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ORIGINAL ARTICLE
Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 393-397  

Prevalence for plantar fasciitis of neural origin in community-dwelling adults


Department of Kinesiotherapy and Movement Sciences, Dr. D.Y. Patil College of Physiotherapy, Pune, Maharashtra, India

Date of Submission08-Sep-2020
Date of Decision12-Apr-2021
Date of Acceptance10-May-2021
Date of Web Publication17-Jan-2022

Correspondence Address:
Akhil Samson
Department of Kinesiotherapy and Movement Sciences, Dr. D.Y. Patil College of Physiotherapy, Dr. D.Y. Patil Vidyapeth, Sant Tukaram Nagar, Pimpri, Pune - 411 018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_501_20

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  Abstract 


Introduction: Plantar fasciitis (PF) is one of the most common causes of heel pain in adults. Common causes of PF include prolonged standing, obesity, flat foot, and nerve entrapment. PF caused due to nerve entrapment is often left unnoticed when making a diagnosis or management for PF. Lateral and medial plantar nerves are the common nerves to get entrapped causing pain and tingling in the foot ultimately leading to PF. Aims: This study aimed to come up with the prevalence of PF of neural origin in community-dwelling adults. Settings and Design: A cross-sectional study was conducted on fifty patients with PF attending Department of Physiotherapy, Dr. D. Y. Patil College of Physiotherapy, Pimpri, Pune, over a 6 months period. Subjects and Methods: Patients were assessed based on their symptoms and whether they meet the criteria for diagnosing the condition as PF. Assessment for classifying PF of neural origin was done using Standard Neurodynamic Testing for Plantar nerves branch of tibial nerve. Statistical Analysis Used: Descriptive statistics was presented as frequency percentage. Results: The prevalence of neural origin PF among fifty patients was 54%. Forty-eight percent of them were females and 6% were males. Conclusion: This study concludes that the burden of PF of Neural Origin is more in Community Dwelling Adults yet goes undiagnosed due to the tendency of following a set battery of physical examination by physiotherapists which does not include neurodynamic tests.

Keywords: Community-dwelling adults, nerve entrapment, plantar fasciitis, prevalence


How to cite this article:
Thakar HD, Samson A, Palekar TJ. Prevalence for plantar fasciitis of neural origin in community-dwelling adults. Med J DY Patil Vidyapeeth 2022;15:393-7

How to cite this URL:
Thakar HD, Samson A, Palekar TJ. Prevalence for plantar fasciitis of neural origin in community-dwelling adults. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 May 21];15:393-7. Available from: https://www.mjdrdypv.org/text.asp?2022/15/3/393/335881




  Introduction Top


Plantar fasciitis (PF) is defined as “inflammation of thick band of tissue that runs across the bottom of our foot that causes pain on the plantar surface of the heel and is the most common cause of posterior heel pain”[1] Symptoms of PF includes stabbing pain, pain with first few steps in the morning, pain subsides, while doing activities, prolonged standing or walking, and getting up from a seated position after a long period of nonweight bearing.[1],[2] The pain can be aggravated by dorsiflexion of first metatarsophalangeal joint which in turn stretches the plantar fascia (windlass mechanism). Risk factors of PF includes obesity, decreased dorsiflexion range, pes planus, prolonged weight bearing, calcaneal spurs, diabetes mellitus, hypothyroidism, and osteoarthritis.[3] PF has multiple etiologies: (1) role of gastrocnemius – A tight gastrocnemius may also be liable of causing PF.[4] It is believed that gastrocnemius may be shortened because of sitting for longer hours, wearing high heels or sleeping in supine or prone position which causes restriction in dorsiflexion movement. This leads to tension in plantar fascia.[5] (2) Flat foot – This increases the tension on plantar fascia leading to heel pain.[4] (3) Heel pronation – When the subtalar joint is pronated, this everts the calcaneus which lengthens the plantar fascia causing pain. (4) Obesity – This is due to increased pressure on plantar fascia because of heavy weight. (5) Improper shoe fit can also cause PF. Shoes with soft soles and poor arch support can cause PF. (6) Nerve entrapment: PF can be caused due nerve entrapment which leads to nerve compression.[6] Nerve entrapments are often left unnoticed when making a diagnosis or management for PF. There are three main nerves which can lead to PF because of their entrapment: Sciatic nerve, peroneal nerve, and tibial nerve. As these nerves traverse down the leg they pass through, underneath, and between the muscles and ligaments of the lower limb and foot. Branches of tibial nerve, i.e. lateral and medial plantar nerves are the common nerves to get entrapped in the foot, leading to pain and tingling in the foot, ultimately leading to PF.[7] Under normal circumstances, the movements of knee and ankle will let the nerves glide and slide smoothly. However, if the muscles in the leg or in the foot become tight or shortened, this can lead to nerve entrapment/compression. The source of pain from neural involvement is often missed and false positively diagnosed as PF alone. PF is a well-known clinical entity yet not much consideration is given to nerve entrapment as a cause of PF.[6] The aim of the present study was to propose that nerve entrapment as a cause of PF is often left unnoticed when making a diagnosis or management for PF. Therefore, this should be kept into consideration while making a diagnosis for PF so that a focused treatment can be given.


