EVIDENCE BASED MANAGEMENT OF

PLANTAR FASCIITIS

Prof. Dr. Ibrahim M. Zoheiry

Vice dean for Community service and Environmental Development
Professor of Physical Therapy
Faculty of Physical Therapy,
October 6 University
Ankle and Foot Overview
 Primary function is to provide shock
absorption and to impart thrust to the
body during walking or ambulation

Pliability to absorb force of body weight

Rigidity to provide propulsive thrust

 Functions through an interaction of

interrelated joints, connective tissues
and muscles
 Foot Anatomical Regions
 Rearfoot – talus, calcaneus and subtalar joint

 Midfoot – remaining tarsal bones, transverse

tarsal joint and distal intertarsal joints

 Forefoot –
metatarsals
and phalanges,
tarsometatarsal
joints
Bones of the Lower Leg

Fibula
 Transfers minority of weight bearing load through the leg
 Distal end is the lateral malleolus of the ankle

Tibia
 Distal end is the medial malleolus of the ankle
 Transfers majority of weight bearing load through the leg
 Torsion Angle of tibia is approximately 20-30 degrees of
intra-tibial external rotation
Talocrural Joint
Tarsal Bones
Talus
 Articulates with the tibia
and fibula at the
talocrual joint, and with
the navicular bone at
the talonavicular joint
 Important kinesiological
role in the foot/ankle
and in the entire lower
extremity
 Superior aspect
covered with articular
cartilage
Tarsal Bones (cont.)
Calcaneus
 Articulates with the talus superiorly at the subtalar
joint and with the cuboid at the calcaneocuboid joint
 Largest tarsal bone – built to absorb shock of heel
strike
 Muscular attachments for achilles tendon, intrinsic
foot musculature and plantar fascia

Navicular
 Articulates with the talus at the talonavicular joint
and with cuneiform bones
 Site of attachment for Tibialis Posterior
Tarsal Bones (cont.)

Cuneiforms
 Contribute to the transverse arch
 Articulations with cuboid, navicular and
MT’s

Cuboid
 Articulates with calcaneus, lateral
cuneiform, navicular and MT’s
 Site of attachment of Peroneus Longus
Metatarsals and Phalanges
 5 MT’s, 14 Phalanges
 Condylar joints
 Plantar surface of MT’s are slightly
concave longitudinally
 1st MT is the shortest and thickest
 2nd MT is the longest – transfer of load
travels through 1st and 2nd during gait
 Motions at the Ankle & Foot
 Motions about the foot and ankle are
considered
“tri-planar” but move through an oblique axis
 Pronation – eversion/abduction/dorsiflexion
 Supination – inversion/adduction/plantar
flexion
Subtalar Joint
 “Tri-planar” pronation/supination
 Pronation mostly eversion/abduction
 Supination mostly inversion/adduction
 During weight bearing activity, most of SJ motion
occurs as the talus rotates and “swan dives” over a
fixed calcaneus
 Ligaments of the STJ prevent extreme inversion and
eversion
 Full supination increases rigidity of the midfoot and
is the closed pack position
 Full pronation increases overall flexibility of the
midfoot
Subtalar Joint (cont.)
Transverse Tarsal Joint
 Along with subtalar joint, TTJ controls
most of pronation/supination
 Allows foot to accommodate different
surfaces
Joints of the Foot
Medial Longitudinal Arch
of the Foot

 Primary load bearing

and shock-absorbing
structure of the foot
 Height of arch is
maintained by plantar
fascia, intrinsic foot
muscles, spring
ligament and stability
of midfoot joints
Medial Longitudinal Arch (cont.)

 Pes Planus – “dropped” MLA

Flexible Pes Planus
Rigid Pes Planus
 Pes Cavus – “raised” MLA
Less common than pes planus
Poor shock absorption
Possible association with stress fractures
Windlass Effect
 Mechanism through which intrinsic and
extrinsic plantarflexors place tension on
the medial longitudinal arch; creating a
rigid/stable mid and forefoot; enabling
the foot to accept the biomechanical
stresses of push off during gait
Windlass effect (cont.)
What is plantar fasciitis ?
 Plantar fasciitis (PF) is a
foot disorder in adults
secondary to an
inflammatory response
caused by repetitive
micro-trauma.
Prevalence
 PF may affect >1 million people
worldwide per year.

  The exact prevalence of PF is not

known.

 The lifetime prevalence may reach 10%

of the general population worldwide
What does the evidence say ?
 Pathoanatomical features

 Increased plantar fascia thickness was associated with

symptoms.
 Changes in plantar fascia thickness were positively associated
with changes in pain levels for individuals receiving treatment.
Risk factors ?
 Limited ankle dorsiflexion ROM
 High body mass index
 Running
 Work-related weight-bearing activities—
particularly under conditions with poor
shock absorption
Diagnosis
1- Plantar medial heel pain 2- Positive windlass 4- Limited ANKLE
test active & passive
ROM

•Initial steps after a

3- Negative tarsal
period of inactivity
tunnel tests
•Following prolonged
weight bearing

•Palpation of the
proximal insertion of the
plantar fascia
Diagnosis (Cont’d)
5- Abnormal FPI score
Diagnosis (Cont’d)
6 – Longitudinal arch angle

Normal = 131 to 152 degrees

Lower than 131 degrees= Low arch
Higher than 152 degrees= High arch
Interventions
 There are many different intervention
procedures to treat plantar fasciitis:
Manual therapy
Stretching exercises
Strengthening exercises
Joint and Nerve mobilizations
Therapeutic modalities
Orthosis
Kinesiotaping & Dry needling
Education & Advices
What does the evidence say ?
Manual Therapy
 High evidence supports the use of
manual therapy to treat plantar fasciitis,
Clinicians should use:
Talocrural joint posterior glide
Subtalar joint lateral glide
Anterior and Posterior glides of the first
tarsometatarsal joint
Subtalar joint distraction manipulation
Neurodynamics for tibial nerve
Stretching exercise

High evidence supports use of plantar fascia–

specific and gastrocnemius/soleus stretching to
provide short-term (1 week to 4 months) pain
relief.
Taping

High evidence support use of antipronation

taping for immediate (up to 3 weeks)
pain reduction and improved function for
individuals with heel pain/ plantar fasciitis.
Foot Orthoses
 High evidence support use
of foot orthoses to support
the medial longitudinal arch
and cushion the heel to
reduce pain
 Improve function for short-
(2 weeks) to long-term (1
year) periods.
Therapeutic Modalities

Weak Evidence Not recommended

Low level laser therapy Therapeutic Ultrasound

Iontophoresis Dry Needling
Phonophoresis
Strengthening Exercise

 Low evidence supports the use of strengthening exercise.

 Clinicians may prescribe 6-week training program to
strengthen the hip abductors and external rotators to
improve lower extremity joint load response during running.
Shoes & Return to sports guidleines
 Running shoes should be changed every 400
Km to 800 Km, as they lose 50% of their
shock absorption capacity.
 Athletes should be advised to use proper
running shoes:
○ Pes cavus foot = cushioned sneaker
 Take home messages
1. Plantar fasciitis is very common& can be treated effectively in

the outpatient setting.

2. Prolonged standing, decreased ankle DF, intense running

regime and obesity are all risk factors.

3. A multi-dimensional approach aimed at reducing the load on the

plantar fascia is most effective.

4. Activity modification, plantar fascia-specific stretches, calf

stretching, orthotics (including cushioned heel cups) and night

dorsiflexion splinting can help alleviate symptoms.