What Causes Plantar Fasciitis - Foot Anatomy - Dr Gill

[Music] foreign medical video today we're going to talk about one of those subjects that medical students should have a good understanding with but also many patients come and complaining about problems with the fault specifically plantar fasciitis so often patients will come to me and say doctor I think I've got plantar fasciitis but what actually is that um and more importantly will all the gadgets and potions and stretch bands and things that are available online and in the supermarkets and things actually help those patients so let's have a look plantar fasciitis occurs when the thick band of connective tissue on the bottom of the foot becomes inflamed and that sense is quite simple fortunately the mechanisms might not be so this information can cause pain in the heel and in the arch of the foot find patients often seem most troubled by the pain as it can sort of strike them off guard but it's particularly sore you know after the first few steps in the morning or after they've been sitting for an extended period hence it becomes more of a problem for them because they think they've managed to cure it and things like that but then it's always there at the worst points for them so we know that plantar fasciitis is an issue with a connective tissue problem but that doesn't really help us much more so far the plantar fascists this thick band of fibrous tissue running from the calcaneus the heel bone all the way up to the base of the toes and it spans the entire length of the foot now this is a vitally important structure for the foot it acts to provide support for the arch of the foot it acts to provide stability and shock absorbing that shock absorbing is one of the reasons why when Runners develop plantar fasciitis they really do need to stop training because without that it's going to potentiate the existing problem which could make things worse and potentially turn from micro tears into much more significant tears that may need an operation why does it hurt so much well the plantar fascia is actually quite fascinating when it comes to running and walking the tissue will stretch store energy and then release it when it recoils back and this is called The Windlass mechanism don't worry if you're not familiar with that we will go through what a windlass mechanism is in a bit as a person walks when the foot is in mid stands are you flat on the floor the tension on the palm plantar fascia changes meaning the foot can adapt to the terrain Distributing body weight and absorbing shock from any gate now with regard to gain when it comes to walking the the big toe the great toe is the most important of your five toes so if you damage that great toe which I've done I've broken it in the past um that can have significant impact on your gait going forwards in fact the great toe is so important that there is a group of people in Africa known as the Doma in I think it's north Zimbabwe they're famed for and what's called an inherited ectodactyly that's where they've got the absence of one or more digits and with this group of people they're specifically missing the three middle digits on each foot so they've just got these two toes in a sort of a u-shape and in spite of just having these two toes there is no impact on their Mobility at all again because they've got that great toe in order to be able to continue their normal gait and the normal biomechanics of the foot so to double down not only is the great tote the most important though but it might also be one of the keys to plantar fasciitis in some people you only need to look at the size of the plantar fascia that's dis that's given specifically to the grape toe I mean it's you can see it's almost double the size of any of the other pieces of tissue on the planter here as with all such differences in proportion in the body particularly when we're talking about tenders and muscles that change has come about because of forces and obviously the development of the foot over time has meant that the great tote needs to have extra tissue supplying it to enable it to handle the forces that come through it during the biomechanics of walking so we know that great toe is important to the foot and we've said that it's connected to plantar fasciitis but how well if a person has reduction in movement in their great toe they will have some gait problem on that side as they can't stretch the plantar fascia as far as a result of that there's less stored energy for the next part of the gate and if we want to get technical when the foot is lifted off the ground the plantar fascia relaxes so the arch of the foot flattens it I mean if that makes sense I mean the foot's in the air it's not doing anything there's no forces acting on the foot however when the foot is lured back to the ground the grape toe extends in doing so and tension on the plantar fascia increases causing this tightening and the lifting of the arch of the foot this increased tension helps to raise up the out of the foot allowing the distribution of weight evenly across the foot meaning that we've got increased stability and these forces in the foot are going to be distributed so they can Propel us forward safely without actually damaging any of the other tissues or structures in the foot and this tightening of the palm of fascia is that windlass mechanism we spoke about before if the great toast got limited extension it can reduce the effectiveness of this windlass mechanism increase and increase the stress and tension on the palm of fascia hence we're going to get more information more micro tears and things which are going to go into form the pain that we associate with plantar fasciitis when it comes to diagnosing plantar fasciitis giving us it's essentially derived from a problem with The Windlass mechanism it kind of makes sense that we've called the test for it the windlass test so for the windlass test we're going to ask the patient to stand on the edge of a step with their toes out in space and we're going to dorsiflex the the great toe at the metatarsal pharyngeal joint in doing so as that toe comes backwards if we get in pain at the medial side of the heel specifically at the medial calcaneal tubercle that kind of confirms