  Subjects and Methods Top


A cross-sectional study was carried out on fifty patients in the Department of Physiotherapy, Dr. D. Y. Patil College of Physiotherapy, Pimpri, Pune, over a period of 6 months. Convenience Sampling was used owing to time constraints. Clearance from the Institutional Ethical Committee of Dr. D. Y. Patil College of Physiotherapy was taken beforehand, and the study was in accordance with the Helsinki Declaration of 1975, as revised in 2000. Patients from age group of 20 years and above (males and females) were screened for PF on the basis of their primary complaint of pain in the plantar aspect. Diagnosis of PF is mainly based on patient's history and results of physical examination. Diagnostic criteria included heel pain presenting in weight-bearing postures such as standing and physical examination showing tenderness around the medial calcaneal tuberosity at the plantar aponeurosis. Clinical symptoms include pain with first few steps in the morning or after periods of nonweight-bearing and later pain subsides with regular activity.[1],[2] Patients having infective conditions of foot, tumor, rheumatoid arthritis, severe vascular disease, fractures, tarsal tunnel syndrome, sciatica, prolapsed intervertebral disc and low back pain (ruled out by special clinical tests), calcaneal spur, turf toe sinus tarsi syndrome, open wounds, and peripheral neuropathy were excluded. The patients were informed in detail about the study and were given a consent form to sign. Then, patients were assessed to find out if they were fit for the criteria stated above for the study and their demographic data were collected. This assessment was based on pain complaints and whether it met the criteria for diagnosing the condition as PF. Clinical history of the subjects included questions related to onset and type of pain, duration of the symptoms, previous medications, and treatments. The subjects were then assessed for neural involvement. The Standard Neurodynamic Testing for Plantar nerves branch of tibial nerve was used as outcome measure.[8]

Test procedure

Plantar Neurodynamic Testing: This test is indicated in patients whose symptoms are located in the course of tibial nerve and its divisions, which consists of medial calcaneal nerves, posterior tibial nerve, plantar (medial and lateral), and digital nerves in the foot. Therefore, this test is indicated in cases of heel pain including PF, calf pain, and pain in the plantar aspect of the foot.

Testing

The patient was in supine position and the therapist stood close to the side of the foot to be tested. The patient was asked to relax themselves and therapist's proximal hand controlled the knee, and the distal hand was around the lateral surface of the foot, under the sole. First movements of the test, i.e. dorsiflexion and eversion were executed at the foot [Figure 1], which was then followed by great toe extension and then by straight leg raise and internal rotation of hip [Figure 2]. The therapist checked if patient complained of pain or tingling in the foot and whether it was the same symptoms experienced by the patient during the course of the test. If the patient complained of same pain along with tingling sensation, then it was diagnosed as PF of neural origin and not otherwise.
Figure 1: Dorsiflexion and eversion of foot

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Figure 2: Great toe extension with straight leg raise and internal rotation of hip

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Statistical analysis

Data were put in Microsoft Excel worksheet and checked for accuracy. Descriptive statistics was presented as frequency percentage. Frequencies and percentages were calculated to summarize qualitative data. The prevalence of neural origin PF was as the percentage of patients having defined PF with neural involvement. A subsequent descriptive analysis was performed to study age-wise and gender-wise prevalence of neural origin PF.


  Results Top


The results are shown in [Table 1],[Table 2],[Table 3] and [Graph 1],[Graph 2],[Graph 3]. There were a significant number of patients having PF of neural origin.
Table 1: Distribution of neural and nonneural origin plantar fasciitis

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Table 2: Age distribution

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Table 3: Gender distribution

