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plantar fasciitis

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THE PLANTAR MYOAPONEVROSITES

The suffering of the plantar fascia or short plantar flexor underlying occurs in athletes practicing running and jumping. A simple but rigorous clinical examination to confirm the cause of symptoms. If in doubt, it is associated with ultrasound and MRI to eliminate the many differential diagnoses. The therapeutic means are multiple. They can be used NSAID, rehabilitation, soles or heels. Rarely seepage or percussion are necessary. During the treatment, it is advisable to continue painless physical activities.

FUNCTIONAL ANATOMY and PHYSIOPATHOLOGY

The plantar fascia is a fibrous layer contributing to the tensioning of the sagittal plantar arch. It is stretched to the tuberosity of the calcaneus to the underside of the metatarsophalangeal joints. Thick back, it gradually thins toward the front. Its average beam is wider, thicker than the external and internal beams, it is only concerned with the micro-traumatic pathology. Indeed, it is strongly stretched during damping mechanisms / propulsion encountered while running and jumping. The plantar fascia integrates with ankle-Achilleo-plantar system and is an extension of the Achilles tendon which "block" on the posterior aspect of the calcaneus.

This passive fiber structure is assisted in its function by an active element: the short plantar flexor. This meaty muscle located under the fascia follows a similar path. It also contributes to the tensioning of the plantar arch, it is biased eccentric and plyometric at receptions and impulses. Its calcaneal insertion may also suffer from microcracks.

Some biomechanical factors promote lesions of the plantar fascia. At the place of the stride, the heel of attack is responsible for contributing to the local strain suffering. static and dynamic plantar disorders also increase the constraints at this level. The hollow foot aggravated a calcaneal varus or short Achilles tendon fails to properly absorb each reception stride. Its fascia is weakened by its lack of flexibility. The flat foot associated with a calcaneal valgus collapse more readily overhand. That battering his plantar fascia sentenced to distension.

CLINICAL EXAMINATION

Usually the victim sportsman plantar myoapon├ęvrosite practice running or disciplines requiring many jumps. Lesions can occur for more moderate stress from 30 years. The patient complains of foot pain in the heel, rather internal. Typically it occurs gradually during training. Sometimes it can disappear after warming to reappear within minutes of stopping the activity.

The inspection found often static or dynamic disorders predisposing. The monopodaux jitter generally reproduce the pain. Sometimes, walking on tiptoes or on the heels enough. Rarely, short plantar flexor contraction is painful. Frequently, the tensioning of the fascia at the slope is sensitive. Systematically, the heel insertion myoapon├ęvrotique complex is painful. Sometimes it is the fibrous body is sensitive. Clinical examination strives mainly to eliminate the many differential diagnoses to consider in case of heel pain.

DIFFERENTIAL DIAGNOSIS

We must eliminate a rupture of the plantar fascia. It is necessary to search a stress fracture of the calcaneus, the Achilles insertion tendinopathy, osteochondrosis Sever, a bursitis, heel, heel pain in a crown, a nerve block syndrome calcaneal nerve or ankylosing.

In case of rupture of the plantar fascia, there is the sudden onset of pain during a pulse, followed by a major functional impairment. Fatigue fracture causes pain on the body of the calcaneus forward of the Achilles tendon. During insertion tendinopathy, the sensitive area is located behind the calcaneus. Children 9 to 11 victims of osteochondrosis Sever have trouble facing the growth zone at the lower back part of the calcaneus. In case of bursitis and heel, there is often a notion of violent reception on the heels and propulsion tests are painless. Individuals over 50 years old suffering from heel pain crown carry a very vertical calcaneus and complained of pain in peripheral horseshoe. Syndrome calcaneal nerve is responsible for paresthesia or burning on the inner side and bottom of the heel. They occur at night or during the racing activities especially if hyperpronation and aggressive buttress. There is often a "Tinel" positive in the tarsal tunnel, just above the calcaneus. In case of bilateral pain, sometimes at night, associated with low back pain, especially in young men, it must evoke ankylosing.

SUPPLEMENTARY EXAMS

X-rays may be helpful. It allows to better visualize the static disorders. Sometimes it shows a small erosion of the calcaneus opposite the insertion myoapon├ęvrotique complex. Classically, it highlights the famous "heel spur". Usually this bone spike is not responsible for the pain. It characterizes the history of mechanical traction on the calcaneus that caused the migration of some bone cells. These shots are mostly an opportunity to seek a stress fracture, an osteochondrosis, abnormalities of achil├ęenne insertion.

Ultrasound is optional. It is necessary in case of diagnostic doubt. It shows contributory expert hands. The fascia normally appears as a hyperechoic strip of 2 to 4 millimeters thick. In case of injury, it is thickened and surrounded by edema. Ultrasound allows especially to eliminate bursitis, hematoma, Achilles tendon pain or recent fascial rupture characterized by the existence of an anechoic area.

MRI is to consider if it persists diagnostic uncertainty. Cooperation is most effective to eliminate all the differential diagnoses. It is sometimes difficult to avoid confusion between old and a partial rupture hypertrophic myoapon├ęvrosite. The presence of lesions and inflammation in the underlying muscles and away from the insertion and the persistence of a concavity directed towards the micro-traumatic etiology.

TREATMENT

Nonsteroidal anti-inflammatory drugs can be prescribed but must be accompanied by an etiological support. The application of topical locally is irrelevant in view of the thick plantar keratinization.

Silicone heel pads help relieve the patient. They act on both lesional components. During the reception, they cushion the strain of impactions. During the drive, they reduce the voltage of the ankle-foot-Achilleo system. When there is a real disorder plantar dynamic, a pair of insoles is highly recommended.

Functional rehabilitation is particularly effective. The physical therapy techniques aim to mechanize the fascia. MTP help break the anarchic scar. Stretching then finally the eccentric and plyometric work promoting the realignment of the fibers in the axis constraints. This protocol provides a gradual retraining of the fascia. Gradually it found histological qualities essential to its biomechanical function.

Percussion shock wave may complete the treatment. They could act as "super MTP". They associeent traditional rehabilitation when it is insufficient.

The infiltrations are possible when the inflammatory component is important. They are practiced internally to avoid the formation of a scar callus on the sole of the foot. The X-ray or ultrasound guidance adjusts the screening on bone insertion or peri-fascial injection. After the plyometric activities against-indicated for 3 to 6 weeks.

The athlete must be relative rest. The maintenance of the physical condition of the injured is possible through many activities. Thus, he finds faster level in his chosen sport. Better yet, these practices gradually dosed involved in processing by promoting the mechanization of the fascia.

Running and jumping are not against-indicated if the heating removes the pain. However, the drive must stop when the pain comes back. The next session will be less burdensome if a gene occurs "cold" in the minutes following the cessation of effort.

In times Algonkian, swimming is highly recommended. A biking, ankle-Achilleo-plantar system assumes that concentric constraints and heel experiences no impaction. Distance runners and triathletes will appreciate these activities to maintain their endurance.

In order to keep the muscle skills plyometric lower limb, the open chain weight should be offered. In the absence of plantar support, it is possible to emphasize the eccentric strengthening of all muscle groups. Runners, jumpers, collective sports practitioners maintain more easily their relaxing qualities. They will have lots of aches when resuming their favorite sport.

Doctor St├ęphane CASCUA. - 11 janvier 2009.

Conflicts of interest: the author or authors have no conflicts of interest concerning the data published in this article.

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