Due to the fact that we use our feet continuously, tendonitis in the foot is a common problem. One of the most frequently affected tendons is the posterior tibial tendon.

This guide will help you understand:

• how posterior tendonitis develops
• how the condition causes problems
• how health care professionals diagnose the problem
• what can be done to treat it
• what First Choice Physical Therapy’s approach to rehabilitation is

Where is the posterior tibial tendon, and what does it do?

The posterior tibial tendon runs behind the inside bump on the ankle (the medial malleolus), across the instep, and into the bottom of the foot. The tendon is important in supporting the arch of the foot and helps turn the foot inward during walking.
Tendons are made up of strands of a material called collagen. Think of a tendon as similar to a nylon rope and the strands of collagen as the nylon strands. As we age, or repetitively use the tendon, some of the individual strands of the tendon can degenerate, lose normal arrangement due to the degeneration, or break, and the tendon loses strength.

How do posterior tibial tendon problems of the foot develop?

Multiple factors can contribute to posterior tibial tendon problems. Patients with flat feet are at a higher risk of having a posterior tibial tendon problem because of the persistent stretch on the tendon. Having flat feet can contribute to posterior tibial tendon problems, but conversely, posterior tibial tendon problems can lead to the medial arch of the foot dropping causing a flat foot.

Injury to the nerves of the foot, bones of the foot, or having laxity (looseness) of the ligaments on the medial side of the foot can all result in deformity of the foot and/or ankle resulting in the posterior tibial tendon being more stressed.  The posterior tibial tendon can even be directly affected by systemic diseases such as diabetes, rheumatoid arthritis, and high blood pressure, or from the prolonged use of steroids. These diseases cause either increased laxity in the ligaments of the foot, which affects the foot biomechanics, or they directly affect the blood supply to the posterior tibial muscle and tendon, and contribute to the problem in that regard.  Obesity is another factor that can cause problems with the posterior tibial tendon.  The excess weight causes pressure on the foot and particularly on the posterior tibial tendon as it struggles to support the medial arch under the extra weight. Poor alignment of the lower extremities in any patient can also lead to pain in the posterior tibial tendon as the alignment forces undue stress down the medial side of the foot.

Problems with the posterior tibial tendon seem to occur in stages. Initially, irritation of the outer covering of the tendon, called the paratenon, causes paratendonitis. This means that there is inflammation between the lining of the tendon and the tendon itself where it runs through the tunnel behind the medial malleolus. This tendonitis can start a process of wear and tear on the tendon fibers.

As the tendon heals itself from wear and tear, scar tissue forms, thickening the tendon. This process can continue to the extent that a nodule, or knot, forms within the tendon. Once the painful tendon has changed in structure, the term tendonosis, rather than tendonitis, is used.  Unlike with tendonitis, recent evidence shows that inflammation is not present with tendonosis. The area of structural change in the tendon is weaker than normal tendon. The weakened tendon sets the stage for the possibility of rupture of the tendon.

What does tendonitis of the foot feel like?

The symptoms of tendonitis of the posterior tibial tendon include pain in the instep area of the foot and swelling along the course of the tendon. In some cases the tendon may rupture due to the degeneration of the tendon. Rupture of the tendon leads to a fairly pronounced flat foot deformity that is easily recognizable. In addition, a patient with a ruptured tendon is unable to rise up very high onto their toes, which also leads to the suspicion of a ruptured tendon.

How do health care professionals identify posterior tibial tendonitis?

The history and physical examination are probably the most important tools that health care professionals, including your Physical Therapist at First Choice Physical Therapy, will use to diagnose this problem. Your therapist will want to know exactly where your pain is, when it started, and what activities ease or aggravate your symptoms.

Next your Physical Therapist will physically examine your foot and entire lower extremity. They will palpate, or touch, around your area of discomfort to determine the exact location of pain. The alignment of your hips, knees, ankles and feet will be observed in both standing and sitting. You may be asked to twist your body with your feet planted on the ground, squat, or walk without shoes so your therapist can observe your feet and arches as you move.

Next your Physical Therapist will assess the position and mobility of the bones of your feet to determine if there is any subluxation, laxity, or even stiffness in any part of the ankle or foot, which may be contributing to your problem.