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  Discussion Top


PF is thought to be caused due to noninflammatory degenerative changes in the plantar fascia. The normal fascia tissue is replaced by an angiofibroblastic hyperplastic tissue which spreads itself throughout the surrounding tissues creating a cycle of degeneration.[9] It is one of the conditions, which has numerous factors causing it mentioned in the literature that includes incorrect footwear, tight gastrocnemius, obesity, flat foot, sedentary lifestyle, increased BMI, pronated foot, and nerve entrapment.[3],[10] In a study done by Tisdale CL in 2003, it was found that the prevalence for PF as a cause of planter heel pain was 80% among patients with symptoms.[11] Various studies have been done on risk factors of PF but none is concentrated on PF caused due to nerve entrapment.[12] In 2007, Chang et al. have stated that thickening of the plantar fascia and plantar aponeurosis more than 3.5 mm on diagnostic Ultrasound is a risk factor for developing PF of neural origin.[13] This will also prevent the normal gliding and sliding of the nerves and can disrupt the blood flow to the nerves supplying the foot which may cause pain, reduced ROM, burning, or tingling sensation in the foot.[14] Nerve conduction studies have shown abnormality in the nerves in patients with foot pain or PF which provides strong evidence of neural mechanism of symptoms in few cases.[7] Nerve entrapments are often left unnoticed when making a diagnosis or management for PF and the reason for relapse of symptoms even after several sessions of conservative management. Therefore, the aim of this study was to find out the prevalence for PF of neural origin.

Many subjects with carpal tunnel syndrome, the symptoms are often nocturnal and shaking the hand relieves the presenting symptoms. This may be associated with slowed axoplasmic blood flow during resting position and has shown similarities with the patients who suffer from heel pain on arising in the morning. Almost all the patients having PF suffered from heel pain at the first step in the morning. Beginning from its originating point, the lateral plantar nerve (LPN) that includes both sensory and motor fibers courses distally to the medial side of the calcaneal tuberosity and then turns in a lateral direction to the proximal part of the abductor digiti minimi muscle. It undoubtedly would be vulnerable to pressure of edema or to local irritation and trauma.[15] Oztuna et al. in 2002 detected that 88% of the subjects with heel pain had degenerative findings in the LPN using nerve conduction velocity (NCV) which supports the role of nerve entrapment in painful heels. They further said that the initial cause of heel pain could be a low-grade inflammatory process around the LPN, with edema and finally fibrosis possibly causing a restriction in a smooth gliding and sliding movement of the LPN. They further concluded that it is possible that some of the subjects actually present with PF and also have neurologic findings in NCV studies.[15] Therefore, in relation to physical and benign causes, there are some key findings about neurodynamic problems at the ankle that are important when considering foot pain.

Alshami et al. in January 2007 conducted a study on a review of plantar heel pain of neural origin: differential diagnosis and management. Several conditions such as PF, rupture of plantar fascia, and calcaneal fracture may lead to plantar heel pain. Injury to the tibial nerve and its following branches is also a common cause. The contribution of nerve entrapment to plantar heel pain has been well studied, its pathophysiology, diagnosis, and treatment is still controversial. They support the aim of this study by concluding that an entrapment of nerve has been considered a cause of plantar heel pain and LPN and medial calcaneal nerve are commonly involved. Therefore, diagnosis of plantar heel pain with a neural origin is majorly dependent on a careful history and physical examination.[16]

Pain in the heel and under the foot is often diagnosed as PF. This is naturally caused due to local tissue changes but another cause is nerve entrapment, mostly in medial and lateral plantar, tibial, and medial calcaneal nerves. Nerve abnormality is either underestimated or misdiagnosed cause of foot pain. Research has shown that subjects with foot pain can show reduced nerve conduction in various nerves in the foot region. Nerve problems tend to masquerade as PF alone.[7]

Normal nerve fibers when stretched experimentally, impulses are activated at the site of mechanical stress and symptoms of pain, stretch pain may be seen.[17],[18] However, in a pathological state, there is a known concept of mechanosensitivity. This is when a compressed nerve is stretched, impulses and pain are evoked more easily than usual.[17],[19],[20] In this study, patients having PF were tested for neural involvement using Plantar neurodynamic testing as given by Shacklock. This applied direct tension on the tibial nerve and its extensions involved. This test is reliable for patients having calf pain, PF, and heel pain.[8] The nerve impulses directly correlated with the symptoms presented by the patients, and the symptoms were elicited by placing the specific neural structure under tension. It was then found that 27 (54%) had neural origin PF and remaining 23 (46%) had nonneural origin PF. This concludes that one of the major and usually underdiagnosed causes of PF, i.e. nerve entrapment should be kept into consideration while making a diagnosis for PF so that a focused treatment can be given. Secondary findings included that females had more prevalence for PF of neural origin than males. Furthermore, the age group of 20–50 has equal number of neural origin patients.

Limitation

This was a prevalence study conducted among only fifty patients owing to time constraint. This same study can be done using other diagnostic methods such as electromyography, NCV studies, magnetic resonance imaging scans, or ultrasound so that precise mechanical interface entrapping the nerve (if any) can be seen precisely.


