Plantar Fasciitis

Introduction –
• Plantar fasciitis is a dense fibrous connective tissue structure originating from the medial
tuberosity of the calcaneus.
• It has 3 bands – a) medial band
b) lateral band
c) central band
• The central band is the largest and originates from the medial process of the calcaneal
tuberosity , superficial to the origin of the flexor digitorum brevis, quadratus plantae and
abductor halluces muscle.
• Plantar fascia extends through the medial longitudinal arch into individual bundles and
inserts into each proximal phalanx.
• Nerve supply is by medial calcaneal nerve for the medial heel.
• Plantar fascia acts as an important static support for the longitudinal arches of the foot.
Pathomechanics –
• When any stress is placed on the longitudinal arches of the foot, it results in a
maximal pull of the plantar fascia especially its origin, this causes it to elongate to act
as a shock absorber but, the elasticity is limited and tends to decrease with the
increasing age.
• In the first 15% of the gait cycle, as much as 120% of the body weight is subjected on
the foot and is stabilized only by the passive structures, i.e., bones and ligaments
alone.
The intrinsic muscles come into action only after 30% of the gait cycle , therefore,
maximum stress of the body weight is on the ligaments and plantar fascia.
Also, significant amount of stress falls on the plantar fascia in the heel off to toe off
phase, when the MTP joints are ectended.
• This form of repeated stress causes plantarfasciitis.
Signs and symptoms –
• Pain is felt over the inner part of the sole or heel in all weight bearing activities.
• Pain or restriction while extending the toes.
• Stiffness and pain worse in the morning or after ambulation and may be increased by stair climbing
or doing toe raises.
• The site is very tender to palpation.