The strength in the muscles of the foot and lower leg will also be assessed.  In addition, your Physical Therapist will assess the strength in the muscles of your hip, as these muscles also play a part in controlling the alignment of your lower leg as well as lifting the arch of your foot. The biomechanical link between the hip and foot can be felt if you stand relaxed and squeeze both buttocks muscles together. As you do this you will feel the arches of your feet slightly lift. It is for this reason that control around the foot cannot only be left to the joints and muscles directly connected to or in the foot. The strong hip muscles will also need assessing and addressing if they are shown to be weak or inadequately functioning.

Muscle testing helps identify any areas of weakness or muscle impairment and imbalance. This will be done in both the weight bearing and non-weight bearing positions.  As briefly mentioned above, an important test that can help identify insufficiency of the posterior tibial tendon is the single heel raise. You therapist will ask you to stand on one foot and rise up on your toes. You should be able to lift your heel off the ground easily while keeping the heel bone (calcaneus) centered and slightly turned inward (inverted) and your knees straight.  If you cannot, your posterior tibialis muscle and tendon may be ruptured.

Posterior tibial tendon problems are usually apparent on physical examination. In some difficult cases, however, a magnetic resonance imaging (MRI) scan may be necessary to confirm whether the tendon has ruptured. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. The MRI creates images that look like slices and shows the tendons and ligaments very clearly. This test does not require any needles or special dye and is painless.

What can be done for the condition?

Physician’s Review

Your doctor may prescribe anti-inflammatory medications, such as ibuprofen or aspirin if you are in the stage of injury where inflammation is a culprit.

A cortisone injection, sometimes used to ease inflammation in other types of injuries, is usually not appropriate for this condition, since the tendon is more likely to rupture following injection. Some physicians recommend a slightly different cortisone treatment, other than injection, called iontophoresis. Iontophoresis is a treatment that uses electric current to deliver cortisone medicine through the skin to the inflamed tendon. The risk of tendon rupture is much less when this method is used.

Nonsurgical Rehabilitation

Physical Therapy at First Choice Physical Therapy is extremely beneficial in treating posterior tibial problems.

During your first few treatments at First Choice Physical Therapy your Physical Therapist will focus on relieving your pain. They may use ice, heat, ultrasound, or other electrical modalities on the instep of your foot or up the medial shin to provide you with relief. Icing or heating these areas at home will provide similar relief. Your therapist may also massage the bottom of your foot, calf, and muscles around your shin. Massage can be particularly useful in relieving your discomfort. Unfortunately these types of treatments only provide temporary relief; addressing the real problem of why the posterior tibial tendon is being stressed will provide more long-term relief to your injury and help to avoid an irritated tendon from developing into a chronic problem, or from rupturing.

Physical Therapy exercises will begin with strengthening exercises for the small muscles of your foot and posterior tibialis muscle. As mentioned above, these muscles work to lift and support the arch of the foot, along with the muscles of the hip, which control alignment down the lower leg chain, and also assist in lifting the arch of the foot. A Theraband may be used to provide added resistance to the muscles of the foot, and to strengthen the hip muscles. Your therapist will also prescribe stretching exercises, particularly for the muscles of your calf, which, when tight, can force the foot out of alignment. When performing all stretches it is imperative that you maintain proper alignment of your foot and arch so as not to compound the forces going through an already irritated posterior tibial tendon.  Your Physical Therapist will give you feedback on whether or not your alignment during your exercises is sufficient.

Being that posterior tibial tendon problems tend to develop over time, it is common for patients to not even notice that their feet may be flat or their alignment is off. The position of your feet becomes the ‘new normal.’ Re-learning the proper position of your arch is crucial to relieving the pain in your posterior tibial tendon as well as stopping the progression of the tendon problem and preventing a resultant deformity developing in the foot. Proprioception is the term used to describe one’s sense of joint position.  Your Physical Therapist will teach you what the correct position of your foot and arch should be and will give you exercises that challenge the proprioception of your knee, foot, ankle, and arch. Initially these exercises may be while you are simply sitting but as you progress, your Physical Therapist will advance your exercises so you are doing them in standing, and eventually just on one foot at a time. The standing position is an important position to work up to as it is much more functional in mimicking normal everyday activities such as walking or stair climbing. Eventually your Physical Therapist will prescribe exercises that are extremely challenging, especially if you are involved in a high-level sport.  Exercises such as squatting and jumping will be added and you will be required to do these activities while maintaining proper foot, arch and leg alignment.

