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PANTAR FASCIITIS
"My heels are very painful. They hurt at the inside towards the front and at the middle of the heel. The pain is the worst first thing in the morning and also after periods of rest."
If the above statement is part of the history you have collected on your client, then Plantar Fasciitis should be suspected, and further examination done to confirm the diagnosis.
If palpation at the anterior medial calcaneus and/or towards the middle of the plantar surface of the calcaneus produces painful symptoms, a diagnosis of Plantar Fasciitis is appropriate.
Plantar Fasciitis is one of the most common foot problems seen today. The problem occurs as a result of repetitive stress on the insertion of the plantar fascia into the calcaneus (plantar aponeurosis).
The plantar fascia is a thick fibrous band of connective tissue originating from the bones and structures of the forefoot, that extends posteriorly to its' attachment into the anterior calcaneus. The plantar fascia provides a site for attachment of many intrinsic foot muscles and plays an important role in maintaining the medial and lateral longitudinal arches of the foot.
The action responsible for this repetitive stress and subsequent inflammation of the plantar fascia is pronation. Excessive pronation (or hyperpronation) of the foot leads to a flattening of the medial longitudinal arch and causes a strain on the plantar fascia. Chronic hyperpronation may also result in associated symptoms such as 'shin splints', medial forefoot callusing, hallux valgus, medial knee pain, and heel spurs.
It is important to note that xray findings of heel spurs illustrates only a symptom of the chronic strain on the plantar fascia insertion, whereby the calcaneus has hypertrophied in response to this strain, and is not the cause of the pain experienced.
Once the diagnosis of plantar fasciitis has been made, treatment should begin immediately. Delay in treatment simply causes more stress to the area and increased damage and pain. But what treatments are appropriate?
To answer this question, one needs to look at the cause of the problem. Since most cases of plantar fasciitis are due to a mechanical problem or poor biomechanical functioning of the foot (hyper-pronation), then the treatment considered should address this.
A professionally made pair of foot orthotics is really the only available treatment that works to correct the underlying cause of the problem. All other commonly used therapies are focused on reducing the symptoms. This does not mean however that other therapies used in the management of plantar fasciitis are not viable. Quite the contrary. For more advanced cases, adjunctive therapies may be necessary to provide a speedy resolution to the painful symptoms. The point being, that applying these therapies without addressing the underlying cause will only stave off the symptoms, and does not address the primary biomechanical problem.
Treatments can include the application of ice to the affected area to help reduce inflammation. Prescribed oral anti-inflammatory medications can also be used to decrease these symptoms. Cortisone injections into the affected area, although more invasive, may be warranted in severe or chronic cases.
Physiotherapy modalities work to strengthen the intrinsic muscles of the feet and improve flexibility of the plantar fascia and the Triceps Suri muscles. Ultrasound to the affected area has also proven to be an effective treatment.Taping by the therapist can provide temporary motion control to the foot, limiting excessive pronation, to reduce symptoms.
Tight Triceps Suri, resulting in decreased dorsiflexion, is often associated with the plantar fasciitis. If this is found, a stretching program targeted to the posterior leg (plantar flexors) should be recommended.
Do off-the-shelf arch supports work? Well, yes they will...if your client has an off-the-shelf foot! Unfortunately, most do not. Foot orthotics of any nature (off-the-shelf or custom made) will only work if they are properly designed for each clients unique biomechanical foot structure.
They need to take into account factors such as the relative angulation of the forefoot versus the rearfoot (forefoot varus/valgus versus rearfoot varus/valgus), the position of the 1st ray (plantarflexed/dorsiflexed), mobility of the 1st ray and midtarsal joints, and position of subtalar joint neutral to name a few.
ACCESS TO ASSISTIVE DEVICES PROGRAM FUNDING IMPROVED
In a Newsletter dated June 12, 1997 from the Ministry of Health, Assistive Devices Branch (ADP), the following changes regarding replacement orthoses delivery models are now in place. These changes allow easier access to replacement devices at or after the eligibility period.
The eligibility period, also known as the minimum replacement period, is determined from the date that the certified orthotist authorized the initial orthosis funded by ADP. Each orthosis has a specific eligibility period which varies from 1 year to 2 years.
In most cases a General Physician (Family Physician) can now prescribe the replacement orthosis if replacement is due to growth/atrophy, change in medical condition, or replacement due to wear at or after the eligibility period. The GP must sign and complete section 2 of the Equipment Supply and Authorization form (ESA). In some cases a Occupational Therapist or Physiotherapist can sign the ESA form. A Certified Orthotist must still authorize the device in all cases. The replacement device must be of similar design as the original device.
These changes provide easier client access to ADP funding and reduce strain on the health system by removing the necessity to return to the specialist physician which originally prescribed the device. In cases where the replacement device is not of a similar design (example: change from Ankle Foot Orthosis to Knee Ankle Foot Orthosis) a specialist physician must be consulted.
ESA forms are available through Applied Biomechanics, a registered authorizer and vendor, or by calling ADP at 1 800 268-6021.
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