Predictive Measurement for Windlass Change in Length and Selected Treatment Outcomes in Chronic Plantar Fasciitis

Published: March 01, 2024

doi:

Sahar Ahmed Abdalbary, Ahmad Alhaskawi, Haiying Zhou, Yanzhao Dong, Tian Tu, Pengfei Li, Hui Lu

¹Department of Orthopaedic Physical Therapy, Faculty of Physical Therapy,Nahda University in Beni Suef, ²Department of Orthopedics, The First Affiliated Hospital,Zhejiang University, ³Department of Plastic and Aesthetic Center, First Affiliated Hospital, College of Medicine,Zhejiang University

Summary

This protocol presents an objective, easy, and economical method to measure the change in length of the windlass in plantar fasciitis and assess the effectiveness of a selected treatment procedure employed in this study over a one-month period.

Abstract

Approximately 10% of patients with plantar fasciitis experience persistent and often severe symptoms, though little is known about its etiology. The goal of this study was to employ an objective, simple, and economical approach to measure the change in length of the windlass and assess the efficiency of a specified therapy protocol applied in this study over a one-month period. Age, weight, normal foot type, and gender were employed as matching factors in a matched design. Fifty individuals diagnosed with unilateral plantar fasciitis and an equal number of healthy volunteers all fulfilled the inclusion criteria and took part in this research. Pain assessment utilized a visual analogue scale and the pain subscale of the foot function index, while a valid goniometric method was employed to evaluate weight-bearing windlass, dorsiflexion and plantar flexion ranges of motion. Additionally, foot plantar pressure (both static and dynamic measures) and tape measurement of windlass change in length were assessed. The assessment was completed by all patients before and after their treatment program. Normal subjects were evaluated for control. Treatment methods encompassed ultrasonic therapy, application of an electrical heating pad, utilization of a night splint, engagement in stretching activities for the plantar aponeurosis and Achilles tendon, as well as both extrinsic and intrinsic strengthening exercises. After one month, the patients were reassessed and compared to control volunteers. In those suffering from plantar fasciitis, a substantial link was found between clinical measurements (tape measurement, windlass range of motion) and foot plantar pressure, indicating improvement. The chosen treatment protocol was effective in 96% of patients. For windlass length change, the measurement technique was found to be valid and objective. The chosen therapy procedure was successful in treating persistent plantar fasciitis in patients.

Introduction

Plantar fasciitis is characterized as an overuse syndrome involving localized inflammation of the plantar aponeurosis at its anatomical origin on the medial tubercle of the calcaneus¹. Although the exact cause is unknown, the prevailing opinion suggests that it arises from repeated partial tears and persistent inflammation within the plantar aponeurosis at its attachment point on the medial tubercle of the calcaneus². Plantar fasciitis has been theorized to result from weak plantar intrinsic or extrinsic muscles, which fail to provide adequate dynamic truss support for the longitudinal arch, thereby transferring additional tensile stress to the plantar aponeurosis. This excess tensile stress may lead to fatigue failure, triggering an inflammatory response and the formation of scar tissue, further shortening the tissue³.

While there is no gold standard diagnostic criterion for plantar fasciitis, the clinical presentation is widely recognized. Symptoms include pain and palpable soreness around the medial tubercle of the calcaneus, increased pain during the first few steps in the morning, and exacerbated pain with sustained weight-bearing. Despite extensive research efforts, foot surgeons continue to debate the cause, etiology, and optimal treatment strategy for plantar fasciitis⁴.

According to the windlass model, increased stresses on the first metatarsal head and hallux result in heightened tension in the medial slip of the plantar aponeurosis, offering a plausible explanation for the pain associated with plantar fasciitis. Pain may manifest in the aponeurosis or at its attachment to the bone when the aponeurosis is strained⁵. The windlass test stands out as the sole specialized diagnostic tool for detecting inflammation of the plantar fascia⁶. Using lateral radiography images of the foot in the loading position, the length of the plantar aponeurosis has been calculated as the distance between two bony markers: the calcaneal medial tuberosity and the base of the first metatarsal head⁷. The force generated by the contraction of the Achilles tendon serves as a reliable predictor of plantar aponeurosis tension⁸^,⁹.

Various conservative treatments, such as physical therapies, manual therapy, stretching exercises, and orthotic equipment, have been recommended for plantar fasciitis. Options also include taping, shoe adjustments, nonsteroidal anti-inflammatory drugs, cortisone injections, or combinations of these treatments¹⁰.

While there is no singular definitive treatment for plantar fasciitis, the condition can be managed in three stages: addressing the inflammatory lesion at the enthesis, correcting precipitating factors, and implementing a progressive rehabilitation program leading to a return to activity¹¹.