If you have not already invested in some orthotics to assist with supporting your arch and taking some pressure off of your posterior tibial tendon your Physical Therapist will advise you on whether you should purchase some, and where to do this. Often taping the bottom of the foot, which your Physical Therapist can do, and can teach you to do on your own, can be trialed before expensive orthotics are purchased. Taping may be enough in mild cases of posterior tibial tendon pain, as long as you can learn to control the position of your foot and maintain this position during high-level activities. In most cases shoe inserts, even pre-fabricated ones, will significantly improve the symptoms of a posterior tibial tendon problem, and will be recommended to both relief symptoms and to avoid any progression of the injury. Custom fit orthotics are recommended for any individuals who have a significant flattened arch, or for whom prefabricated ones do not relieve their symptoms.

As mentioned above, excess weight can be the cause of posterior tibial tendon problems. Losing excess weight can greatly improve the pain you feel in your foot and make it easier to maintain normal foot alignment during everyday activities. Your Physical Therapist at First Choice Physical Therapy can discuss weight loss strategies with you and if need be, refer you to a Nutritionist who can also assist with this goal. Often it is difficult to exercise and increase your energy expenditure to lose weight when you have a painful foot, however, there are several safe activity options that your therapist can discuss with you, such as stationary cycling or swimming.

Activity modification is an important part of our treatment for posterior tibial problems at First Choice Physical Therapy. Your Physical Therapist will strongly advise you to avoid any activities that cause you discomfort while you still have symptoms. This may also mean resting for a short period from any sport you do, or at least decreasing your amount of activity over a period of time. Your Physical Therapist will specifically guide you regarding the needed rest for your individual injury. This rest may seem quite difficult to achieve, however it is well known that without a relative rest for a painful foot, there is little chance for it to heal.  A period of rest where the foot is not being aggravated also greatly improves the ability of any medication you may be taking, along with the Physical Therapy treatment you are receiving, to assist the healing of the injury. Your Physical Therapist will advise you when it is safe to slowly start back at your activity after your period of rest.

Unfortunately, not all posterior tibial tendon problems will respond to the Physical Therapy treatment we provide at First Choice Physical Therapy. If your symptoms persist or it appears that your foot is not responding to the treatment the way that your Physical Therapist would expect it to your Physical Therapist will refer you on to your family physician or an Orthopaedic Surgeon to discuss a more aggressive form of treatment.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

If all else fails to resolve your condition, surgery may be required.

Tendon Debridement

If the problem appears to be primarily tendonitis with thickening of the tissue around the tendon (the tendon sheath), a tendon debridement operation can be performed to remove the thickened tissue around the tendon. This is done to try to decrease the symptoms of pain and to prevent rupture of the tendon.
This procedure is usually done through a small incision in the instep of the foot just over the posterior tibial tendon. The surgeon simply identifies the tendon and removes the thickened tissue.

Tendon Repair

A degenerated tendon that has not ruptured may only need to be repaired and not reattached. The surgeon divides the sheath around the tendon. Areas where the tendon is degenerated are carefully removed. Tears within the tendon are sutured along the length of the tendon. If the surgeon is concerned that the repaired tendon is at risk for rupturing, a graft procedure to add strength to the tendon may be needed (described below). The tendon sheath is repaired, and the skin is closed with sutures.

Tendon Graft

A badly degenerated or a ruptured tendon may require a tendon graft. Usually, another tendon in the foot, such as the tendon that flexes the four smaller toes (the flexor digitorum longus), is used as a tendon graft to work in place of the posterior tibial tendon.

Fusion

Finally, in cases which have been neglected and a fixed flatfoot deformity is present, a fusion (or arthrodesis) of the foot may be required. A fusion is an operation where a joint between two bones is removed and the two bones on either side of the joint are allowed to grow together, or fuse. This type of operation is used to stop pain from joints that are worn out. It can be used to realign the bones when the mechanisms for maintaining normal alignment are lost, such as when the tendons and ligaments no longer work properly. Usually, several joints must be fused to control a flatfoot deformity that develops after a posterior tibial tendon rupture.

You will likely wear a bandage or dressing for about a week following a surgical procedure for your posterior tibial tendon problem. The stitches will be removed in 10 to 14 days. If your surgeon used dissolvable stitches, these will not need to be removed.
It will take about eight weeks before the soft tissues are well healed after surgery.  Simple debridement of the tendon takes much less time for the tendon to heal. If the tendon has been repaired or grafted, you will be placed in a cast or cast boot during this period to protect the tendon while it heals. You will probably need crutches as well.  A Physical Therapist in the hospital will teach you how to properly use the crutches on level ground as well as on stairs.

