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Plantar Fascitis\ Calcaneal spur

Plantar fascitis is an inflammatory and calcific process at the insertion of the plantar arch of the foot to the heel bone (calcaneus). This is caused due to micro-tears of the long plantar ligament or an overload placed traumatically or in the course of time on the plantar arch. The plantar arch is functioning as a “fan” like string and that maintains the arch of the foot and its anatomical structures and absorbs the load of the body during weight bearing . The term “spur” was given in the past due to the fact that when a calcific process starts, in x-ray it is be presented as a kind of a boot spur.

Common symptoms:

usually pain is felt at the bottom of the foot around the base of the heel and slightly medially, even though pain can be felt in the entire foot. Pain is aggravated usually in the morning after getting out of bed and improves as motion resumes. Pain is aggravated during running on an unbalanced surface (the beach, terrain running), pain appears sometimes during normal or prolonged walking activities or prolonged standing. These symptoms might aggravate to the point where the person cannot withstand to bear weight on the foot.

There are many disorders that might cause similar symptoms as nerve impingements in the back or the ankle, stress fractures, arthritic conditions, myofascial trigger points etc. none the less a good diagnosis is important in order to rule out these other disorders and in order to formulate an adequate treatment plan.

Influencing factors:

  1. Deformations or faulty foot and ankle mechanics that might over load the arch. These deformations might be congenital or acquired throughout life
    due to traumas, overload, improper footwear etc.
  2. muscle weakness or shortening: the gastrocnemius and soleus muscles (the calf muscles) push the heel up in a tiptoeing motion, thus relieving the
    stress from the arch. If these muscles are shortened or weak, their dysfunction will overload the arch and might cause plantar fascitis.
  3. The flexor muscles in the foot that provide movement of the toes and clawing motions. If these muscles are week or shortened they either will
    present similar symptoms to plantar fascitis primarily or will overload the arch and will cause actual plantar fascitis secondarily. 50% of the force generated during running is generated in these muscles and in the elastic components of the arch so it is clear why weakness in these muscles has great implications.
  4. Weak pelvic and hip muscles. One of the main functions of the gluteal muscles around the pelvis and hip, the pelvic floor muscles, abdominal muscles, is to stabilize the pelvis and hip during movement. If those muscles do not function in their role of the entire lower limb kinetics, the hip and knee will move in a more internally rotated and medial line to the axis of movement. The end of this kinetic chain is located in the medial part of the foot where the arch is, thus increasing the load on the arch and contributing to this disorder.
  5. Incorrect posture in standing might overload the arch as well as limitations in the range of motion of hip and knee joints. These limitations will again over load the end of the kinetic chain where the plantar arch is, throughout motion and in standing.
  6. Hyper obesity.
  7. Lack of motor control and stability: Instability or lack of control in the rest of the lower limb muscles and the pelvis. strength in these muscles is not enough. The ability of the nervous system to control the activity and timing of contraction of these muscles is just as important. There’s a vast system of sensors situated in muscles, tendons, joint capsules and even the skin that sends signals associated with stretch, tension, muscle contraction respectively to the brain and central nervous system.  The brain processes all of these signals and develops an image of how the movement is carried out. If this system is untrained or neglected, the movement image in the brain isn't presented properly. Therefore, over use of muscles, unbalanced contractions can occur and lead to overload on more distal structures like the knee, ankle and foot. This system is also known as the proprioceptive system and its sensors- the propriosensors.
  8. External factors as faulty footwear, improper and excessive training without warm up. e.g- a person that decided to start training in running one day for 8 km in the frequency of 3-4 times a week without allowing the body structures to acclimatize to the strain of the activity.

Treatment:

  1. rest and stopping (or at least modifying) the level of activity for allowing the tissue to heal properly without additional strain.
  2. Localized treatment as ultrasound, shock wave therapy, ice, soft tissue mobilizations and massage.
    plantar fascitis treatment
  3. Dry needling: overloaded muscles might cause trigger points which are inner contraction points or nodules within the muscle fibers. These nodules stay contracted passively and limit the ability of the muscle to either generate a functional contraction or stretch (thus even limiting the range of motion). These trigger points might refer pain themselves to other areas that might present symptoms. The dry needling technique (that can be read in “types of treatment” page) release those trigger points instantly, thus restoring functional contraction, muscle length and ROM.
    dry needling plantar fascitis
  4. Taping- athletic and kinesio taping that unloads and\ or facilitates certain tissues while movement occurs. This allows for the treatment effect to be prolonged beyond the actual treatment time at the physiotherapist.
    plantar fascitisplantar fascitis 2
  5. Anti-inflammatory non streroid drugs to reduce the inflammation.
  6. Orthopedic insoles, designed specifically for every patient's foot shape. This provides prolonged support for the plantar arch and reducing the strain off it.
  7. There is a surgical procedure of removing the arch or loosening it but this surgical technique show very poor results and often an aggravation of the symptoms and increase in pressure and load on structures in the foot in addition to a lack of stability.
    It is important that the treatment will be carried out by a certified physiotherapist and according to his\ her clinical reasoning.
    When the initial pain and the acute stage subside, it is crucial to analyze the kinetics and mechanical faults in the movement of the lower limb and the entire body. These faulty movement patterns might have caused the condition in the first place and they need to be corrected by proper training, strengthening and body awareness accordingly to each individual patient.

Remember that controlling the inflammatory process isn't enough. Inflammation is a normal reaction of the body to a noxious stimuli. It is our 1st line of defense and a crucial element in the healing process. it shouldn't be stopped without paying attention to the reason why it started. Some researches actually showed evidence that stopping the inflammation repeatedly with non steroidal anti inflammatory drugs caused more damage to the tissue in long term effects.

***This article mentions several methods of evaluation and treatment. These are merely guidelines. They are not an independent treatment program nor intended to replace a thorough evaluation and treatment program executed by a certified physiotherapist. Its advised to undergo such evaluation and treatment by a certified physiotherapist if such injury occurs and act upon their professional judgement call***