  Conclusion and Recommendation Top


This study suggests that nerve entrapment plays a key role in causing PF and therefore, this factor should also be well considered while taking a clinical history and a physical examination so that new horizons of physiotherapy management can be formulated that targets neural entrapment too. By no means, the authors intend to generalize the results as this may cause sampling error owing to less sample size. The intention was just to sensitize professionals about the possible presence of neural dysfunction in PF which tends to be seldom overlooked.

Acknowledgment

Although this study was not funded by any organizations or personnel, we acknowledge everyone's help in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ebnezar J, John R, Ebnezar J. Textbook of Orthopedics. 5th ed. New Delhi: Jaypee Brothers Medical Publishers; 2017.  Back to cited text no. 1
    
2.
Waclawski ER, Beach J. Systemic review: Plantar fasciitis and prolonged weight bearing. Occup Med 2015;65:97-106.  Back to cited text no. 2
    
3.
Attar S. Plantar fasciitis: A review article. SJIM 2012;2:13-7.  Back to cited text no. 3
    
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Brotzman S, Wilk K. Clinical Orthopaedic Rehabilitation. 2nd ed. Philadelphia: Elsevier Mosby; 2003.  Back to cited text no. 4
    
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Pascual Huerta J. The effect of the gastrocnemius on the plantar fascia. Foot Ankle Clin 2014;19:701-18.  Back to cited text no. 5
    
6.
Williams SK, Brage M. Heel pain-plantar fasciitis and Achilles enthesopathy. Clin Sports Med 2004;23:123-44.  Back to cited text no. 6
    
7.
Schon LC, Glennon TP, Baxter DE. Heel pain syndrome: Electrodiagnostic support for nerve entrapment. Foot Ankle 1993;14:129-35.  Back to cited text no. 7
    
8.
Shacklock M. Clinical Neurodynamics: A New System of Musculoskeletal Treatment. Edinburgh: Elsevier Butterworth-Heinemann; 2005. p. 137-8.  Back to cited text no. 8
    
9.
Lemont H, Ammirati KM, Usen N. Plantar fasciitis: A degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc 2003;93:234-7.  Back to cited text no. 9
    
10.
Van Leeuwen K, Rogers J, Winzenberg T, van Middelkoop M. Higher body mass index is associated with plantar fasciopathy/'plantar fasciitis': systematic review and meta-analysis of various clinical and imaging risk factors. British Journal of Sports Medicine. 2015;50(16):972-981.  Back to cited text no. 10
    
11.
Tisdale CL. Heel Pain in Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2003. p. 113-9.  Back to cited text no. 11
    
12.
Goweda RA, Alfalogy EH, Filfilan RN, Hariri GA. Prevalence and risk factors of Plantar Fasciitis among patients with heel pain attending primary health care centers of Makkah, Kingdom of Saudi Arabia. JHIPH 2015;45:71-5.  Back to cited text no. 12
    
13.
Chang CW, Wang YC, Hou WH, Lee XX, Chang KF. Medial calcaneal neuropathy is associated with plantar fasciitis. Clin Neurophysiol 2007;118:119-23.  Back to cited text no. 13
    
14.
Gray J, Gray S. Foot Pain Due to Nerve Entrapment; 2015. Available from: https://www.graychiropractic.ca/foot-pain-due-to-a-nerve-entrapment/. [Last accessed on 2020 Jul 30].  Back to cited text no. 14
    
15.
Oztuna V, Ozge A, Eskandari MM, Colak M, Gölpinar A, Kuyurtar F. Nerve entrapment in painful heel syndrome. Foot Ankle Int 2002;23:208-11.  Back to cited text no. 15
    
16.
Alshami AM, Souvlis T, Coppieters MW. A review of plantar heel pain of neural origin: Differential diagnosis and management. Man Ther 2008;13:103-11.  Back to cited text no. 16
    
17.
Neurodynamic Aspect to Heel Pain. Neurodynamic Solutions; 2019. Available from: http://www.neurodynamicsolutions.com/neurodynamic-aspect-to-heel-pain.html. [Last accessed on 2020 Jul 30].  Back to cited text no. 17
    
18.
Gray JA, Ritchie JM. Effects of stretch on single myelinated nerve fibres. J Physiol 1954;124:84-99.  Back to cited text no. 18
    
19.
Howe JF, Calvin WH, Loeser JD. Impulses reflected from dorsal root ganglia and from focal nerve injuries. Brain Res 1976;116:139-44.  Back to cited text no. 19
    
20.
Howe JF, Loeser JD, Calvin WH. Mechanosensitivity of dorsal root ganglia and chronically injured axons: A physiological basis for the radicular pain of nerve root compression. Pain 1977;3:25-41.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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