%Physiotherapy at First Choice Physical Therapy can begin as soon as your surgeon indicates that it is safe to begin. Most often this is after the 8-week mark.  Post-surgical rehabilitation at First Choice Physical Therapy will initially focus on minimizing the pain and swelling from the surgery. Similar to non-surgical rehabilitation, your Physical Therapist may use modalities such as ice, ultrasound, or interferential current to accomplish this. They may also use gentle massage around the muscles of your foot and lower leg. Your Physical Therapist will guide you on when to increase the weight-bearing load on your surgical foot by using the crutches less. You will likely move from using two crutches down to just one, or a cane or stick, before going without any aid at all and putting full weight through your surgical foot. Walking as normally as possible before going without any walking aid is imperative. It is easy to develop compensatory walking patterns that cause other injuries if you stop using your walking aid too early.

One of the first exercises your Physical Therapist will prescribe post-surgically will be some gentle range of motion exercises for your foot and ankle to gradually regain full movement and to help decrease the swelling. These exercises may be as simple as ankle circles and also pointing and pulling your toes and foot upward.  The exercises should be done within a relatively pain-free motion, however, movement will be encouraged even if it causes a slight bit of discomfort as the movement itself can greatly assist with dispersing any swelling as well as improving the overall level of pain. Elevating your foot as often as possible in these early stages can also assist greatly with removing any swelling from the ankle. It is best, if you can, to elevate your foot higher than your heart to allow gravity to assist with the fluid drainage.

If you have a stationary cycle you will be encouraged to use it. A stationary bicycle can be very useful in the initial stages post-surgically to assist with gaining ankle range of motion and decreasing swelling.  Even if you are unable to fully rotate the pedals, the back and forth motion on the bike is an excellent method of slowly encouraging the ankle to regain its full range of motion.

If you have access to a pool or whirlpool, your Physical Therapist may also encourage you to do your exercises in the pool , once the surgical wound heals.  Weight bearing in the pool is easier and the warmth of the water can assist with range of motion.
As soon as you begin treatment at First Choice Physical Therapy your Physical Therapist will immediately prescribe exercises that address the proprioception of your foot, ankle and leg, as well as the alignment of the entire lower limb.  Regaining a feel for the proper position of your foot and arch is crucial to avoiding a recurrence of your symptoms. Simple strengthening exercises for the bottom of your foot, posterior tibial muscle, as well as your hip muscles will also begin early on. Again, all exercises should be done within a relatively pain-free range of motion, however, some mild discomfort at the end ranges of motion may be felt as you begin to strengthen the muscles within their new range of motion.

As stressed under non-surgical rehabilitation above, It is crucial that you pay particular attention to the alignment of your arch, foot, ankle, and lower limb as you perform any of the exercises your Physical Therapist prescribes. Poor alignment of any of these areas can begin re-creating a situation where you are again prone to posterior tibial tendon symptoms. Your Physical Therapist will repeatedly remind you to be conscious of the overall alignment of the entire lower limb during both the rehabilitation exercises you do at First Choice Physical Therapy as well during everyday activities such as walking and stair climbing.

Significant improvement in your foot after surgery occurs gradually over a four-to-six month period of time. During that time, your Physical Therapist will progress your exercise program, but your appointments at First Choice Physical Therapy will decrease in frequency. For those patients who have had a fusion, there will be stiffness and loss of motion in the foot and/or ankle, so this should be expected. The amount and location of the stiffness depends on which bones were fused together.
Some prolonged swelling and discomfort are not uncommon even six to 10 months after surgery for this problem. Standing on your feet for a long time or walking long distances can also cause foot pain or discomfort. Eventually these symptoms will disperse.

Returning to regular activities will also occur slowly over a period of approximately 4-6 months. Your Physical Therapist will guide you regarding the appropriate time to add more aggressive activities to your exercise and rehabilitation regime. If you are eager early on to get back to some cardiovascular activity, your Physical Therapist can advise you regarding a safe intensity and duration of non-weight bearing cardiovascular activities such as swimming or cycling, and will also advise you on when it is safe to return to more aggressive activities for your foot and ankle such as jogging.

Generally post-surgical rehabilitation for posterior tibial tendon problems at First Choice Physical Therapy goes extremely well, however, if your pain lasts longer than it should or your rehabilitation is not progressing as quickly as your Physical Therapist feels it should be, they will ask you to follow up with your surgeon to ensure there are no complicating factors impeding your recovery.

