PLANTAR FASCIITIS

PLANTAR FASCIITIS

Plantar fasciitis, one of the common causes of pain in heel, is due to irritation and inflammation of plantar fascia (a long thin band that connects heel to front of toes, and supports the arch of the foot).

The plantar fascia is designed to absorb the high stresses and strains we place on our feet. But, sometimes, too much pressure damages or tears the tissues. The body's natural response to injury is inflammation, which results in the heel pain and stiffness of plantar fascia.

Risk factors for plantar fasciitis include:

•  Walking gait abnormalities, which place excessive stress on the heel bone, ligaments, and  nerves near the heel
•  Running or jogging, especially on hard surfaces
•   Poorly fitted or badly worn shoes, especially those lacking appropriate arch support
•   Excess weight and obesity

Other risk factors associated with plantar fasciitis include:

•  Increasing age, which decreases plantar fascia flexibility and thins the heel's protective fat pad
•  Diabetes
•  Spending most of the day on one's feet
•  Frequent short bursts of physical activity
•  Having flat feet or high arch feet.

Heel Spurs

Heel spurs are often associated with plantar fasciitis, though are not the cause of pain most of the times. One out of 10 people has heel spurs, but only 1 out of 20 people (5%) with heel spurs have foot pain. Because the spur is not the cause of plantar fasciitis, the pain can be treated without removing the spur.

Symptoms

The most common symptoms of plantar fasciitis include:

• Pain on the bottom of the foot near the heel
• Pain with the first few steps after getting out of bed in the morning, or after a long period of rest, such as after a long car ride. The pain subsides after a few minutes of walking
• Greater pain after (not during) exercise or activity.

Examination

Examination would reveal,

• A high arch or flat feet
• An area of maximum tenderness on the bottom of your foot, just in front of your heel bone
• Pain that gets worse when you flex your foot and the doctor pushes on the plantar fascia. The pain improves when you point your toes down
• Limited "up" motion of your ankle.

Treatment

Conservative: Conservatively patient can be managed with physiotherapy, which may include cold therapy, contrast bath or hot fermentation depending upon the pain, stretches (plantar fascia and calf), and myofascial release. Ultrasonic therapy and LASER have proved beneficial in the management of plantar fasciitis. Muscle stimulation can be implemented in cases of flat feet.

Home regime: 
It may include ice rolling for 15-20 minutes, avoiding activities that increase the pain, self stretch techniques several times in a day, strengthening the sole muscles, balance exercises as shown in the picture above.

Nonsteroidal anti-inflammatory medication: 
Drugs such as ibuprofen or naproxen reduce pain and inflammation.

Cortisone Injections: 
Cortisone, a type of steroid, is a powerful anti-inflammatory medication. It can be injected into the plantar fascia to reduce inflammation and pain.

Supportive shoes and orthotics:
Shoes with thick soles and extra cushioning can reduce pain with standing and walking. As you step and your heel strikes the ground, a significant amount of tension is placed on the fascia, which causes microtrauma (tiny tears in the tissue). A cushioned shoe or insert reduces this tension and the microtrauma that occurs with every step. Soft silicone heel pads are inexpensive and work by elevating and cushioning your heel. Pre-made or custom orthotics (shoe inserts) are also helpful.

Night splints:
 Most people sleep with their feet pointed down. This relaxes the plantar fascia and is one of the reasons for morning heel pain. A night splint stretches the plantar fascia while you sleep. Although it can be difficult to sleep with, a night splint is very effective and does not have to be used once the pain is gone.

Surgical treatment: 

we shall not discuss the surgical procedure.

Surgery is considered only after 12 months of aggressive nonsurgical treatment.

For any query or treatment for plantar fasciitis contact...

Pain Free Physiotherapy Clinic

31 A, DDA Flats, Pocket II, Behind sector 6 Market,
Dwarka, New Delhi 110075

Carpal tunnel syndrome

Carpal tunnel syndrome occurs when the median nerve is compressed at the wrist. The median nerve originates from cervical  spinal nerves and controls movement and sensation to the palmer side of the hand, thumb, and fingers. The carpal tunnel, a narrow passageway in the wrist, is formed by bones on the bottom and sides and a ligament which composes the top of the tunnel. The tunnel also contains nine tendons that are connected to the bones and muscles of the hand. Under various circumstances these tendons may swell and enlarge causing compression of the median nerve against the ligamentous roof which results in the symptoms experienced in carpal tunnel syndrome.

Numbness and a “pins and needles” sensation are the most common symptoms. Most often the thumb, index, and middle fingers are involved. Symptoms are often worse upon waking or during activities that involve flexing and extending of the wrist. As the syndrome worsens, decreased grip strength makes it difficult to perform tasks with the involved hand.

Due to the fact that the median nerve emerges from the neck, it is important that the patient be thoroughly assessed to determine that the symptoms are not coming from a nerve entrapment (pinched nerve) in the neck, shoulder, or forearm.

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Diagnosis:

Phalen's test helps diagnose the problem, with compression of dorsal aspects of hands the numbness and tingling sensation aggrevates. Other test would include tinel's sign, X-ray to rule out bony abnormalities and EMG and NCV to determine the extend and detrimental  effect of nerve compression.

