Yim Physio Near Me: Physiotherapy with 3 therapeutic stretching options in Plantar fasciitis

Ref: https://feetfirstclinic.com/conditions/plantar-fasciitis/

Heel pain results from plantar fasciitis is one of the most common causes to pause sports activity and see me in the physiotherapy clinic. They complained about heel bad pain at early steps after waking up and worse with prolonged ambulation. I have seen and marked these patients with a high arch of foot.

Plantar fascia works with tension and stress to maintain arch of foot during standing and walking, especially at the last stance which is heel off. The biggest suspect is overuse that is always related to military training and athletes with running activity. The competitive tension and stress induce plantar fascia degenerate and inflammation.

Ref: https://splitfit.com/

My rehabilitation refers to the golden standard. I focus on P.R.I.C.E protocols for patients with acute pain i.e. skip weight bearing activity, ice compression, walk with crutches in case of strong pain, sports taping to support arch of foot that I have not started stretching because it may irritate inflammatory sites. I start gentle stretching and strengthening after pain and inflammation subside, with therapeutic ultrasound. I pay attention with tension load to plantar fascia the most that I am always providing low - dye taping to support arch of foot until full recovery.

Every protocols recommend calf stretching to increase achilles tendon flexibility that you can learn more on https://yimphysionearme.blogspot.com/2022/07/physiotherapy-with-9-options-to-stretch.html

3 options to stretch plantar fascia that add on from calf stretching

Exercise #1: Seat and hand pulling toe

Exercise #2: Sit on heel and toe bending

Exercise #3: Stand toe wall

Risk factors of plantar fasciitis

Plantar fasciitis can affect both young active patients and older more sedentary individuals. It results from chronic overload of the plantar fascia that becomes overused. Military exercises and runners training has prolonged and competitive walking and running that make many overload occasions. Overload stress could have seen in obese (body mass index >30) sedentary individuals and those who stand for prolonged periods of time, as well. Plantar fasciitis occurs more frequently in individuals with structural foot deformities, including pes planus, pes cavus, and leg length discrepancies, each of which are associated with tightness of the intrinsic foot muscles or achilles tendon.

Pes planus (left) and Pes cavus (right) are more risky than neutral (center)
(Ref: https://stock.adobe.com/th/)

Functional anatomy of plantar fascia

Plantar fascia is a thick fibrous band of plantar aponeurosis that originates at the medial tubercle of the calcaneus and inserts at 3 locations in the forefoot, creating 3 distinct bands including medial, central, and lateral.

The medial portion was less obvious and thinner than the others. It covered the plantar surface of the abductor hallucis muscle and included many insertions of this muscle’s fibers. The medial portion of the plantar fascia extended to the flexor retinaculum of the foot and medially to the dorsal fascia of the foot. It was ultimately inserted in the first metatarsal joint.

Plantar fascia
(Ref: https://www.levinchellenchiropractic.com/)

The abductor hallucis arises from the medial process of tuberosity of the calcaneus, flexor retinaculum, plantar aponeurosis, and adjacent intermuscular septum. An insertion attachment at the medial side of the base of the proximal phalanx of the great toe. Some fibers are attached to the medial sesamoid bone, and a tendinous slip may extend to the base of the proximal phalanx of the great toe. It acts to abduct and assists in flexion of the metatarsophalangeal joint of the great toe, and assists with adduction of the forefoot. In addition, it supports the medial longitudinal arch.

Abductor Hallucis
(Ref: https://www.kenhub.com/en/)

The lateral portion covered the plantar surface of the abductor digiti quinti muscle (abductor digiti minimi), then continued with this muscle’s fascia and laterally with the dorsal fascia. It was distally thin and proximally thick, where it formed a strong band in which some abductor digiti quinti muscle fibers were inserted, and it continued onto the inferior peroneal retinaculum. Distally, it was inserted in the fifth metatarsal joint capsule.

The abductor digiti minimi muscle has an unexpectedly wide origin arising from the lateral process of the calcaneal tuberosity, from the lower surface of the calcaneus, from the medial process, from the plantar aponeurosis and from the intermuscular septum between it and the flexor digitorum brevis muscle. Its tendon is inserted into the lateral side of the base of the proximal phalanx of the fifth digit. It acts to abduct the fifth toe at the metacarpophalangeal joint and plays an accessory role in its plantar flexion. In addition, it supports the lateral longitudinal arch.

abductor digiti minimi (Ref: https://www.kenhub.com/en/)

The central portion was the thickest, arising on the medial tuberculum of the calcaneus and extending forward to cover the plantar surface of the flexor digitorum brevis muscle, before dividing unevenly into five digitations inserted each in a different metatarso-phalangeal joint capsule. Most of the PF fibers were arranged longitudinally and obliquely, whereas there were some superficial fibers lying transversally, particularly on the proximal and distal portions. In all cases the PF continued over the calcaneal bone with a thin band (approximately 1–2 mm thick) corresponding to the periosteum of the calcaneal bone. This layer surrounded the calcaneus and was in continuity with the paratenon of the Achilles tendon.

