​Kembara Xtra - Medicine - Plantar Fasciitis

​Kembara Xtra - Medicine - Plantar Fasciitis 
Pain on the plantar surface, usually at the calcaneal insertion of the plantar fascia upon weightbearing, especially in the morning or on initiation of walking after a prolonged rest is a sign of degenerative change in the plantar fascia at its origin on the medial tuberosity of the calcaneus. 

Incidence
Annual patient visits in the United States are estimated at 1 million.

Most frequent cause of plantar heel discomfort during the course of a person's life affects 10- 15% of people, with a peak incidence between the ages of 40 and 60 and an earlier peak in runners. 

Pathophysiology and Etiology 

Chronic degenerative alteration (-osis/-opathy rather than -itis) of plantar fascia generally at insertion on medial tuberosity of calcaneus. Repetitive microtrauma and collagen degeneration of plantar fascia. 

Intrinsic Risk Factors: Age (>40 to 60 Years)
- Pregnant female - Obesity (BMI > 30)
- Overpronation, pes planus (flat feet), pes cavus (high arches), and disparity in leg length - Tightness in the hamstring, calf, and Achilles - Weakness in the calf and intrinsic foot muscles
- A dorsiflexed ankle with a limited range of motion (equinus or a tight heel cord; 15 degrees of dorsiflexion)
- Diseases of the systemic connective tissue
Extrinsic - Dancers, runners, court athletes - Jobs requiring extended standing, particularly on hard surfaces (nurses, letter carriers, warehouse/factory employees) - Rapid rise in activities requiring repetitive loading 

Prevention 
Retain a healthy weight.
 Avoid overtraining and training errors, such as rapidly increasing the intensity, distance, duration, and frequency of high-impact exercises.
 Appropriate footwear (supportive shoes with the right padding) Running shoes should be changed every 250 to 500 km.

Associated Conditions Posterior tibial neuropathy, which is typically isolated, heel spurs that are prevalent but neither pathognomonic nor indicative of severity


Typically, diagnoses are made clinically.

Pain on the plantar surface of the foot is historically most common at the fascial insertion at the calcaneus (medial calcaneal tubercle), although it can occur anywhere along the plantar fascia's length. Pain usually worsens with the first few steps in the morning or after extended periods of rest or standing (poststatic dyskinesia). Pain usually gets better after the first few steps only to return later in the day or after prolonged ambulation. Chronic pain may be mild and persistent.
Numbness and burning in the medial hindfoot are more indicative of posterior tibial nerve compression than a limp with increased toe walking.

clinical assessment 
Point tenderness on the medial tuberosity of the calcaneus at the insertion of the plantar fascia; pain along the plantar fascia with dorsiflexion of the foot; the Windlass test, which involves extending the MTP while allowing passive flexion of the IP joint of the hallux; pain indicates a positive test; high specificity, low sensitivity; sensitivity improves (13.5% to 31.8%) if the test is performed while standing.

Differential diagnosis includes calcaneal stress fracture, Heel Fat Pad Syndrome (painful or atrophic heel pad), longitudinal arch strain, posterior tibial nerve—tarsal tunnel syndrome, medial calcaneal branch of the posterior tibial nerve, and abductor digiti quinti tendonitis. Other diagnoses include Achilles tendinopathy, calcaneal contusion, plantar calcaneal bursitis, tendon

Laboratory Results 
Typically not necessary; a clinical diagnosis is usually sufficient Only when a diagnosis is unclear, there is chronic heel pain after 4 to 6 months of conservative therapy should you consider further imaging.
 Two views of the foot should be radiographed to check for fractures, tumors, cysts, periostitis, and bone erosions; weight-bearing films are recommended; calcaneal spurs are common but not diagnostic.  MRI can assess for other soft tissue etiologies. Ultrasound: hypoechoic at insertion, thickened plantar fascia (4 mm); can improve injection accuracy and extracorporeal shock wave therapy (ESWT); can objectively evaluate change in plantar fascia thickness to monitor effects of an intervention.
A CT or technetium-99m bone scan can detect infections and rule out calcaneal stress fractures.
Nerve entrapment can be ruled out by nerve conduction testing.
 Consider inflammatory markers for young patients or bilateral heel pain 

Management 

The bulk of treatment is nonoperative management.