The objective of this study was to employ an objective, simple, and economical approach to measure the change in length of the windlass and assess the efficiency of a specified therapy protocol over a one-month period. The study investigated the response of patients with chronic plantar fasciitis to a treatment protocol involving structure-specific plantar aponeurosis stretching, Achilles tendon stretching, extrinsic and intrinsic foot muscle strengthening, a night splint, and the use of pulsed ultrasonic waves and an electrical heating pad. This regimen was selected based on clinical experience, with a significant percentage of patients reporting symptom relief. The hypothesis was that there is a correlation between clinical outcome measurements (tape and goniometer) and foot plantar pressure values, and that patients with chronic plantar fasciitis managed with this specific treatment protocol show improved outcomes after four weeks compared to measurements taken prior to treatment and those of normal subjects.

Participants
The study comprised two groups: one group included fifty patients diagnosed with unilateral plantar fasciitis, and another group consisted of fifty normal subjects. All patients were referred to the outpatient physical therapy clinic at Kasr Al-Aini Hospital by orthopaedic surgeons. Every patient experienced pain in the region where the plantar aponeurosis attaches to the medial tubercle of the calcaneus. In every instance, pain manifested when patients took their initial steps in the morning and intensified with weight-bearing activities throughout the day. Exclusion criteria encompassed patients diagnosed with spinal disorders, tarsal tunnel syndrome, cortisone injections in the heel area, or any pathology like hammer toe or hallux valgus, as well as anatomical abnormalities like pes cavus or pes planus that may predispose to the development of this condition, and the presence of a calcaneal spur. Patients with bilateral plantar fasciitis were also excluded. The mean age of the patients was 39.18 ± 5.43 years, with a gender distribution of 35 women and 15 men. The mean weight was 88.3 ± 11.46 kg, and the mean body mass index was 24.64 ± 32.76 kg/m². The mean duration between the onset of pain and admission to the study was 9 months.

This study was designed with a 1:1 matching, assigning one control for each patient, as 40% of individuals with unilateral plantar fasciitis develop symptoms in the contralateral limb¹². The control group was selected to compare the patients' measurements after treatment with those of normal subjects. Matching criteria included age, gender, weight, and body mass index. The control group comprised 50 subjects who reported never being diagnosed with plantar fasciitis and had no lower extremity injuries in the previous year or any abnormalities like pes cavus or pes planus. The control group was recruited from Kasr Al-Aini Hospital employment, with a mean age of 37.38 ± 38.6 years, a gender distribution of 36 women and 14 men, a mean weight of 88.94 ± 8.1 kg, and a mean body mass index of 24.5 ± 31.82 kg/m².

Protocol

All procedures conducted in this study adhered to the pertinent guidelines and regulations of Helsinki 2013. Ethical approval was obtained from Kasr Al-Aini Hospital's ethical committee. The informed consent form was prepared in accordance with the standards set by the Ethics Committee of the hospital and obtained from the patients by the hospital's secretary, who played no role in this trial. Eligible patients were thoroughly informed about the interventions before signing the consent form. All subjects provided…

Representative Results

The Statistical Package for the Social Sciences (SPSS, see Table of Materials) was employed for all statistical procedures, as all outcome variables exhibited a normal distribution. Means, standard deviations, and standard errors were used as summary statistics. Analyses were conducted to examine differences in the general characteristics of participants (patients and control groups), including age, gender, weight, and body mass index. Differences in each dependent variable of interest (pain, windlass ch…

Discussion

The outcomes for individuals with persistent plantar fasciitis are generally positive, with conservative therapy showing success rates ranging from 46% to 100%¹. Prolonged issues may lead to additional treatments, including surgery, but the recovery time is often lengthy and may not allow for full function²¹. Therefore, optimizing nonoperative therapy is crucial before considering surgical options. Despite its chronic nature, most nonoperative therapies for plantar fasciiti…

Disclosures

The authors have nothing to disclose.

Acknowledgements

None.

Materials

Electrical hot pad	koolpak.co.uk		Treatment by Heat; Reusable Hot & Cold Pack With Elasticated Strap & Physio Hot & Cold Pack
Goniometer	ASA TECHMED	ASATECHMED	Measure ROM; 6 Pcs 360° 12, 8 and 6 Inch Medical Spinal Goniometer Angle Protractor Angle Ruler
Pulsed ultrasonic	TAGWW		Ultrasonic-Personal-Massager-Spasmodic-Relaxation
Slant board	StrongTek		StrongTek Professional Wooden Slant Board, Adjustable Incline Board and Calf Stretcher, Stretch Board – Extra Side-Handle Design for Portability
SPSS software	IBM		https://www.ibm.com/products/spss-statistics?utm_content =SRCWW&p1=Search&p4 =43700078595923635&p5 =e&gclid=Cj0KCQiA2KitBh CIARIsAPPMEhJOBrK6zP 26critWGEWE_6CVZnZeG tXQmgdUh9Na0LgSspKzB Zg7vAaAvdIEALw_wcB&g clsrc=aw.ds
Tekscan software		version 5.20	https://www.tekscan.com/support/drivers

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