pathology: plantar fasciitis

yogabook / pathologie / plantar fasciitis

plantar fasciitis / plantar fasciopathy

Definition of

Partly inflammatory (21%), partly fibromatous (25%), traumatic or rather degenerative painful disease of the plantar fascia, usually radiating forwards from the heel of the heel; peak age 40-60 years. Plantar fasciitis usually occurs as overuse syndrome and is quite common, usually due to repeated overuse, especially if it occurs in unfavourable conditions, such as hyperpronation, with a flattened longitudinal arch of the foot, as found in kinked foot with lower foot or flat foot. However, the excessive arch, as in hollow foot, can also overload the plantar fascia. Scarred repair processes can lead to calcification of the tendon area and thus to plantar heel spurs. Basically, the plantar fascia is a very robust structure with a tensile strength of over 1000 N. It is the passive and most important part of the tensioning bandage of the longitudinal arch of the foot. It originates proximally from the calcaneus and is distally connected to structures of the MTP. Via the windlass mechanism, it is the most important factor in restoring the longitudinal arch at the end of the stance leg phase in the gait cycle. This inverts the rearfoot from the calcaneus and supports the exorotation of the lower leg in the knee joint, as it is also part of the final rotation in the knee joint. The now raised longitudinal arch of the foot buffers the inertia-mediated shock during the next step when this foot becomes a stable foot again. The passive tensioning by the plantar fascia is supported by the active tensioning by the toe flexors, as with dorsiflexion at the end of the stance leg phase, also exerting traction on the calcaneus in the direction of the MTP. The plantar fascia is part of the dorsal kinetic chain of the lower limb, starting with the ischiocrural group via the calf muscles and the Achilles tendon, some of whose fibres radiate into the plantar fascia.

With every step, the plantar fascia is subjected to tensile stress from the cranial load on the longitudinal arch of the foot, as it acts as a tension belt for the longitudinal arch of the foot. One in ten people are affected once in their lifetime, women more frequently. 70% unilaterally. In 50%, a heel spur is present at the same time (usually on the quadratus plantae, but also on the abductor hallucis or, more rarely, on the abductor digiti minimi). However, the heel spur is not considered the cause of plantar fasciitis, but also occurs due to increased tensile stress. 80% have an additional shortening of the Achilles tendon / triceps surae. More than 80% show hyperpronation. The dorsiflexion is almost always reduced! 70% of those affected are obese. In athletes, the correlation between incidence and BMI/weight is cancelled out. It is not uncommon for the tibialis posterior to be insufficient, which leads to hyperpronation, increased traction on the tibial nerve and thus to tarsal tunnel syndrome. If all three occur simultaneously:

  1. Plantarfasziitis
  2. tibial posterior dysfunction
  3. Tarsal tunnel syndrome

is referred to as a heel-pain triad. Additional tearing or tearing of the plantar fascia is possible, which usually makes any strain very painful.

Plantar fasciitis affects 10% of the population and increases with age. the distribution across the sexes is reported inconsistently. The plantar heel spur is found in 10 to 30% of the population, although it is predominantly asymptomatic; in the group affected by plantar fasciitis it is present in half of the cases. There is no evidence that the heel spur is involved in the symptoms. Predisposing factors for plantar fasciitis are obesity, foot deformities, age, occupations with a high proportion of standing and walking, shortened triceps surae, shortened ischiocrural group and running. Ruptures of the plantar fascia are rare and usually partial due to their high tensile strength. They can then lead to abruptly occurring stabbing pain, which is usually triggered by sport. Relevant differential diagnoses include Baxter’s neuritis/neuropathy of the lateral plantar nerve, Jogger’s foot of the medial plantar nerve (terminal branch of the tibial nerve), the foot of the medial plantar nerve, the tibialis), tarsal tunnel syndrome, fat pad atrophy, cysts of the calcaneus, stress fractures of the calcaneus, Morbus Ledderhose, as well as apophysitis calcanei in adolescence. If plantar fasciitis occurs on both sides, a rheumatic disease, an autoimmune disease such as psoriasis or Morbus Reiter (reactive arthritis) should also be considered. Plantar fasciitis is mainly characterised by morning start-up pain, which subsides without major exertion, but increasing exertion and sporting activity cause the pain to reappear and increase. The distal-plantar enthesis of the calcaneus is clearly painful under pressure, as is the tendon tissue over the next few centimetres towards the MTP. It is often found in people with limited dorsiflexion due to shortened triceps surae and with shortened ischiocrural group, but these are not accompanying symptoms in the sense of comorbidity, but rather predispositions and factors of aetiopathology. In addition to pressive tenderness at and before the enthesis, part of the intrinsic foot musculature is often also evident, mainly the toe flexors more or less pronounced pressure pain, as the active part of the tensioning girdle works closely together with the passive part. X-rays can detect or rule out changes in the bones or the plantar heel spur, sonography allows a dynamic view, MRI is usually not necessary and also not very informative.