Physiotherapy:

Physiotherapy treatment would comprise of modalities that includes US and IFT, stretching of median nerve (this also reduces the chances of double crush syndrome). Exercises would include reverse phalen's maneuver ( i.e namaste pose, with elbow and wrist at 90-90 position and shoulders resting by the sides) and strengthening of musculatures around the wrist. Tendon gliding exercises are also very helpful in increasing the mobility of tendons in the tunnel.

Rheumatoid Arthritis (Patient Education and Physiotherapy)

RHEUMATOID ARTHRITIS (RA)

(I Shall be discussing only the articular features)

RA is a chronic inflammatory disease. The cells lining the synovial membrane are activated by some process not yet understood, triggers the immunological response. These cells proliferates, resulting in thickening and inflammation of the synovial membrane. These cells are invasive, fibroblast like cell mass (called PANNUS), which is capable of eroding cartilage and bone. The synovial fluid accumulates, and the joint swells, distending the capsule, pulling on its periosteal attachment and causing pain and potential rupture. The ligaments and muscles around the joint are also subjected to weakness and potential rupture.

Factors which may (suspected) evoke the immunological reactions are Climate, Race, Diet, Psychosomatic disorders, trauma, Endocrinal dysfunction, Hereditary, disturbance in autoimmune system and infections.

Diagnosis ( Criteria given by American Rheumatoid Association)

Detection of abnormal protein, known as Rheumatoid serum factor (Rh. Factor)

(There are also sero negative variants of arthritis presenting similar feature)

Other abnormal findings,

Raised ESR, serum fibrinogen and immunoglobulins

Reduced albumin

Synovial Fluid examination reveals yellowish/greenish in colour, cloudy in clarity, low viscosity and neutrophills (75%) predominantly.

Clinical Findings

Onset between 35-55 years of age

male:female- 3:1

Severe pain

swelling

raised temperature

morning stiffness

phebitis (extruded synovial fluid may irritate the soft tissue around)

contractures, , fibrous/ bony ankylosis

secondary osteoarthritic changes

Deformities- wrist, small joints of hand, knee, elbow, shoulder, hip most commonly affected.

common deformities

Hand - ulnar drift of the hand, Boutonniere deformity, Swan neck deformity

Foot - Hallux Valgus, Hammer Toe

Rheumatoid Arthritis also includes non articular affection ( systemic illness, blood disorders, vascular, cardiac, respiratory, reticulo-endothelial, skin

CLASSIFICATION

 A]  ON THE BASIS OF PROGRESSION OF RA :-

STAGE I (EARLY)

1. No destructive changes on X- ray,

2. X- ray evidence of osteoporosis may be present.

STAGE II (MODERATE)

1. X-ray evidence of osteoporosis, with/without slight subchondral bone destruction; slight cartilage       damage may be present,

2. No joint deformity, although limitation of joint range of motion (ROM),

3. Adjacent muscle atrophy,

4. Extra-articular soft tissue lesions, such as nodules and tenosynovitis may be present.

STAGE III (SEVERE)

1. X-ray evidence of cartilage and bone destruction in addition to osteoporosis,

2. Joint deformity such as subluxation, ulnar deviation or hyper-extension without fibrous or bony           ankylosis,

3. Extensive muscle atrophy,

4. Extra articular soft tissue lesions such as nodules and tenosynovitis may be present.

STAGE IV (TERMINAL)

1. Fibrous or bony ankylosis,

2. criteria's of stage III.

 B]  ON THE BASIS OF FUNCTIONAL STATUS OF RA PATIENTS :-

CLASS I -

Completely able to perform usual activities of daily living (self care, vocational and avocational)

CLASS II -

Able to perform usual self care activities and vocational activities but limited in avocational activities

CLASS III -

Able to perform usual self care activities, but, limited in vocational and avocational activities

CLASS IV -

Limited in ability to perform usual self care, vocational and avocational activities.

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Usual self care activities include dressing, bathing, grooming and toileting.

Avocational includes recreational and leisure activities.

Vocational includes work, school, homemaking etc (age and sex specific)

CLINICAL COURSE

1] Acute phase/ Active phase

2] Chronic phase

- There may be exacerbations and remissions during the course of the disease.

PRINCIPLES OF PHYSIOTHERAPY MANAGEMENT

1. Relief of pain and inflammation

2. Restoration and maintenance of joint range of motion

3. Improvement of muscle strength and endurance

4. Prevention of deformity

5. Correction of deformity

6. Optimization of functional level

7. Management of re-occurrence. 

Joint Protection/ Patient Education to Prevent Deformity (in Acute Stage)

1. Monitor the activities and stop when discomfort or fatigue begins to develop.

2. Use frequent but short episodes of exercise

3. Decrease level of activity or omit provoking activities if joint pain develops and persist for more         than 1 hour.

4. Balance work and rest to avoid muscular and total body fatigue.

5. Increase rest during flare of the disease.

6. Avoid Deforming positions

• properly supported positioning of the involved joints and correct bed postures are important
• the use of firm mattress minimizes the effect of mal-positioning thereby preserves the                 integrity of the joints.

7. Avoid prolong static positioning; change positions during the day every 20-30 mins.

8. Use appropriate adaptive devices

Ref- J. Maheswari, hall n broody.