Causes –
• A research suggests the role of decreased intrinsic muscle strength as a causative factor in
planatrfasciitis pain.
• More common in sports that involve running, long distance walking. Frequent in dancers, tennis
players etc.
• Direct repetitive microtrauma is implicated for middle aged , over weight , non-atheletic individuals.
• Predisposing factors include, high BMI, improper footwear, flexible flat foot or high arch, and
repetitive trauma.
Management –
• Phase 1 –
1. Relative rest- discontinue running, walking for exercise untill asymptomatic for 6 weeks. Switch to
low impact exercises such as stationary bicycling, swimming, deep water running with aquatic belt,
etc.
2. Heel inserts- cushioned heel inserts can be used. For people with pes-cavus or pes-planus may
benefit from the eventual use of custom made cushioned orthotics.
3. Ice massage- to the area of inflammation, use ice in a paper or Styrofoam cup for 5-7 minutes, avoid
frost bite.
4. Anti- inflammatory medications.
5. Exercises – to be performed before the first steps in the morning, before standing after long period
of rest , do 5-10 reputations.
 Grab all 5 toes and pull the toes towards the knee, hold 30 seconds and repeat 5 times.
 Kneel with toes curled under feet, sit back on heels until tension is felt in the plantar fascia origin.
Hold 30 seconds.
 Plantar fascia stretching against the wall. Place foot against the wall, gently lean forward slowly and
hold for 30 seconds. Repeat 3-5 times.
• Phase 2 –
 If the phase 1 measures fail, proceed to phase 2. Start by reassessing the patient.
1. Casting- it has shown to be helpful in 50% of the patients. Short leg walking cast used for 1
month. Removable cast/ boot is used if right foot is involved to allow driving. Gradually
progress/ transition from boot back to running shoes.
2. Orthotics- patients with very high or very low arches benefit wth shoe inserts.
3. Night splints- A 5 degrees dorsiflexion night splint is beneficial. It holds the plantar fascia in a
continuously tensed state creating a minimal change in tension on the fascia.
Other splints are placed in zero degrees neutral.
4. Modalities – Iontophoresis, ultrasound, deep friction massage can be beneficial.
5. Cortisone injection – injection into the area close to the plantar fascia often improves pain, but
may weaken the plantar fascia and lead to rupture.
One or possibly 2 steroid injections should be given in a 3 to 6 months period, and only after
failure of phase 1 .
• Phase 3 –
Failure of phase 1 and phase 2 for 18 months is indicative of surgical
intervention.
De-Quervains Tenosynovitis
• De-Quervains is the most common over use injury involving the wrist.
• Often occurs in individuals who regularly use a grasp coupled with ulnar deviation of the wrist,
such as in tennis serve.
• Injury is because of inflammation around the tendon sheath of the abductor pollicis longus and
extensor pollicis brevis in the first dorsal compartment.
• Patient complains of gradual onset of pain and tenderness localized over the radial aspect of the
wrist.
• The patient is usually 40 years or older.
• Finklestein test is diagnostic for the condition. In this test the patient is asked to do flexion and
ulnar deviation of the wrist with finger flexed over the thumb.
Pain over the first compartment strongly suggests De-Quervains.
• The pain is caused as the test places stress on the APL and the EPB by placing the thumb into
the palm of a fist then ulnarly deviating the wrist.
• Also, when resisted finger movements are performed, pain occurs over the radial styloid region,
on resisted thumb extension.
Management –
• Conservative –
1. Use of thumb splint to immobilize the 1st dorsal compartment tendon.
The splint maintains the wrist in 15o to 20o of extension and the thumb in 30o of radial and palmar abduction.
The IP joint is left free and movements at this joint s are encouraged.
2. Reduce use of thumb to offer rest and time to heal to the tendon affected. Pinch or repetitive movements
are to be avoided.
3. NSAIDS for initial 6 to 8 weeks of treatment.
4. Icing over radial styloid.
5. Phonophoresis with 10% hydrocortisone can be used to control edema.
6. Gentle active ROM of thumb and wrist 5 minutes after every hour to avoid joint contractures and tendon
adhesions.
7. Corticosteroid injection with pain and symptoms for more than 3 weeks.
• Operative management –
De-compression surgery id done if the symptoms last for more than 3 weeks affecting the ADLs.
• Management –
 0 to 2 days – leave the IP joints free and encourage free movement.
Suture care. Remove dressing after 2 days.
Begin with gentle active motion of the wrist and thumb.
 2 to 14 days – splint worn for comfort and AROM exercises conted.
At 10 to 14 days sutures are removed .
Compains of hypersensitivity and numbness at distal to the site of incision site are common and
treatment involves digital massage.
 1 to 6 weeks – strengthening and scar mobilization . Activities to be performed with caution
for at least 6 weeks after surgery.
Trigger and Mallet Finger
Flexor tendon zones -
• Zone 1 – from the insertion of the profondus tendon at the distal phalanx to just distal to the insertion
of the sublimis.
• Zone 2 – ‘No Man’s land’. Between the insertion of sublimis and the distal palmar crease.
• Zone 3 – ‘area of lumbrical origin’. From the beginning of the pulleys to the distal margin of the
transverse carpal ligaments.
• Zone 4 – area covered by the transverse carpal ligament.
• Zone 5 – area proximal to transverse carpal ligament.

