Plantar Fasciitis
Anna Dumont
Douglas J. DiOrio
BasicsDescription
-
Degeneration and irritation of the plantar fascia origin at the medial calcaneal tuberosity on the anteromedial side of the heel and surrounding perifascial structures
-
Synonym(s): Enthesopathy of plantar fascia; Plantar fasciosis
Epidemiology
-
Plantar fasciitis accounts for 80% of patients with plantar heel pain.
-
Nearly 2 million patients receive treatment each year in the U.S.
-
In the running population, plantar fasciitis accounts for 10% of running injuries.
-
Peak age of incidence is between 40 and 60 yrs, but can occur in adults of all ages.
Risk Factors
-
Excessive torsion and hyperpronation with poor supporting footwear
-
Poor shock dissipation with cavus foot
-
Hindfoot valgus with pronation deformity
-
Limited ankle dorsiflexion
-
Obesity and those who are on their feet most of the day
Etiology
-
∼50% of patients with plantar fasciitis will have heel spurs. Up to 19% of patients without plantar fasciitis will also have heel spurs. Heel spurs can occur with plantar fasciitis, but they are not the cause.
-
Histologic findings include myxoid degeneration, microtears in the fascia, collagen necrosis, and angiofibroblastic hyperplasia.
DiagnosisHistory
-
Insidious and progressive pain in the inferior heel
-
Worst with 1st few steps out of bed in the morning
-
Worsens after period of prolonged standing
-
Pain tends to lessen with activity and worsens at the end of the day.
-
Pain exacerbated with walking barefoot, on toes, or up stairs
Physical Exam
-
Pain at the anteromedial aspect of the heel
-
Worsens with activity such as running or walking
-
Worst pain with 1st few steps in the morning
-
Pain intensity increases with prolonged weight-bearing, especially while walking barefoot and in dress shoes.
-
Pain can radiate across the medial side of the heel and less so to the lateral aspect.
-
Pain can involve both feet.
-
Pain can be described as throbbing, searing, or piercing.
-
Tenderness localized to anteromedial aspect of the heel with palpation
-
Tight Achilles heel cord
-
Pes planus or pes cavus foot deformity
-
Passive range of motion: Hypermobility of subtalar joint, midtarsal joint, and 1st ray
-
Pain with passive dorsiflexion of toes
-
Gait evaluation: Calcaneus everted at heel lift
Diagnostic Tests & Interpretation
Imaging
-
Imaging plays a limited role in routine clinical evaluation and is rarely needed. Radiographic evaluation would be appropriate in patients who fail to improve with appropriate treatment in a reasonable amount of time or if patient presents with an atypical history or physical exam.
-
X-rays may show calcifications in the soft tissues around the heel or osteophytes on the anterior calcaneus (ie, heel spurs). US may show thicker heel aponeurosis.
-
Triple-phase bone scan can differentiate between plantar fasciitis and a calcaneal stress fracture. A bone scan or MRI should be ordered when heel pain has not improved after 4–6 mos of nonsurgical treatment.
P.475
Differential Diagnosis
-
Skeletal:
-
Calcaneal stress fracture
-
Bone contusion
-
Subtalar arthritis
-
Inflammatory arthropathies
-
Infections (osteomyelitis/subtalar pyoarthrosis)
-
-
Soft tissue:
-
Intrinsic muscle strain (abductor hallucis, flexor digitorum brevis, quadratus plantae)
-
Plantar fibromatosis
-
Plantar fascia rupture
-
Achilles tendinitis
-
Posterior tibial tendinitis
-
Retrocalcaneal bursitis
-
Fat pad atrophy
-
-
Neurologic:
-
Entrapment of branches of the posterior tibial nerve usually at or after passage through the posterior tarsal tunnel: Medial plantar nerve, lateral plantar nerve, or medial calcaneal nerve
-
Radicular symptoms of L4–S1 (sciatic nerve)
-
Abductor digiti quinti nerve entrapment
-
Peripheral neuropathy
-
Treatment-
NSAIDs of choice for analgesic effect
-
Early morning stretching of heel cord as well as throughout the day
-
Ice massage and deep friction massage of the arch and insertion
-
Shoe inserts: Prefabricated insoles (ie, soft heel pads/Silastic), custom orthotics, or medial heel wedges
-
Arch taping during athletic activities
-
Motion-control shoes with rigid heel counters
-
Posterior-tension night splints
-
Supination strap
-
Judicious use of long-acting steroid injections for the in-season athlete (1–3/yr)
-
Risk of fat pad atrophy must be noted
-
Dexamethasone (Decadron) iontophoresis
-
Physical therapy with plantar fascia: Specific stretching and Achilles tendon stretching programs
-
Extracorporeal shock wave therapy
-
Walking cast
-
Conservative therapy should be used for a minimum of 6 mos and, preferably, for 12 mos because >90% respond positively to nonsurgical management.
Complementary and Alternative Medicine
Acupuncture
Surgery/Other Procedures
-
Surgery can be considered after failure of extensive conservative therapy, even up to 2 yrs: Operative release of proximal fascia of deep abductor fascia
-
Plantar fasciotomy can be either partial or complete and is a common surgical procedure for treating recalcitrant cases of plantar fasciitis.
-
Postoperative therapy includes splint for 2 wks, mild stretching and ambulation with crutches and walking boot, pool running for 3 wks, and return to activity in 3–4 mos.
Additional Reading
Clanton TO, Porter DA. Primary care of foot and ankle injuries in the athlete. Clin Sports Med. 1997;16:453–466.
Cole C, Seto C, Gazewood J. Plantar fasciitis: evidence-based review of diagnosis and therapy. Am Fam Phys. 2005;72:2237–2242.
Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treatment. J Am Acad Orth Surg. 2008;16:338–346.
CodesICD9
728.71 Plantar fascial fibromatosis
Clinical Pearls
-
Surgery should only be considered after exhaustive conservative treatment of at least 6 mos to 1 yr has failed.
-
A Cochrane review showed that corticosteroid injections improved plantar fasciitis at 1 mo but not at 6 mos when compared with control groups.