Rupture of the Plantar Fascia

Rupture of the Plantar Fascia

Plantar fascia rupture is not a very common injury, and it has the characteristic of acute pain in the arch of the foot. It occurs due to a tear in the plantar fascia, and that tear is painful. Rupture is often associated with long standing flat feet deformity or can occur from steroid injections. Another predisposing factor for plantar fascia rupture is plantar fasciitis.

Anatomy

The plantar fascia is formed by three bands: the medial, the central, and the lateral. The plantar aponeurosis is the central part of the plantar fascia. The plantar fascia is inserted into the medial tuberosity of the

calcaneus and extends distally, becoming broader and thinner. The plantar fascia acts as a bow string.

The rupture of the plantar fascia may be misdiagnosed as plantar fasciitis. When the plantar fascia tears, the patient will describe a tearing pain that usually occurs during athletic activity. The tear may be complete or incomplete. Complete tear of the plantar fascia occurs from sudden trauma or injury. The patient feels “popping” or “snapping” suddenly. Walking will be very difficult with tenderness, swelling and significant bruising on the sole of the foot (the condition is painful). Some patients may have a noticeable tightness of the calf muscle (equinus contracture) in association with rupture of the plantar fascia. Partial rupture is less common and occurs from overuse, as in running. MRI will identify the rupture, and it can also identify if the rupture is partial or incomplete. Rupture is often in the arch of the foot opposed to where the plantar fascia inserts into the heel (calcaneus). Ultrasound has the same accuracy as MRI for imaging the plantar fascia. Interpretation of the plantar fascia rupture may be difficult. You may need dynamic maneuvers with dorsal flexion of the forefoot to stretch the plantar fascia. Usually the proximal part of the plantar aponeurosis is clearly visualized on ultrasound. MRI is probably better in diagnosis plantar fascia rupture.

Treatment of Plantar Fascia Rupture

-Non-Weight Bearing for 2-3 Weeks

-Walking Boot

-Crutches

-Physical Therapy

-Surgical Treatment is the last resort.

-Could be used in some athletes who continue to have pain despite a well conducted conservative treatment

-Surgery is done to release the fascia and the excise the scar

Patients with rupture of the plantar fascia typically achieve a favorable outcome with return to full activity. 

Anterior Interosseous Nerve- The Benedictine and O.K. Sign

A patient with a complete anterior interosseous nerve injury or a high medial nerve injury should be asked to make a fist. The first and second digits will have difficulty in flexing, while the other digits will flex. The third digit will be weak, while the fourth and fifth digits are normal. This position of the hand is similar to the position taken during a hand blessing. The Benedictine sign is different from an “ulnar claw hand”. Ulnar claw hand refers to damage to the ULNAR nerve and is seen when attempting to extend all the digits (leaving the 4^th and 5^th digits flexed). The O.K. sign is used to check for paralysis of the anterior interosseous nerve due to entrapment or compression injury. A patient with paralysis of the anterior interosseous nerve will be unable to make the O.K. sign. This is due to weakness of the flexor pollicis longus and flexor digitorum profundus muscles. A typical pinch attitude is associated with anterior interosseous nerve injury.

The anterior interosseous nerve arises from the median nerve about 4-6cm distal to the elbow, which is about 1/3 of the way down the forearm. It exits from the anterolateral aspect of the median nerve and it runs between the radius and the ulna on the interosseous membrane between and below the muscles of the flexor digitorum profundus and the flexor pollicis longus.

The anterior interosseous nerve supplies the flexor digitorum profundus muscle for the index and long fingers. It also supplies the flexor pollicis longus and the pronator quadratus muscles. The flexor digitorum profundus muscle for the index and long fingers is supplied by the anterior interosseous nerve. The medial part of the FDP is supplied by the ulnar nerve (FDP has dual innervation). The anterior interosseous nerve passes dorsal to the pronator quadratus with the anterior interosseous artery and provides innervation to the volar wrist capsule. The terminal branch of the anterior interosseous nerve innervates the carpal joint capsule.

In patients with Martin-Gruber Connection, the median nerve, or anterior interosseous nerve to the ulnar nerve in the forearm may present with intrinsic muscle weakness. It may be differentiated also from Parsonage-Turner Synrome (acute brachial plexus neuritis) and patient may have pain in the affected extremity. In anterior interosseous nerve entrapment, the median nerve conduction study result will be normal, however the needle EMG of the anterior interosseous innervated muscles will be abnormal.

Profunda Femoris Artery

The profunda femoris artery is the main blood supply of the thigh. The profunda femoris artery arises from the posterolateral aspect of the femoral artery about 4 cm below the inguinal ligament. The profunda femoris artery crosses the pectineus muscle and the adductor brevis muscles, and runs under the adductor longus muscle. Then it runs between the adductor magnus and the adductor longus muscles. When it reaches the adductor magnus, it gives three perforating branches and it ends by perforating the adductor magnus as the fourth perforating branch. The perforating arteries are called “perforating” because they perforate the insertion of the adductor margnus in order to reach the back of the thigh. The first three perforating arteries are branches of the profunda femoris itself, while the fourth perforating artery is a continuation of the profunda femoris artery itself. During posterior exposure of the hip, partial section of more than 2cm of the gluteus maximus tendon attachment on the femur can be associated with a risk of injury to the first perforating branch. The profunda femoris artery gives the medial circumflex femoral artery and the lateral circumflex femoral artery. The MCFA will give the ascending, the acetabular, and transverse branches. The LCFA will give the ascending, the descending, and transverse branches.