Pulles –
• Thumb has – 1 cruciate and 2 anular pulleys.
• Fingers have – 3 cruciate and 5 anular pulleys.
Trigger Finger –
• Also called stenosing flexor tenosynovitis.
• It is a painful snapping phenomenon that occurs as the finger flexor tendons suddenly pull through
a tight A1 pulley portion of the flexor sheath.
• It occurs because of the inability of 2 flexor tendons to slide smoothly under the A1 pulley hence
placing an increased tension to force the tendons to slide resulting in the sudden jerk or trigger
which pulls through the constricted pulley.
• It most commonly occurs in the thumb, middle finger and the ring finger . More common in
menopausal women, people with DM ,RA etc.
• Patients present with clicking , locking or popping in the finger that is often painful.
• Often a palpable nodule in the thickened area of the A1 pulley is seen which moves with the
tendon and is usually painful to deep palpation.
• To induce the trigger while examination the patient should be asked to male a full fist and then
completely extend the fingers, to avoid partial flexion of the fingers by the patient to avoid the
trigger.
Management –
• Conservative –
1. Splinting of finger in extension to avoid trigger but discarded as joint
prone to contractures/stiffness and poor results.
2. Injection of corticosteroids. 1 injection usually relieves triggering in
about 66% of the pts, multiple injections can relieve triggers in 75 to
88% of the patients.
• Operative management –
surgery can be performed on an OPD bases under local anaesthesia .
The surgery involves a 1 to 2 cms incision in the palm to identify and
completely divide the A1 pulley.
Mallet Finger
• It is the avulsion of the extensor tendon from its distal insertion at the dorsum of the DIP joint
producing a extensor lag at the DIP joint.
• It can also involve a bony fragment and is called as Mallet finger of bony origin and if not then it is
called Mallet Finger of tendinous origin.
• The hallmark of mallet finger is a flexed posture or dropped posture of the DIP joint and an inability
to extend or straighten the DIP joint.
• Mechanism of injury is typically forced flexion of the finger tip.
• Doyle classification –
Type 1- extensor tendon avulsion from the distal phalanx
Type 2 – laceration of the extensor tendon
Type 3 – deep avulsion injuring the skin and tendon
Type 4- fracture of the distal phalanx with 3 subtypes
a) Trans-epiphyseal # in a child
b) Less than half of the articular surface of the joint involved with no subluxation
c) More than half of the articular surface of the joint involved and may involve volar subluxation
• Factors that may lead to poor prognosis include-
1. Age older than 60 years
2. Delay in treatment beyond 4 weeks
3. Initial extension lag of more than 50o
4. Too short a period of immobilization
5. Short, stubby fingers
6. Peripheral vascular diseases or associated arthritis

• Conservative management –
1. Continuous extensor splinting of the DIP joint , leaving the PIP free for 6 to 10 weeks.
2. If no extensor lag exists at 6 weeks, night splinting for 3 weeks and splinting during sport activities for an
additional 6 weeks are employed .
3. DIP joint is not allowed to move at all or the treatment should be restarted.
4. Patient should work on AROM of the MCP and PIP joints to avoid stiffening of uninvolved joints.
TFCC Injury
• TFCC stands for triangular fibrocartilage complex . It is an arrangement of several
structures of which the primary structure is the triangular fibrocartilage or meniscal disc
which is relatively avascular disc like structure that provides a cushion effect between
the distal articular surface that ulna and the proximal carpal row, primarily the
triquetrum.
• Central defects or tears tends to have difficulty in healing and more peripheral injuries
heal at a much higher rate as there is less vascularity centrally, where as peripherally 15-
20% has the arterial inflow.
• The disc is a biconcave structure with a radial attachment that blends with the articular
cartilage of the radius.
• It also has ulnar attachment which lies at the base of the ulnar styloid .
• 2 layers of TFCC , superficial and deep attach separately to the ulnar styloid.
• The anterior and posterior thickening of TFCC merges with the anterior and posterior
Radio ulnar capsule and are also called palmar and dorsal Radio ulnar ligament.
• These structure are responsible for the build up of tension as the forearm is
supinated and pronated while providing primary stabilisation to the distal radio
ulnar joints.
• TFCC is in maximal tension in neutral rotation.
• The normal functioning of the distal radio ulnar joint requires normal relationship
between the TFCC and other attachments to the capitate, lunate, hamate and the
5th metacarpal base. Any tear, injury or degeneration of any one of the structures
leads to altered kinesis of wrist and forearm.
• Classification
The most widely accepted classification system of TFCC injury is that developed by
Palmer. It divides TFCC into 2 categories- traumatic and degenerative.
This system uses clinical, radiographic, anatomic and biomechanical data to define
each tear. Traumatic Degenerative
A. Central perforation A. TFCC wear
B. Ulnar avulsion B. TFCC wear
with ulnar styloid fracture with lunate or ulnar chondromalacia
without ulnar styloid fracture

C. Distal Avulsion C. TFCC perforation

With lunate or ulnar chondromalacia
D. Radial Avulsion D. TFCC. perforation
with sigmoid notch fracture with lunate or ulnar chondromalacia
without sigmoid notch fracture with lunotriquetral ligament perforation.