Therapeutically, foot deformities must be compensated for as far as possible, and the choice of footwear is also important. A very important pillar of therapy is stretching exercises, performed regularly and independently, both for the plantar fascia and the intrinsic foot muscles as well as for the rest of the dorsal kinetic chain, i.e. the triceps surae and the ischiocrural group. To relieve the strain, the heel can be temporarily raised, i.e. increased springing can be used. Walking barefoot is contraindicated, especially on hard floors with existing plantar fasciitis due to the significantly higher biomechanical stress on the plantar fascia. Special splints can be worn at night. There are various physiotherapeutic and physical therapy options, from ultrasound, stimulation current and iontophoresis to cryotherapy and extracorporeal shock wave therapy, although these must not be overdosed. X-ray therapy can also be successful. The rate of successful conservative therapy is around 75%, but somewhat lower for recurrences of plantar fasciitis. Although cortisone infiltrations can provide relief, they pose a risk to the plantar fat pad, which can necrotise. The risk of rupture of the plantar fascia also increases. They should therefore be avoided. Anti-inflammatory drugs such as NSAIDs appear to be of little help, except in the case of systemic inflammatory diseases that cause or favour plantar fasciitis. Surgical therapy is indicated at the earliest after 6 months of conservative therapy have failed. There are no clearly positive studies on the simultaneous removal of an plantar heel spur. If necessary, nerve decompression can be performed as part of the procedure. After surgery, the foot is immobilised for 14 days and then fully weight-bearing in a walker for up to 6 weeks. The use of insoles and stretching exercises should be maintained to maintain the success of the therapy and prevent recurrence. There are not yet sufficient studies on platelet-rich plasma, but the results are promising. To prevent recurrence, neither too soft nor too hard shoes should be worn, and walking barefoot on hard floors should also be avoided.

Cause

  1. Possible weakness of important muscles involved in walking kinetics: gluteus medius, gluteus minimus, tensor fasciae latae
  2. Possible lack of extensibility of the triceps surae and thus reduced dorsiflexion

Predisposing

– Behavior

  1. prolonged standing or walking
  2. longer requirements with poor training level, also e.g. switching to flip-flops, sandals, barefoot walking
  3. Cross-country skiing
  4. Risk sports: basketball, tennis, soccer, dancing

– Musculoskeletal system

  1. Hyperpronation and foot misalignments that lead to
  2. Flat foot
  3. Hollow foot
  4. Leg length differences
  5. Hypertonus of the triceps surae or Achilles tendon

– Diseases

  1. RA and other arthritides
  2. Repeated cortisone infiltrations

– Other factors

  1. higher BMI
  2. Age

Diagnosis

Tests and signs: manual pressure pain provocation, Windlass test for plantar fasciitis

Symptoms

  1. morning start-up pain (decreasing pain on exertion), pain after prolonged rest
  2. Increase in pain under stress
  3. Pressure soreness
  4. gradual onset
  5. later possibly also pain at rest
  6. Sprinting and jumping aggravate
  7. palpatory sharp tenderness at the leading edge of the heel
  8. Sono: attachment of the plantar fascia to the calcaneus is at least 4 mm thick or 0.6 mm thicker in lateral comparison

Complications

  1. Nerve bottleneck syndrome between the calcaneus and plantar fascia
  2. Disorder in the lateral leg, SI joint or hip joint due to pain avoidance with shifting of force to the outer edge of the foot

Therapy

  • As a rule: spontaneous healing within max. 1 a; with conservative procedures healing in 90% of cases within 6 months. After 1 year, 1% remain with surgical need, which improves in 90% to 80% (even in athletes)
  • Taping
  • Radiotherapy
  • Take it easy, avoid frequent impact loads such as running; temporarily switch to shorter steps when walking; stop walking barefoot
  • Stretching the Achilles tendon, even better: stretching the plantar fascia itself. In a study with stretching as monotherapy, 72% showed improvement. Stretching at least 3/d
  • Insoles that cushion the heel, they mainly improve the function but less the pain
  • Leg splints that immobilize the foot at night without dorsiflexion, and thus without the possibility of further contraction
  • Massage: Cross-frictions at the base are unpleasant but pain-relieving
  • The efficacy of the frequently administered NSAIDs could not be proven
  • Local cortisone infiltrations (maximum once due to the risk of increased fat pad shrinkage and increased risk of rupture)
  • Platelet-enriched autologous plasma, still being tested, promising so far
  • Botox injections, still being tested, promising so far
  • Iontophoresis
  • Extracorporeal shock wave therapy, inconsistent study situation