Adult Acquired Flatfoot Deformity

Anatomy

Causes

Symptoms

Diagnosis

Treatment

Nonsurgical Rehabilitation

Surgery

Post Surgical Rehabilitation

Two pea-sized bones, called sesamoids, are embedded within the soft tissues under the main joint of the big toe. Even though they are small in size, the sesamoids play an important role in how the foot and big toe work. If the sesamoids are injured, they can be a source of severe pain and disability.

This article will help you understand:

• how the sesamoid bones in the foot work
• how sesamoiditis develops
• what can be done for the condition

Anatomy

Where are the sesamoids, and what do they do?

The main joint of the big toe forms the inside edge of the ball of the foot. The two small sesamoid bones are located on the underside of this joint. There is one sesamoid bone on each side of the base of the big toe.

Sesamoid Bones

One Sesamoid Bone (on each side)

The muscles that bend the big toe down (the toe flexors) pass underneath the main joint of the big toe, crossing over the bump formed by the sesamoid bones. This bump acts as a fulcrum point for the toe flexors, giving these muscles extra leverage and power. The sesamoids also help absorb pressure under the foot during standing and walking, and they ease friction in the soft tissues under the toe joint when the big toe moves.

Causes

How does sesamoiditis develop?

Sesamoid pain can develop a number of different ways. When the tissues around the sesamoid bones become inflamed, doctors call the condition sesamoiditis. Sesamoiditis is often caused by doing the same types of toe movements over and over again, which happens in activities like running and dancing.

Fractures can also cause pain in the sesamoids. Fractures can occur when a person falls and lands bluntly on the ball of the foot. Stress fractures can also occur in the sesamoid bones. Stress fractures are usually caused by the strain of overworking the soft tissues. Athletes most often suffer stress fractures of the sesamoids because of the heavy and repeated demands that training places on the soft tissues of the foot and big toe.

Arthritis can develop where the sesamoids glide under the bone of the big toe. The sesamoid bones create a joint where they move against the bone of the big toe. Like other joints in the body, this joint can also develop arthritis. Arthritis is more likely to be a problem in people who have high arches in their feet. The high arch causes the main joint of the big toe to become rigid. This focuses strain and pressure on the sesamoids.

In some cases, blood supply to the sesamoid bone is decreased. This condition is called osteochondritis. Osteochondritis causes a piece of the bone to actually die. The body’s attempts to heal the area may build up extra calcium around the dead spot.

Sometimes sesamoid pain comes from extra tissue under the big toe joint, similar to a corn. Doctors call this extra tissue an intractable plantar keratosis.

Plantar Keratosis

Symptoms

What does sesamoiditis feel like?

People with sesamoid problems usually feel vague pain under the main joint of the big toe. The sesamoids typically feel tender when touched. Movement of the big toe is often limited. People tend to notice pain mostly when their big toe is stretched upward, which can happen when the back foot pushes off for the next step. Occasionally the joint catches or pops. The catching or popping is often followed by increased pain, which usually eases after resting. Some people report feelings of numbness in the web of the first two toes.

Toe Stretched Upward

Diagnosis

How do health care providers identify this problem?

When you first visit First Choice Physical Therapy, our Physical Therapist will ask many questions about your medical history. We’ll ask you about your current symptoms and whether you’ve had other foot and joint problems in the past. Our Physical Therapist will then examine your painful toe by feeling it and moving it. This may hurt, but it is important that we locate the source of the pain and determine how well the toe is moving. You may also be asked to walk back and forth.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

What can be done for the condition?

Many cases of sesamoiditis can heal completely with careful treatment. There are two methods for treating sesamoid problems, nonsurgical treatment and surgery. Surgery is most often used as a last resort, when other forms of treatment aren’t helping.

Non-surgical Rehabilitation

Although each patient recovers at a different rate, as a general rule, our patients with sesamoid problems typically undergo four to six Physical Therapy treatments. Your Physical Therapist can offer ideas of pads or cushions that help take pressure off the sesamoid bones. We may recommend that special padding in the shape of a J can be placed inside your shoe to ease pressure on the sesamoids as you stand and walk. You may need to limit the amount of weight placed on your foot when you’re up and about. Shoes with low heels may also ease the pressure. Your doctor may also recommend supplementing rehabilitation with nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen.

