INTRODUCTION:

The plantar fascia is a broad band of connective tissue that supports the arch of the foot. It includes a thick central component and thinner medial and lateral components.¹Functionally, the plantar fascia provides a windlass effect on the sole of the foot and helps maintain the longitudinal arch. It attaches proximally to the medial tubercle of the calcaneum. Extending distally, it divides into five digital bands that insert to the base of the periosteal of the proximal phalanx of each toe and the metatarsal heads. Fibers from the plantar fascia also blend in with the dermis, transmetatarsal ligament and flexor sheath.²

Gastrocnemius is superficial two headed muscle that is in lower legs.³Two heads [medial and lateral] originates from medial and lateral femoral condyles of femur and get inserted into mid posterior calcaneum.⁴Achilles tendon is the largest and powerful tendon of ankle.⁵ Its tensile force is transmitted to insertion by active contraction of gastrocnemius and soleus muscle.⁶

Plantar fascitis is pain caused by inflammation of insertion of plantar fascia on medial process of calcaneal tuberosity.⁷

Most commonly stabbing pain and it is usually worse with the first few steps after awakening. Pain may be substantial resulting in alteration of activities.⁸

The gastrocnemius –soleus complex plantar flexes at tibiotalar joint and tightness in muscle result in equines contracture.⁹As gastrocnemius crosses the knee it is tight in extension of knee and flexion shortens distance between the insertion and origin of the muscle, reducing muscle tension and allowing greater dorsiflexion of ankle.¹⁰ It has been determined that 20 degree of knee flexion is sufficient to achieve this. As the soleus does not cross the knee, the tightness is independent of position of knee.¹¹

Passive tension can occur because of an increase in dorsiflexion of foot or because of gastrocnemius or soleus tightness.¹²Thus, correctly gastrocnemius tightness refers to difference between maximal dorsiflexion of tibiotalar joint with knee flexed and extended.¹³

Prevalence of plantar fascitis is 10% in runner related injury, 11%-15% in occupational related problems, 10% in general population. The prevalence of gastrocnemius tightness in plantar fascitis is 60%. Women are affected by plantar fascitis twice as men. Race and ethnicity plays no role in plantar fascitis. Peak instance may occur in women aged 40 to 60 years.¹⁴

Excessive stretching of plantar fascia can result in microtrauma of this structure either along its course or where it inserts on to the medial calcaneal tuberosity.¹⁵This micro trauma, if repetitive, can result in degeneration of plantar fascia fibers. The loading of the degenerative and healing tissue at the plantar fascia may cause significant plantar pain, particularly with the first few steps after sleep or other periods of inactivity.¹⁶

The cause of plantar fascitis is often unclear and may be multifactorial. Possible risk factors include obesity, occupation requiring prolonged standing and weight bearing, and heel spurs. The factor which disrupt the normal biomechanics of foot increase plantar fascitis tension.¹⁷The addition of speed workouts, plyometric and heel workouts are high risk behaviors for development of plantar faculties. Structural risk factors include pesplanus, over pronation, pescavus, leg length discrepancy, excessive lateral tibial torsion and excessive femoral antevertion.¹⁸

Foot function index is used to evaluate foot and ankle disorders. The injection of corticosteroids usually mixed with local anesthetics and injected with use of medial approach, is the common treatment for heel pain.

The surgical procedures used for plantar fascitis include variations of open or closed, partial or complete plantar fascia release with or without calcaneal spur resection, excision of abnormal tissue and nerve decompression.¹⁹

A wide variety of prefabricated and custom-made orthosis, including heel pads and cups that are variously designed to elevate and cushion the heel, provide medial arch support, or both, are used to treat plantar fascitis. The use of night splints, designed to keep the ankle in a neutral position with or without dorsiflexion of the metatarsophalangeal joints during sleep.

Gastrocnemius stretching improves ankle dorsiflexion range of motion and gait. Extracorporeal shock wave therapy, ultrasound, low level laser therapy, icing were used for treatment for plantar fascitis and stretching for gastrocnemius tightness.²⁰

In this study ultrasound, gastrocnemius stretching and home program will be given to the patient with plantar fascitis. The response to the treatment will be analyzed and tabulated. This would provide evidence to the application of ultrasound and calf stretching in gastrocnemius tightness in plantar fascitis subjects.

METHODS AND METHODS:

A experimental study was conducted at Saveetha college of physiotheraphy OPD, thandalam, Chennai. following the approval of scientific review board and ethical committee, data collection procedure was initiated. Total of 30 subjects was selected according to inclusion and exclusion criteria and informed consent was obtained from the subjects. Subjects where not blinded as they where informed regarding the study and intervension to be given while obtaining the informed coscent. They where explained about safety and simplicity of the procedure.

Inclusion criteria:

1. Both males and females.

2. Age : 40 -60years

3. Pain at the bottom of the heel produced by weight bearing

4. Tenderness, swelling in region of proximal plantar fascia and at medial plantar tuberosity of the calcaneus

5. Worsening symptoms 1^st step in morning or at the beginning of walking

6. Acute stage of plantar fascitis

7. Silfverskiold test positive

8. Ability to visit the hospital for treatment and evaluations.

Exclusion criteria:

1. Peripheral neuropathy

2. Calcaneal cyst

3. Osteoarthritis of foot fingers

4. Rheumatoid arthritis

5. Pregnancy

6. Diabetic foot

7. Psychiatric disorders

Procedure:

Total of 30 individuals with plantar fascitis will be selected by convenient sampling based on inclusion and exclusion criteria. Detailed procedure will be explained in patient’s words and informed consent will be obtained from all the patients. Subjects will be assessed for presence of gastrocnemius tightness by diagnostic testing. The demographic data of each subjects and their baseline data of outcome measures (pain intensity and functional disability) were taken. Physiotherapeutic interventions were given for eight sessions at frequency of twice per week (total =12 sessions). After completion of the therapeutic session of 4 weeks post-intervention data of the outcome measures (pain and functional disability) will be taken.

