Diabetic Foot & Podiatry

Active Lifestyle

India is becoming the "Diabetes capital of the world". Currently, the number of diabetic patients in India is around 40.9 million & is expected to rise to 69.9 million by 2025. The effect of diabetes on the heart, kidney & eyes is very well known. 

So the aware population tries to adopt an active lifestyle. But they are unaware of the fact that diabetes can even affect their feet. This un-noticed complication is known as Diabetic Neuropathy, which can turn to be the biggest barrier to achieving an active lifestyle. 60 - 70 %  of those with diabetes develop peripheral neuropathy. 20% of those develop a foot ulcer.

Every 20 seconds, a limb is lost as a consequence of diabetes.

How Diabetes can hurt your feet...?

Diabetes causes two problems that can hurt your feet.

DIABETIC NEUROPATHY

With damaged nerves, you might not feel pain, heat, or cold in your legs & feet. A sore or cut on your foot may get worse because you do not know it is there.

SYMPTOMS:

• Burning, tingling sensations (worst in night).
• Numbness or insensitivity to pain or temperature.
• Extreme sensitivity to touch, even light touch.
• Sharp pain sensation & cramps.
• Loss of balance & coordination.

PERIPHERAL VASCULAR DISEASE (P.V.D.)
The second problem happens when not enough blood flow makes it hard for a sore or infection to heal.

SYMPTOMS:

• Numbness & swelling in feet.
• Coldness of legs.
• Heaviness in legs or cramps, usually more at night.



Vicious Circle of Diabetes

• Discoloration of skin.

These two problems can work together to cause a foot problem. While standing & walking certain areas of the foot are subjected to excessive pressure called "PRESSURE AREAS". These areas are prone to ulceration. Once the ulcer is developed, it causes a restriction in mobility & results in an increased sugar level. A person is trapped in a vicious circle.

WHAT IS THE SOLUTION...?

All these complications can be prevented & treated with the patient's education & the help of "Podiatry Doctor"(Foot Doctor).

Podiatry

Interventions

"Podiatry is a branch of medicine devoted to the study of diagnosis & treatment of disorders of the foot, ankle & lower limb." 

Podiatrist's aim is to improve mobility & quality of life, by following ways:

Conducting a thorough clinical evaluation of foot & lower limb.

Gait Analysis.

Foot health education regarding self-care techniques for prevention of foot pathology.

Prescribe the right size of the footwear, according to the client's foot length & width.

Prescribe customized orthotics: which help in redistribution of pressure under feet.

Non-surgical management of corn & calluses.

Correcting early foot deformity to avoid chronic mobility issues thus preventing the patient from discomfort & future expense.

Role Of Podiatry to prevent AMPUTATION

Take a step in the right direction by having your feet checked regularly by a podiatrist.

SAVE IT BEFORE YOU LOSE IT..!!

Listen to him..!