Our Physical Therapist may apply treatments to the painful area to help control pain and swelling, such as ultrasound, moist heat, and soft-tissue massage. Our Physical Therapy sessions sometimes include iontophoresis, which uses a mild electrical current to push anti-inflammatory drugs, prescribed by your doctor, into the sore area.

If simple modifications are made to your shoes you may be allowed to resume normal walking immediately, but you should probably cut back on more vigorous activities for several weeks to allow the inflammation and pain to subside. If we must use more aggressive treatment during your recovery, you may be required to use crutches for several weeks to keep weight off the foot.

Post-surgical Rehabilitation

After a surgical procedure to shave or remove bone, patients are generally placed in either a rigid-soled shoe or a cast for two to three weeks. We will help you learn to properly use crutches to limit the weight that you put on your foot during the early stages of your recovery.

Treatment is more cautious after bone graft surgery. Patients usually wear a cast for up to four weeks. Then they wear a short walking cast for another two months, at which time active exercises can start.

The Physical Therapists at First Choice Physical Therapy can develop a personalized Physical Therapy program to help speed your rehabilitation. When your recovery is well under way, regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will eventually be in charge of doing your exercises as part of an ongoing home program.

Surgery

If surgery becomes necessary, several procedures are available to treat sesamoid problems. Which one your surgeon chooses will depend on your specific condition.

Bone Removal

Your surgeon may recommend removing part or all of the sesamoid bone. When bone is removed from only one sesamoid, the other sesamoid bone can still provide a fulcrum point for the toe flexors. However, if both of the bones are taken out, the toe flexors lose necessary leverage and can’t function. When this happens, the big toe will either bend up like a claw or slant severely toward the second toe. Thus, surgeons usually try to avoid taking both sesamoids out.

When a sesamoid bone is fractured in a sudden injury, surgery may be done to remove the broken pieces. To remove the sesamoid on the inside edge of the foot, an incision is made along the side of the big toe. The soft tissue is separated, taking care not to damage the nerve that runs along the inside edge of the big toe. The soft tissues enclosing the sesamoid are opened, and bone is removed. The tissues next to the sesamoid are stitched up. Then the soft tissues are laid back in place, and the skin is sewed together.

Surgery is similar for the sesamoid closer to the middle of the foot. The only difference is that the surgeon makes the incision either on the bottom of the big toe or in the web space between the big toe and the second toe.

Scraping

For patients diagnosed with stubborn plantar keratosis, surgeons generally perform surgery to scrape off the extra tissue. Your surgeon may decide to shave off only the affected part of the bone. The bottom half of the sesamoid is cut off, and the rough edges of the remaining part of the bone are filed with a special tool to leave a smooth shell. This surgery is easier on the body than procedures that completely remove the sesamoid.

Bone Graft

When patients continue to have problems with nonunion stress fractures, a bone graft may help the parts of the bone heal together. Surgeons mostly use this type of surgery for high performance athletes to keep the fulcrum point intact. The surgeon makes an incision along the inside edge of the main joint of the big toe. This exposes the sesamoid bone. The surgeon gathers small bits of bone from a nearby part of the big toe bone. The bone fragments are then packed into the unhealed area of the sesamoid. The soft tissue surrounding the sesamoid is stitched closed. Then the soft tissues are laid back in place, and the skin is sutured together.

Plantar Fasciitis (Heel Pain)

Plantar fasciitis is a painful condition affecting the bottom of the foot. It is a common cause of heel pain and is sometimes called a heel spur. Plantar fasciitis is the correct term to use when there is active inflammation. Plantar fasciosis is more accurate when there is no inflammation but chronic degeneration instead. Acute plantar fasciitis is defined as inflammation of the origin of the plantar fascia and fascial structures around the area. Plantar fasciitis or fasciosis is usually just on one side. In about 30 per cent of all cases, both feet are affected.

This article will help you understand:

• how plantar fasciitis develops
• how the condition causes problems
• what can be done for your pain

Anatomy

Where is the plantar fascia, and what does it do?

The plantar fascia (also known as the plantar aponeurosis) is a thick band of connective tissue. It runs from the front of the heel bone (calcaneus) to the ball of the foot. This dense strip of tissue helps support the arch of the foot by acting something like the string on an archer’s bow. It is the source of the painful condition plantar fasciitis.

The plantar fascia is made up of collagen fibers oriented in a lengthwise direction from toes to heel (or heel to toes). There are three separate parts: the medial component (closest to the big toe), the central component, and the lateral component (on the little toe side). The central portion is the largest and most prominent.