General Actions 

Weight loss if overweight, discomfort relief, and increased strength of the intrinsic foot muscles Strengthening the intrinsic foot muscles will help to maintain the arch.
 Use the towel drag/pickup exercise and barefoot single leg balance to strengthen the calf and intrinsic foot muscles.
 Relative rest/activity modulation combined with a reduction in high-impact activities that cause injury Stretching: Non-weightbearing stretches may be preferred, and plantar fascia stretches are more beneficial than stretches for the Achilles tendon and gastrocnemius-soleus.
According to a comprehensive review, plantar fascia mobilization performed in-office and taught to patients is helpful.
- Plantar fascia mobilization: invert the foot, squeeze the sore area, and then invert the foot again along the plantar fascia.
The tibialis anterior can be massaged with ice (a frozen water bottle roll) or tennis or golf balls. Reduce your weight if your BMI is over 25. Consider supportive footwear with a solid midfoot or orthotics.
- Not to be worn forever as they may prolong intrinsic muscular weakening; for acute pain alleviation (2–3 weeks). - Alternatives include the following: Thomas heel, medial heel wedge, soft heel pad, navicular pad, heel cup, and soft heel pad (1). Custom orthoses are more expensive and offer no advantages over prefabricated orthoses.
- Night splint effectiveness is increased when orthotics are worn in conjunction with them Surgical treatment of "heel spurs" is not recommended.

First Line of Medicine
Ibuprofen 600 to 800 mg PO TID PRN or naproxen 500 mg PO BID are NSAIDs prescribed for 2 to 3 weeks to treat pain.  For pain, 1,000 mg of acetaminophen PO TID PRN 

Referral 

 Physical therapy, including joint and soft tissue manipulation, massage, and teaching in appropriate strengthening and stretching techniques. Consider gait analysis and biomechanical considerations for chronic cases.
Podiatry: Take into account if preventative measures don't work after 3 to 6 months.
If conservative approaches don't work after 6 to 12 months, consider surgery.

Corticosteroid injections - Temporary pain alleviation - Medial heel approach or sites of maximum soreness along the plantar fascia - When possible, recommend ultrasonography guidance.
- Risk for plantar fascia rupture and calcaneal fat pad atrophy, which results in chronic heel pain. - Platelet-rich plasma (PRP) injections may improve pain and function more than CSI. - ESWT is a good substitute for CSI in terms of pain relief and function improvement. Low-dye and calcaneal tape, a short walking cast, and hopeful treatments with conflicting data
- Myofascial trigger point dry needling - Radiofrequency nerve ablation - Plantar iontophoresis - Intralesional autologous blood injection - Low-level laser therapy (6)[B]
- Injections of polydeoxyribonucleotide (PDRN), botulinum toxin (BT) A, and ozone

10% of patients require surgery, which is more likely to be useful for those who are extremely obese.  Suggested if persistent pain persists and conservative treatment fails after 6 to 12 months.
 Open/endoscopic plantar fasciotomy (reduced danger and complications with endoscopic approach, but needs specialist gear and abilities; not frequently used) Calcaneal spur resection Cryosurgery


Healthcare Alternatives 
Short-term pain relief via acupuncture may be possible, but more research is required.


After 3 to 6 months of ineffective conservative treatment, consider other therapies or referrals. Ensure the patient uses proper stretching technique.

Modification of Lifestyle 
Exercises to mobilize the plantar fascia at home if the BMI is over 25 and weight loss To build foot muscles, place a towel on the ground and draw yourself inward with your toes and ball of foot without elevating your heel. Stretch plantar fascia: Pull toes into dorsiflexion prior to walking after lengthy sitting or sleep. Wear the right shoes (cushioned and supportive of the arch).
Use a frozen water bottle to apply ice to the foot by rolling it over for 10 minutes each morning and evening.
Roll your foot over a golf ball to massage your plantar fascia.
 Reduce persistent tension.

Prognosis: Self-limited (resolves within 12 months) in up to 80–90% of patients; generally excellent. 

Complications include chronic discomfort, irregular gait, and plantar fascia rupture (which is more common with frequent corticosteroid injections).

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