1. Allama Iqbal Medical College, Lahore, Pakistan; naseem-jamil11@gmail.com
2. Allama Iqbal Medical College, Lahore, Pakistan; shamsi-prof@gmail.com
3. Allama Iqbal Medical College, Lahore, Pakistan; gill_sara039@gmail.com

*             Correspondence: gill_sara039@gmail.com

Keywords: myofascial release, stretching, efficiency, planter fascia

1. INTRODUCTION

Planter Fascitis is defined as most common cause of heel pain characterized by inflammation of a thickened band of tissues present at the lower side of the foot. Planter Fascitis is associated with stab like pain that is more severe in the morning time [1]. Plantar Fascitis also known as Planter heel pain is most prevalent condition affecting large number of general community. Planter Fascitis is health problem affecting 1 in 10 people during lifetime. It is most common prevailing complaint causing foot pain in both athletic and non-athletic community. Its incidence peak at the age of 40 – 60 years and it equally affects both Genders males and females. This disease is not gender biased [2]. Foot is the important locomotor organ of human body that play an important role in stability and gait of human body. Foot is the dial part of skeletal system comprises of 26 small bones covered dorsally by loose skin while plantar surface covered though thick hairless skin [3]. The bones of foot are designed as: tarsal including seven bones as Talus, calcaneus, navicular, cubeoid and 3 cunrifoems as medial, intermediate and lateral cuneiforms. Metatarsals as these are small bones five in number that forms the plantar area of foot and attaching tarsals to phalanges. Phalanges these are 14 small bones, forming basic toes of foot, on which tiptoe movement occur. Big toe has only two phalanges while remaining toes have three phalanges [4]. The inferior surface of foot is covered through a thick fascia named as plantar fascia. It is white connective tissues in white fibers are arranged in longitudinal fashion [5]. The fascia extends from the medial calcaneal tubercle of calcaneus bone and extends up to the toes by blending with the five bands of flexor tendons .The fascia is thicker at the central portion while its origin and insertion is thinner as compared to central potion. It is important as it act as thick fat pad that have the ability to absorb shock 110% during walking and 250% shock during running [6]. The vascular supply of foot begins from popliteal artery gives off superficial femoral artery that gives three main branches of lower leg anterior tibial artery, peroneal artery, and posterior tibial artery. Anterior tibial artery supply Anterior and dorsal part of foot. Dorsalis pedis artery supply extensor hallucis longus and give medial and lateral branches. Medial branches are medial tarsal arteries and arcuate artery. The lateral branches are proximal tarsal arteries, distal tarsal arteries and the arcuate artery [7].  The main venous supply of foot is deep veins and superficial veins of lower limb [8]. Plantar fasciitis (PF) is the common pathology of foot. The causes of planter fasciitis ranges from deformities in anatomical structures including flat foot, causes related to biomechanical changes for example increased movement at subtalar joint of foot. It is also caused by diabetes mellitus which is a chronic disease and is associated with obesity [9]. Of the many risk factors contributing to Planter Fasciitis includes decreased dorsiflexion of foot, obesity with increase in body mass index, sedentary life style and occupations requiring standing for prolonged period of time [10]. Other factors and causes are increase foot pronation, increase and sudden weight bearing activities, improper shoe, sub calcaneal spur formation, leg length discrepancy and weakness / tightness of gastrosoleus muscle [11]. The pathophysiology of PF is described as degenerative condition in which multiple described factors lead to degeneration of plantar fascia. This is aggravated by the repetitive micro-tearing of fascia. This tearing causes initiation of local inflammatory response. There is increase in the activity of advanced glycation end-products (AGEs) that cause increase cross linkage of collages that alter the organization of collagen and lead to thickening and painful origin of plantar fascia [12]. Diagnosis of PF is highly depending on signs and symptoms, physical examination and diagnostic tools. Plantar Fasciitis is associated with signs and symptoms of sharp pain at the lower side of heel, patients feel extreme problems with walking. Often patient’s presents with pain at morning time and pain with extended time of sitting and lying in non-weight bearing positions. When chronic, Planter Fasciitis affects quality of life by affecting activities of daily life, limitations of physical activity and social isolation of patients [13]. Pain is aggravated by palpating at heel and passive dorsiflexion of foot and toes. There is tightness of gastrocnemius muscle and pes planus or pas cavus history [14]. Physical examination includes ankle passive dorsiflexion, eversion test and Windlass test. Among all, Windlass test is highly reliable and valid test with 100% specificity. Physician-stabilized test performed by flexing knee at 90 degree and affected ankle. The metatarsophalangeal joint is extended with flexion of Interphalangeal joint this lead to production of signs and symptoms [15]. Other than physical examination, X-Rays and Ultrasounds are most authentic diagnostic tools that help in making an accurate diagnosis of PF. Heel spur or calcification of heel is identified through X-Ray and Ultrasound. Furthermore, Ultrasound provides detail information about thickenings of plantar fascia and signs of inflammation. MRI can also be used for identification of any tear, stress fracture and defects at osteochonrdal level [16, 17]. There are many management options available for plantar fasciitis. This wide list of treatment options includes NSAIDs, orthosis, rehabilitation programme and injection of steroids. Among several conservative options for management, extracorporeal shock wave therapy is also considered as one of standardized treatment for Planter Fascitis [13]. Physiotherapy provides additive effectiveness in the cure of patients with Planter Fascitis. Among physiotherapy management plans, soft tissue techniques can prove to be effective for pathologies associated with Planter Fascitis to reduce pain and improve functional status of patients [16]. Myofascial release technique for Planter Fascitis by utilizing gentle pressure can prove to be beneficial to reduce pain and eliminating restrictions which are due to excessive usage and injury to fascia. The purpose of Myofascial release technique is to remove restrictions which are present in the deep parts of the fascia. This can be achieved through stretching the elastic parts of musculature of planter fascia. It assists in changing the viscosity for the elastic components of planter fascia [17]. Myofascial release technique is also beneficial when given along with Strengthening of lower limb to patients with Planter Fascitis and assists in reduction of pain and improving the functional status hence prevent foot deformities among patients with Planter Fascitis [18].  Planter fascia stretching plays a beneficial role in management of Planter fasciitis. Stretching of planter fascia can be performed in different ways it could be active or passive stretching and it can prove to be beneficial in patient with Planter Fascitis. It causes changes in elastic, plastic properties of soft tissues that results in wellness as well as it results in decreased chances of injury and re-injury to soft tissues. Plantar Fasciitis is highly prevalent condition affecting large population because of occupations requiring prolonged standing or sitting positions. Large population is enrolled in job and occupations to meet the ends, fulfilling the job requirements. The purpose of this study was therefore to improve functional status in patients with Planter Fascitis. The purpose to conduct this study to review the prevention of deformities associated with Planter Fascitis as well as education among society about the causes and prevention of planter fasciitis so that functional status of affected population can be improved.