Both the plantar fascia and the Achilles’ tendon attach to the calcaneus. The connections are separate in the adult foot. Although they function separately, there is an indirect relationship. If the toes are pulled back toward the face, the plantar fascia tightens up. This position is very painful for someone with plantar fasciitis. Force generated in the Achilles’ tendon increases the strain on the plantar fascia. This is called the windlass mechanism. Later, we’ll discuss how this mechanism is used to treat plantar fasciitis with stretching and night splints.

Causes

How does plantar fasciitis develop?

Plantar fasciitis can come from a number of underlying causes. Finding the precise reason for the heel pain is sometimes difficult.

As you can imagine, when the foot is on the ground a tremendous amount of force (the full weight of the body) is concentrated on the plantar fascia. This force stretches the plantar fascia as the arch of the foot tries to flatten from the weight of your body. This is just how the string on a bow is stretched by the force of the bow trying to straighten. This leads to stress on the plantar fascia where it attaches to the heel bone. Small tears of the fascia can result. These tears are normally repaired by the body.

As this process of injury and repair repeats itself over and over again, bone spur (a pointed outgrowth of the bone) sometimes forms as the body’s response to try to firmly attach the fascia to the heelbone. This appears on an X-ray of the foot as a heel spur. Bone spurs occur along with plantar fasciitis but they are not the cause of the problem.

As we age, the very important fat pad that makes up the fleshy portion of the heel becomes thinner and degenerates (starts to break down). This can lead to inadequate padding on the heel. With less of a protective pad on the heel, there is a reduced amount of shock absorption. These are additional factors that might lead to plantar fasciitis.

Fat Pad

Some physicians feel that the small nerves that travel under the plantar fascia on their way to the forefoot become irritated and may contribute to the pain. But some studies have been able to show that pain from compression of the nerve is different from plantar fasciitis pain. In many cases, the actual source of the painful heel may not be defined clearly.

Symptoms

What does plantar fasciitis feel like?

The symptoms of plantar fasciitis include pain along the inside edge of the heel near the arch of the foot. The pain is worse when weight is placed on the foot. This is usually most pronounced in the morning when the foot is first placed on the floor.

Prolonged standing can also increase the painful symptoms. It may feel better after activity but most patients report increased pain by the end of the day. Pressing on this part of the heel causes tenderness. Pulling the toes back toward the face can be very painful.

Diagnosis

How do health care providers diagnose the condition?

When you first visit First Choice Physical Therapy, our Physical Therapist will examine your foot and speak with you about the history of your problem. Diagnosis of plantar fasciitis is generally made during the history and physical examination. There are several conditions that can cause heel pain, and plantar fasciitis must be distinguished from these conditions.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

Nonsurgical management of plantar fasciitis is successful in 90 per cent of all cases. When you begin therapy at First Choice Physical Therapy, our Physical Therapist will design exercises to improve flexibility in the calf muscles, Achilles’ tendon, and the plantar fascia.

We will apply treatments to the painful area to help control pain and swelling. Examples include ultrasound, ice packs, and soft-tissue massage. Our Physical Therapy sessions sometimes include iontophoresis, which uses a mild electrical current to push anti-inflammatory medicine, prescribed by your doctor, into the sore area.

We may have a customized arch support, or orthotic, designed to support the arch of your foot and to help cushion your heel. Supporting the arch with a well fitted orthotic may help reduce pressure on the plantar fascia. Alternatively, we may recommend placing a special type of insert into the shoe, called a heel cup. This device can also reduce the pressure on the sore area. Wearing a silicone heel pad adds cushion to a heel that has lost some of the fat pad through degeneration.

Your Physical Therapist will also provide ideas for therapies that you can perform at home, such as doing your stretches for the calf muscles and the plantar fascia. We may also have you fit with a night splint to wear while you sleep. The night splint keeps your foot from bending downward and places a mild stretch on the calf muscles and the plantar fascia. Some people seem to get better faster when using a night splint and report having less heel pain when placing the sore foot on the ground in the morning.

We find that many times it takes a combination of different approaches to get the best results for patients with plantar fasciitis. There isn’t a one-size-fits-all plan. Some patients do best with a combination of heel padding, medications, and stretching. If this doesn’t provide relief from symptoms within four to six weeks, then we may advise additional Physical Therapy and orthotics.