DD

  1. Ankylosing spondylitis
  2. Reiter’s disease
  3. RA

Asana practice

In plantar fasciitis, the focus is on stretching the longitudinal ( intrinsic) plantar foot muscles and stretching the triceps surae and thus also preventing the Achilles tendon from tightening. The longitudinal plantar foot musculature consists primarily of toe flexors in the plantar direction. Accordingly, dorsal stretching of the toes in the metatarsophalangeal joints is one of the most important tasks. This can be achieved excellently with postures in which the toes point upwards on the wall while the sole of the foot stands on the floor in front of the wall, such as setu bandha sarvangasana with wall. Stretching these muscles with a small fascia roller is also very helpful. These should be performed at least three times a day, with sufficient pressure and for a sufficient length of time per area worked on. In addition to the intrinsic foot muscles, which are the active tension belt for flexing the foot, the passive tension belt, which consists of the affected plantar fascia and the plantar long ligament, is also stretched. Simply rolling the foot moderately over the fascia roller, on the other hand, can hardly fulfill more than an alibi function.

In addition to the plantar fascia and the intrinsic foot muscles, it is important to stretch the triceps surae, which is the main plantar flexor of the ankle (more precisely: the ankle joint) and therefore works closely with the tension belt system. The significantly weaker plantaris must also be mentioned here. Deficiencies in one system will not remain without consequences for the other in the long term. In the triceps surae, a distinction must be made between the monoarticular soleus and the biarticular gracilis. Therefore, stretches in the direction of dorsiflexion of the ankle must be performed both with the knee joint flexed (for the soleus) and with the knee joint extended (for the gracilis). Here you test and practice one or the other as required.

A lack of strength in the ankle-stabilizing muscles can also promote plantar fasciitis. Above all, all relevant muscles or muscle groups that are used with a certain minimum amount of force during the frequent activities of walking and standing must be considered. This does not usually include the foot lifts, as they only have a restoring function for renewed plantar flexion. Therefore, in addition to various types of common foot exercises, strengthening the plantar flexors, pronators and supinators of the ankle is particularly helpful.

Asana practice

In plantar fasciitis, the focus is on stretching the longitudinal ( intrinsic) plantar foot muscles and stretching the triceps surae and thus also preventing the Achilles tendon from tightening. The longitudinal plantar foot musculature consists primarily of toe flexors in the plantar direction. Accordingly, dorsal stretching of the toes in the metatarsophalangeal joints is one of the most important tasks. This can be achieved excellently with postures in which the toes point upwards on the wall while the sole of the foot stands on the floor in front of the wall, such as setu bandha sarvangasana with wall. Stretching these muscles with a small fascia roller is also very helpful. These should be performed at least three times a day, with sufficient pressure and for a sufficient length of time per area worked on. In addition to the intrinsic foot muscles, which are the active tension belt for flexing the foot, the passive tension belt, which consists of the affected plantar fascia and the plantar long ligament, is also stretched. Simply rolling the foot moderately over the fascia roller, on the other hand, can hardly fulfill more than an alibi function.

In addition to the plantar fascia and the intrinsic foot muscles, it is important to stretch the triceps surae, which is the main plantar flexor of the ankle (more precisely: the ankle joint) and therefore works closely with the tension belt system. The significantly weaker plantaris must also be mentioned here. Deficiencies in one system will not remain without consequences for the other in the long term. In the triceps surae, a distinction must be made between the monoarticular soleus and the biarticular gracilis. Therefore, stretches in the direction of dorsiflexion of the ankle must be performed both with the knee joint flexed (for the soleus) and with the knee joint extended (for the gracilis). Here you test and practice one or the other as required.

A lack of strength in the ankle-stabilizing muscles can also promote plantar fasciitis. Above all, all relevant muscles or muscle groups that are used with a certain minimum amount of force during the frequent activities of walking and standing must be considered. This does not usually include the foot lifts, as they only have a restoring function for renewed plantar flexion. Therefore, in addition to various types of common foot exercises, strengthening the plantar flexors, pronators and supinators of the ankle is particularly helpful.

Asanas

Asanas in 851: Stretching the plantar flex ors
Asanas in 852: Strengthening the plantar flexors
Asanas in 856: Stretching the gastrocnemius
Asanas in 857: Strengthening the gastrocnemius
Asanas in 971: Stretching the toe flex ors
Asanas in 972: Strengthening the toe flexors
Asanas in 861: Stretching the supinators
Asanas in 862: Strengthening the supinators
Asanas in 871: Stretching the pronators
Asanas in 872: Strengthening the pronators