2. LITERATURE REVIEW

In 2022, a study was performed by Laizu yeasamine Lipa, Abhijit Kalitta to determine the effectiveness of Myofascial release technique on patients with Planter Fascitis. 30 subjects were added in study and randomized into two study groups with 15 patients in each group. Myofascial release technique was assigned to one group with stretching and Myofascial release technique to the second group. Study demonstrated that Myofascial release technique is effective in management of planter fasciitis [17]. A randomized control trial was performed by Ratgleff and colleagues involving 48 patients with ultrasonographic verified Planter Fascitis randomized into two study groups. 24 patients were randomized to Planter specific stretching and 24 patients to high load strength training Outcomes showed that patients randomized to high load strength training reported significant decreased heal pain [19]. In 2019, a randomized control trial was performed involving 84 patients with Planter Fascitis by Suthasinee and colleagues. All patients received 8 physical therapy interventions two times a week. They were assigned Strengthening and stretching techniques every day with 3 repetitions a day. Results showed significant reduction of pain, including morning pain and improvement in ranges and functional performance [20]. In 2021, a trial was performed by Anam Javed, Rabbiya Riaz, Iqra Khalid, Nasir khan. 30 patients were allocated in two group each group having 15 patients with diagnosed Planter Fascitis. Group 1 received Myofascial release technique with conventional therapy while On the other hand group B assigned conventional therapy alone. Study results showed that mayofascial release technique with conventional therapy was beneficial in patient with Planter Fascitis to reduce pain [22]. In 2018,Richa Dipak Shah, G Varadharajulu performed a randomized control trial involving 40 subjects allocated two group with 20 patients in each group. Group A was given conventional therapy alone while Group B was given Myofascial release technique with conventional therapy. Myofascial therapy in the form of Myofascial release showed improvement in functional status and reduction of pain (22). In 2019,study was performed by Hemlata,Shama Parveen and Neraj Kumar involving patients randomized in two groups. Group A was assigned mayofascial release technique while Group B was given Stretching techniques to determine the effectiveness of Myofascial release technique and stretching of planter fascia on Planter Fascitis. It was concluded group received mayofascial release techniques showed better results than individuals receiving stretching [23]. A study results supported by Siriphon et al (2020) that stretching is most effective treatment protocol in managing plantar fasciitis patients as compared to other approaches. The patients managed by stretching showed significant improvement in VAS scoring [23]. Similarly current study results were confirmed by Engkananuwat et al (2018), reported that stretching exercises lead to produce significant improvement in VAS scoring along with foot and ankle scoring within 4 week of intervention [24]. Do K et al (2018) also reported that Myofascial release by using foam roller produce acute effects in pain and functional status of plantar fasciitis wit p-value <0.05 [25]. Another study supported our study results. In this study, the pain was assessed by using Visual Analogue scale (VAS) which showed marked reduction in the pain intensity level in both groups which confirmed that Myofascial release and Stretching are clinically and statistically are better options for the treatment of the plantar fasciitis. That is according to current study result as group treated with Myofascial release showed significant improvement in pain and FFI scoring. Do K et al (2018) also reported that Myofascial release by using foam roller produce acute effects in pain and functional status of plantar fasciitis wit p-value <0.05 [26]. Similarly, Siriphon et al (2020) demonstrated that stretching is most effective treatment protocol in managing plantar fasciitis patients as compared to other approaches. The patients managed by stretching showed significant improvement in VAS scoring [27]. Similarly current study results were confirmed by Engkananuwat et al (2018), reported that stretching exercises lead to produce significant improvement in VAS scoring along with foot and ankle scoring within 4 week of intervention [28]. Hemlata et al (2019) reported a comparative study of Myofascial release and stretching exercises in managing plantar fasciitis patients.

3. CONCLUSIONS

The results of this study concluded that Myofascial release and Stretching were effective to improve pain and functional status in patients suffering with plantar fasciitis. However, on comparison; it was concluded that there was no statistical significant as Stretching was statistically highly significant in reducing pain and improving functional status in patients suffering with plantar fasciitis.

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