Finding the right combination for you may take some time. Don’t be discouraged if it takes a few weeks to a few months to find the right fit for you. Most of the time, the condition is self-limiting. This means it doesn’t last forever but does get better with a little time and attention. But in some cases, it can take up to a full year or more for the problem to be resolved.

Post-surgical Rehabilitation

Although recovery rates vary among patients, it generally takes several weeks before the tissues are well healed after surgery. The incision is protected with a bandage or dressing for about one week after surgery. You will probably use crutches briefly, and your Physical Therapist can help you learn to properly use your crutches to avoid placing weight of your foot while it heals.

The stitches are generally removed in 10 to 14 days. However, if your surgeon used sutures that dissolve, you won’t need to have the stitches taken out. You should be released to full activity in about six weeks.

Surgical release of the plantar fascia decreases stiffness in the arch. However, it can also lead to collapse of the longitudinal (lengthwise) arch of the foot. Releasing the fascia alters the biomechanics of the foot and may decrease stability of the foot arch. The result may be increased stress on the other plantar ligaments and bones. Fractures and instability have been reported in up to 40 per cent of patients who have a plantar fasciotomy.

Throughout your post-surgical recovery, our Physical Therapist will note your progress and be watchful for the development of fractures and instability. When your recovery is well under way, regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will eventually be in charge of doing some therapeutic exercises as part of an ongoing home program.

Physician Review

Your doctor may order an X-ray to rule out a stress fracture of the heel bone and to see if a bone spur is present that is large enough to cause problems. Other helpful imaging studies include bone scans, MRI, and ultrasound. Ultrasonographic exam may be favored as it is quick, less expensive, and does not expose you to radiation.

Laboratory investigation may be necessary in some cases to rule out a systemic illness causing the heel pain, such as rheumatoid arthritis, Reiter’s syndrome, or ankylosing spondylitis. These are diseases that affect the entire body but may show up at first as pain in the heel.

A cortisone injection into the area of the fascia may be used but has not been proven effective. Studies show better results when ultrasound is used to improve the accuracy of needle placement. Cortisone should be used sparingly since it may cause rupture of the plantar fascia and fat pad degeneration and atrophy, making the problem worse.

Botulinum toxin A, otherwise known as BOTOX, has been used to treat plantar fasciitis. The chemical is injected into the area and causes paralysis of the muscles. BOTOX has direct analgesic (pain relieving) and antiinflammatory effects. In studies so far, there haven’t been any side effects of this treatment.

Shock wave therapy is a newer form of nonsurgical treatment. It uses a machine to generate shock wave pulses to the sore area. Patients generally receive the treatment once each week for up to three weeks. It is not known exactly why it works for plantar fasciitis. It’s possible that the shock waves disrupt the plantar fascial tissue enough to start a healing response. The resulting release of local growth factors and stem cells causes an increase in blood flow to the area. Recent studies indicate that this form of treatment can help ease pain, while improving range of motion and function.

Clinical trials are underway investigating the use of radiofrequency to treat plantar fasciitis. It is a simple, noninvasive form of treatment. It allows for rapid recovery and pain relief within seven to 10 days. The radio waves promote angiogenesis (formation of new blood vessels) in the area. Once again, increasing blood flow to the damaged tissue encourages a healing response.

Antiinflammatory medications are sometimes used to decrease the inflammation in the fascia and reduce your pain. Studies show that just as many people get better with antiinflammatories as those who don’t have any improvement. Since these medications are rarely used alone, it’s difficult to judge their true effectiveness.

Surgery

Surgery is a last resort in the treatment of heel pain. Physicians have developed many procedures in the last 100 years to try to cure heel pain. Most procedures that are commonly used today focus on several areas:

• remove the bone spur (if one is present)
• release the plantar fascia (plantar fasciotomy)
• release pressure on the small nerves in the area

Usually the procedure is done through a small incision on the inside edge of the foot, although some surgeons now perform this type of surgery using an endoscope. An endoscope is a tiny TV camera that can be inserted into a joint or under the skin to allow the surgeon to see the structures involved in the surgery. By using the endoscope, a surgeon can complete the surgery with a smaller incision and presumably less damage to normal tissues. It is unclear whether an endoscopic procedure for this condition is better than the traditional small incision.

Surgery usually involves identifying the area where the plantar fascia attaches to the heel and releasing the fascia partially from the bone. If a small spur is present that is removed. The small nerves that travel under the plantar fascia are identified and released from anything that seems to be causing pressure on the nerves. This surgery can usually be done on an outpatient basis. This means you can leave the hospital the same day.