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Valentina Carlile Osteopata
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Plantar fasciitis in onset, etiology, differential diagnosis, local treatment


Plantar fasciitis in onset, etiology, differential diagnosis, local treatment


At its onset, this disorder presents as pain in the medial tubercle of the calcaneus which can radiate along the plantar aponeurosis. This pain is much more present when you put weight on the foot after resting for a while, especially in the morning, and the symptoms can then ease during the day or worsen following prolonged activity.


The plantar fascia plays a key role in the functionality of the foot, especially due to its function as a winch. It attaches to the sesamoid bones at the base of the five proximal phalanges and in stepping, since the first metatarsophalangeal joint extends with the extension of the big toe, the calcaneus is pulled against the big toe shortening and supinating the foot, thus providing a rigid base on which you can push.


The plantar fascia will then be tensioned again after the heel is placed when the arch lowers during pronation. The 1st ray (1st metatarsal and medial cuneiform) is therefore of fundamental importance.


Regarding the etiology, studies have been done on athletes but no association has been found between body mass indices, weight or height. Only some evidence was seen to suggest an appreciable increase in the development of the disorder with a progressive reduction in the dorsiflexion range. Those with less than 0 degrees of dorsiflexion were 23 times more likely to have plantar pain. In fasciitis sufferers, a restriction of mobility in the direction of extension of the 1st finger was also highlighted.


The key to effective re-education of plantar fasciitis is, as with cases, an accurate diagnosis.


The main differential diagnoses for chronic plantar pain are:

- Tibialis posterior syndrome: Dysfunction of the tibialis posterior tendon is a common cause of plantar pain. Symptoms include pain in the ankle and medial part of the foot in the medial arch. Palpation of the plantar fascia may be painful but must be compared with the asymptomatic side. Reduced heel inversion during tiptoe raising is a sign of tibialis posterior weakness. The medial border of the ankle is frequently painful and can reproduce plantar fasciitis pain.


- Calcaneal/navicular stress fracture: often related to excessive activity, acute and localized tenderness may be found at the origin of the plantar fascia but it is necessary to explore the rest of the calcaneus and navicular. The calcaneus is frequently painful if crushed medially and laterally at the same time and the navicular on direct palpation. A bone x-ray is the exam par excellence in both cases.


- Damage to the fat pad: often related to excessive activity, acute and localized tenderness can be found at the origin of the plantar fascia but the rest of the calcaneus and navicular bone must be explored. The calcaneus is frequently painful if crushed medially and laterally at the same time and the navicular on direct palpation. A bone exam (X-ray) is the exam par excellence in both cases. Treatment is often immobilization followed by mobilization and gradual rehabilitation.


- Neurogenic pain related to the tibial nerve: Neurogenic peripheral pain is caused by trauma or compression of the peripheral nerves. A critical area for compression of the tibial nerve is the medial side of the calcaneus at the level of the tarsal tunnel. The medial calcaneal nerve crosses the flexor retinaculum medially. Compression of any of these can cause heel or plantar pain. Palpation of these nerves is possible along with appropriate neurodynamic testing for the posterior tibial nerve. Conservative treatment involves reduction of activity, resolution of biomechanical disorders, mobilization of soft tissues in critical areas and neural mobilization.


- Trigger point pain: trigger points are local, hyperirritable and located in a tense area of a skeletal muscle. They produce localized pain and can cause referred pain in a specific point. Trigger points that can mimic plantar fasciitis can be found in the gastrocnemius, soleus, and accessory flexors. There are many treatments available and include acupressure, myofascial release or acupuncture.

OSTEOPATHIC TREATMENT OF PLANTAR FASCIITIS

The Osteopathic Professional will carry out a biomechanical-functional evaluation of the entire lower limb and of the entire patient both standing (orthostatism) and lying down (supine decubitus) to verify correct or incorrect management of the load both in static and dynamic conditions, with the aim of reconstructing the dysfunctional scheme which must then be integrated into the specific work.


To examine the plantar fascia tissue specifically, physiological - specific soft tissue mobilizations are generally used in order to evaluate its ability to stretch physiologically in all directions under manual pressure. The plantar fascia is tensioned by forces applied medially, laterally, superiorly and inferiorly. This is repeated with the 1st toe extended which further tensions the plantar fascia. The Osteopathic Professional will always appear with the contralateral side.

These maneuvers will bring out certain symptomatic areas that can be stressed through gradual constant pressure with small oscillations of mobilization on the site of restriction and reproduction of pain. The objective of the pressures is to promote tissue adaptation to the load and a normal healing process. The various studies carried out suggest using pain to guide the magnitude of the force applied since there are no other reference parameters.

At the end of the osteopathic evaluation and treatment, the Osteopathic Professional will be able to give self-management advice.

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