flexor digitorum brevis (Ref: https://www.kenhub.com/en/)

The flexor digitorum brevis has variation of anatomy that lies immediately deep to the central part of the plantar aponeurosis. It takes origin from the central part of the plantar aponeurosis, medial tubercle of calcaneal tuberosity and from the medial and lateral intermuscular septa. It divides into four tendons for the lateral four toes. Each tendon is divided into two slips at the base of their proximal phalanges, to allow the flexor digitorum longus tendons, and finally attaches to both sides of the shaft of the middle phalanx. The most common variations of its are absence of tendon to the little toe, the tendon arising as a separate muscle, it has a deep head originating from the flexor digitorum longus which either joins the main muscle or proceeds as a separate tendon to the little toe, and presence of supernumerary slips. The function is flexion of the four lateral toes at the proximal interphalangeal and metatarso-phalangeal joints, regardless of the position of the ankle joint. Along with other muscles of the foot, it reinforces the longitudinal arch of the foot.

Ref: https://teachmeanatomy.info/lower-limb/muscles/foot/)

Windlass mechanism and the pathomechanics

A ‘‘windlass’’ is the tightening of a rope or cable. The plantar fascia simulates a cable attached to the calcaneus and the metatarsophalangeal joints. Dorsiflexion during the propulsive phase of gait winds the plantar fascia around the head of the metatarsal. This winding of the plantar fascia shortens the distance between the calcaneus and metatarsals to elevate the medial longitudinal arch. The plantar fascia shortening that results from hallux dorsiflexion is the essence of the windlass mechanism principle.

Windlas mechanism
(Ref: https://www.sciencedirect.com/science/article/abs/pii/S1877132720300397)

Stiffness of achilles tendon is vital factor to get plantar fasciitis because there are linkage between the central portion of plantar fascia, the periosteum of the calcaneal bone, and the paratenon of the Achilles tendon that the periosteum of the calcaneal bone is in - between. The loose elastic tendon could increase tension and stress to plantar fascia via the periosteum in Windlass mechanism.

Windlass mechanism in the late stance phase (right)
(Ref: https://dubinchiro.com/plantar-fasciitis/)

The windlass mechanism shows up in the late stance phase of walking which initiates toe off for propulsive to swing leg. At this timing, the ankle joint starts dorsiflexion to clear the foot from the floor. If a tight Achilles tendon restricts ankle dorsiflexion during the late stance phase of gait, thus blocking forward progression of the center of mass. Patients may compensate for the lack of ankle dorsiflexion by increasing motion through the subtalar axis, which is oriented obliquely relative to the long axis of the foot, resulting in increased dorsiflexion, but also valgus of the hindfoot and abduction of the forefoot. This overpronation leads to increased stress in, and eventually attenuation of, the plantar fascia and the other musculotendinous structures supporting the arch leading to the development of PF and pes planovalgus (flatfoot). In contrast, the high-arched foot of pes cavus has restricted mobility through the transverse tarsal joints, leading to an inability to dissipate shock from ground strike, thus increasing the load in the plantar fascia, and leading to plantar fascia overload.

Ref: https://barefootstrongblog.com/)

By mechanics, stretch tension from the plantar fascia prevents the spreading of the calcaneus and the metatarsals and maintains the medial longitudinal arch. The excessive tensile strain within the plantar fascia produces microscopic tears leading to chronic inflammation. However, current understanding is that PF occurs through a degenerative rather than an inflammatory process, that is, a “fasciosis,” rather than a fasciitis, where tensile strain is the key feature in the pathogenesis. Specifically, the increased fascial load is sensed by the gap junctions between fibrocytes (mechanotransduction), which then mediate changes in the extracellular matrix, resulting in myxoid degeneration and fragmentation of the plantar fascia and perifascial structures.

Physiotherapy treatment

The physiotherapy treatment consists of machines and exercise. Stretching is recommended as the gold standard. Gastrocnemius and soleus muscle stretching to improve the dorsiflexion range of motion should be included in the exercise prescription for both the high and low arched feet. Moreover, stretching plantar intrinsic muscle may provide more treatment effects. One orthosis can help auto stretch that is very convenient. The name “plantar fasciitis night splint”, is always recommended as well.

plantar fasciitis night splint

During the period of healing, I prefer to provide low - dye taping to support arch of foot and decrease overload to plantar fascia. It is a good result, however, some patients are allergic to the adhesive. If that is the case, I will recommend them to use insoles or heel cups.

low - dye taping

Strengthening, proper training program, and proper equipment should be paid attention to in treatment and prevention in the future.

Heel cup

The principle to stretch this muscle is the same as the others: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations following demonstrated VIDEO.