E. TFCC perforation
with lunate or ulnar chondromalacia
with lunotriquetral ligament perforation.
with ulnocarpal arthritis
Clinical Features.
• Patient complains of ulnar sided wrist pain, Clicking and often
crepitation with forearm rotation, gripping or ulnar deviation of the
wrist.
• Tenderness is present on either dorsal or the palmar side of the TFCC.
Diagnosis
• Thorough history is critical to diagnose TFCC lesion
• Onset, duration of symptoms, type and force of trauma, eliciting activities,
recent changes in symptoms, and past treatment attempts should be noted.
• Provocative maneuvers are often helpful in differentiating from lunotriquetral
pathology.
• Three test that help to differentiate are 1)Shuck test
2)Shear test
3) Press test
• TFCC grind test is performed to confirm TFCC injury. Piano key test is
performed to evaluate the DRUJ instability.
• Shuck test : described by Regan. The lunotriquetral joint is grasped between
the thumb and the index finger, while the wrist is stabilized with the other
hand and the lunotriquetral joint is shucked in dorsal to palmar direction.
• Shear test : 1 thumb is placed against the pisiform and the other thumb
stabilizes the lunate on its dorsal surface. A shear force is then applied.
• Press test : the patient grasps both sides of a chair seat while sitting in the
chair. The patient then presses the body weight, and if the pain replicates the
ulnar sided pain, the test is positive.
• TFCC grind test : the wrist is in neutral rotation and ulnarly deviated, it is then
rolled palmarly and then dorsally. Pain or click suggests a TFCC tear.
 With full pronation- dorsal RU ligaments are tested.
 With supination- volar RU ligaments are tested.
Diagnostic studies
• Radiograph of the wrist include PA, lateral and oblique views taken
with the shoulder abducted to 90, elbow flexed to 90 and forearm flat
to table.
• When indicated special views such as supination, pronation, a
clenched fist PA, and 30 degree supination view is taken.
• MRI and arthrography are also performed.
• The gold standard in diagnosing wrist injury is arthroscopy as it allows
the surgeon to palpate and observe every structure in wrist making it
easier to treat all possible components of the injury.
Treatment
• Conservative –
1. Wrist brace for 4-6 weeks
2. NSAIDS
3. Cortisone injection maybe beneficial
4. Immobilisation
5. Active assisted and Passive ROM exercises
6. Resisted strengthening followed by sports specific rehabilitation

If non operative care fails and symptoms persist surgery is indicated.

• Operative
Surgical intervention is predicted on the type of TFCC tear.
1. For 1A tears debridement of the central tear.
2. For 1B tears affect the periphery of TFCC repair of this tears usually heals because of the adequate blood supply.
3. For type 1D tears fall in controversial category. Traditinally treatment has been debridement of the tear, early
motion.
4. Type 2 tears are degenerative. Non operative treatment is taken for 3 months before arthroscopy. Debridement of
central degenerative disc followed by extra articular ulnar shortening procedure .
Post Operative Management
• After TFCC debridement –
after tfcc repairs is performed, the wrist is immobilized for 6-8 weeks and forearm
pronation and supination is prevent for the same time period with the use of a Munster
cast.
1. Phase 1 (0-7) days :
Soft dressing to encourage healing and decrease soft tissue edema.
2. Phase 2 (7 days variable) :
ROM exercises are encouraged.
Return to normal activities as tolerated.
3. Phase 3 ( when pain free) :
Resisted strengthening exercises, polymetric and sports specific rehabilitation.