Treatment prescription:

Ultrasound-striker

Calf stretching

Ultrasound:

Frequency: 1.0Hz

Intensity: 1.2watts/cm

Mode: Continuous

Application: applied over the painful site

Calf stretch:

Position the patient in supine lying with head supported. The therapist hand should firmly place on heel of the patient and flex the knee joint up to 30 to 40 degree. Extend the knee joint from flexed position and induce the dorsiflexion movement of the ankle. The patient feels stretch on the calf muscle(gastrocnemius).

Treatment protocol:

Sets: 3sets

Repetitions: 10 repetitions

Frequency: 2-3 times a day

Hold: 15seconds

Outcome measures:

Foot Function Index [FFI]

Silfverskiold test

RESULTS:

The mean value of Foot Function Index (FFI) in Posttest is 94.83 and in Pretest are 141.77. The mean value of Silfverskiold test in Posttest is17.00 and in Pretest 13.83. This shows that FFI and Silfverskiold test in Posttest were improving than Pretest, P<0.001. Statistical Analysis of posttest (FFI) Foot Function Index and Silfverskiold test revealed that there is high statistically significant difference seen in Post-test than Pretest.

Table 1 Pretest and posttest values of Foot function index (FFI)

Outcome measure	Pre test		Post test		P value	T value
	Mean	Sd	Mean	Sd
Ffi	141.77	22.40	94.83	22.06	<0.0001	13.8145

Table 2 Pretest and posttest values of Silfverskiold test

Outcome measure	Pre test		Post test		P value	T value
	Mean	Sd	Mean	Sd	P value	T value
Silfverskiold test	13.83	2.57	17.00	1.97	<0.0001	9.7292

The study investigates the effectiveness of ultrasound and calf stretching in relieving pain and to improve functional activity among age group from 40-60 years of both male and female with plantar fascitis in a period of 4 weeks of training. We select 30 subjects randomly by convenient sampling method and our study is an experimental study in which we assess the effectiveness of ultrasound and calf stretching. The duration of treatment plan is 4weeks FFI and Silfverskiold test is used as an outcome measure. Bihter Ankinglu et al. (2017) stated that the ultrasound treatment increases the cellular activity level and the circulation with its thermal, nonthermal, mechanical, and micromassage effects and heals the inflammatory process while creating an analgesic effect. We believe ultrasound treatment caused a more significant reduction in pain and decreased activity limitations and disability. The results of this study provide evidence that ultrasound treatment and radial extracorporeal shockwave therapy treatment are effective methods to reduce pain and increase functionality in PF when combined with exercise. Yigal Katzap et al. (2018) stated that " The addition of therapeutic ultrasound did not improve the efficacy of conservative treatment for plantar fascitis. Therefore, the authors recommend excluding therapeutic ultrasound from the treatment of plantar fascitis and agree with results of previous studies that stretching may be an effective treatment for healing plantar fascitis. Lindsey luffy et al (2018) stated that that stretching is a successful treatment because it addresses plantar fascitis caused by tight gastrocnemius and intrinsic foot muscles. Julia maria et al. (2009) stated that, Active stretching of the gastrocnemius muscle and the plantar fascia may improve painful symptoms in cases of plantar fascitis. In the present study, all treated patients were advised to perform such stretching. Better functioning of the foot and ankle, particularly with regard to gait, is of prime importance for maintaining the improvements gained by therapy. And also reported that Shockwave treatment was no more effective than conventional physiotherapy treatment when evaluated three months after the end of treatment.

Portal et.al. (2003) stated that stretching improves the ankle dorsiflexion in correlation with decrease in pain. DiGiovanni et al. (2002) compared calf muscle stretching with plantar fascia stretches over eight weeks, both groups experienced reductions in pain.

Foot function index (FFI) was developed to measure the impact of foot pathology on function in terms of pain, disability and activity restriction. The FFI is a self-administered index consisting of 23 items divided into 3 sub scales. According to Nelson F. Soohoo et al. (2006) Foot function index is reasonable method to measure outcomes in foot and ankle disorder.

Silfverskiold test is a clinical test used to assess isolated gastrocnemius tightness. Maximum ankle dorsiflexion that is less than 5 degrees with the knee in full extension than corrects when the knee is flexed to 90 degrees, a positive Silfverskiold test. Ngenomeule T. Nakale et al. (2017) have used Silfverskiold test to assess gastrocnemius tightness.

There are limited published studies in which authors assessed the treatment for plantar fascitis in relation with gastrocnemius tightness. The aim of the study is to assess the effectiveness of ultrasound and calf stretching in relieving gastrocnemius tightness in subjects with plantar fasciitis.

CONCLUSION:

From the statistical analysis and graphical interpretation the final derived results concluded that combined therapy of ultrasound and calf stretching is found to be effective in relieving gastrocnemius tightness in patient suffering with plantar fascitis and it can be used to improve the functional activities.

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Received on 29.07.2019 Modified on 02.03.2021

Research J. Pharm. and Tech. 2021; 14(6):3025-3028.

DOI: 10.52711/0974-360X.2021.00529