our diagnosis because guess where the majority of the force of the plantar fascia is going to go into yes on the medial side of the calcaneus and guess what's inserts there at the medial side of the calcaneus absolutely the plantar fascia so there you've got it we're going to Inc we're going to move the foot we're going to cause pain at the heel and we're going to confirm our diagnosis of plantar fasciitis so we've managed to confirm that the patient has plantar fasciitis but how do we want to treat it well obviously we need to look at the great toe and over 60 percent of plantar fasciitis is related to overuse and strain issues that have come from there however the remaining 40 percent is from area from issues with regard to Mobility specifically linking to movement of the foot and the tightness of the Achilles tendon and calf muscles so it makes sense this reduction in the great tote will affect the fascia but why would tighter killies affect plantar fasciitis you see tight calf muscles contribute to the development of plantar fasciitis because the Achilles tendon which connects the calf muscle into the heel shares some of the load of the plantar fascia deals with during weight-bearing activities kill this tendon will affect The Windlass mechanism we spoke about previously because it limits the range of movement at the ankle joint specifically in dorsiflexion so lifting the foot up meaning the biomechanics of the foot are going to change this change is seen as the plantar fascia not being able to correctly raise the arch of the foot and subsequently placing additional load on the fascia resulting in plantar fasciitis so we know that reduction of movement in the great toe and the ankle will result in a stress to the plantar fascia but how does this actually become plantar fasciitis over time this repeated excess stress on the tissue on any tissue for that matter but in this case the plantar fascia will cause micro tears and information ultimately this is going to lead to the pain and here's the crucial bit the imped function there so we know what plantar fasciitis is we know the potential causes of plantar fasciitis how do we treat it well painkillers to start off with and I know that seems almost an annoying thing to say but people just won't engage as well with the physical therapy that they're required to do to help their plantar fasciitis without adequate analgesia because physical therapy is often painful so once we've encouraged them to use appropriate analgesia then we can start by trying to stretch and strengthen the Achilles tendon and calf muscles note I haven't said stretching the plantar fascia at this point and by doing that we're trying to improve the ankle flexibility and reduce the abnormal loading onto the plantar fascia so stretching exercises to loosen the calf muscles do reduce the strain on the plantar fascia and alleviate these symptoms and that's why this stretching approach is going to be the core of the exercise that we're going to recommend and often that's going to be done by having the patient push against the wall pressing their affected heel down into the ground so stretching the calf and the insertion into the heel at the same time over time that will helpfully cause lengthening I mean we're going to reduce the strength of the stress on the plantar fascia there similarly as we spoke about with the windlass test where we're getting the patient to stand with their toes off the end of a step we can turn the patient around and we can have them facing up the stairs but with their heels off the back of the step and we can carefully allow them to lower themselves down so they get their foot is dipped with the heel below the center of left foot putting again strain on their calves with gravity helping to move things down it's a very good test because you get an excellent stretch there but obviously it requires good Mobility on the patient before they can do something like that for example we wouldn't want a patient who has an increased risk of fall doing something like a stretch like that conversely some people will opt to try um ice and compressing and trying to reduce inflammation on the Palmar fascia by that route it'll certainly provide an analgesic benefit although how much improvement you're going to get with regard to the reducing the micro tears is unclear some patients can look to use foam rollers both on their calves and the Palmer fascia it's effective but I can personally attest it is really quite unpleasant the bottom line for me though there is even once we've made that diagnosis of plantar fasciitis I'm going to strongly recommend that patient goes and sees the physio physiotherapist so they can give them specific guidance to try and improve the problem and give them the most effective stretches for whatever it is that's caused their plantar fasciitis now in the short term whilst the patient is waiting to get access to the physio we'll often advise the patient to wear proper shoes I'm not quite sure what they mean by that does that mean no slippers no Billy Connolly star Banana Shoes I think in reality what they're meaning by that is supportive shoes ideally so that those which have good arch support to reduce the strain on the the fascia there is a middle option however between our stretches and our supportive shoes and that's going to be much more effective for patients who can't change their shoes for example they're using specific safety shoes at work and that's getting supportive in assaults both to try and correct any pronation or supination which again might be effect in the gate but also making sure that that insole has good arch support to compensate for any issues they may be with the shoe so I hope this has been an effective overview on plantar fasciitis explaining why we get these micro tears and strains and pain from those in turn but also things that we might be able to do to help reduce it if this has been useful please consider liking the video because it tells YouTube we're here and subscribing to the channel because then you can gain engages on the community Tab and help us plan and decide which further videos we're going to do with that in mind take care thank you for watching and I'll see you in the next area [Music]