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Plantar fasciitis

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There are many causes of plantar heel pain, but one of the most common is plantar fasciitis. Unfortunately, plantar fasciitis is poorly understood and the actual source of pain is still under debate. Some feel The most common explanation is that the pain is caused by trauma around the plantar calcaneal tuberosity from traction and shear forces from the plantar fascia, while others feel it is from a compressive neuropathy. Plantar fasciitis can be a painful and debilitating condition, which often frustrates not only the patient but also the treating physician because of its recalcitrant nature. Typical findings of the condition include pain and palpable tenderness in the area of the plantar-medial calcaneal tuberosity, significant “start up pain” when taking the first few steps in the morning, and worsening pain with prolonged weight-bearing. No universally accepted treatment algorithm exists for this condition, but fortunately more however, calf stretching (gastrocnemius) with the knee straight, plantar fascia specific stretching, the use of orthotics with a medial arch support, and activity modification have been demonstrated to be effective in improving symptoms in the vast majority of patients.  More than 90% of cases resolve with non-surgical conservative care within 6-8 weeks.1

Structure and function  

The plantar fascia is a multilayered, fibrous aponeurosis located at the sole of the foot that originates from the plantar aspect of the calcaneus. It spreads broadly from the central third of the foot at the medial tuberosity of the calcaneus, then divides into five digital bands at the metatarsalphalangeal joints. Each band inserts into the base of the proximal phalanges, and fibers merge with the dermis, transverse-metatarsal ligaments, and flexor tendon sheaths. Three distinct compartments of intrinsic plantar muscles are also formed through strong vertical septa that divide the medial, central, and lateral portions of the plantar fascia. The terminal branches of the posterior tibial nerve and artery and the medial calcaneal, medial plantar, and lateral plantar nerves supply cutaneous branches through the plantar aponeurosis.

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There is no widely accepted agreement as to the cause of plantar fasciitis , but mechanical although the end result is chronic microscopic (and sometimes macroscopic) injury to the plantar-medial origin of the plantar fascia.  Mechanical derangements and restriction of motion are at least contributory causes of both classic proximal fasciitis and the less-common distal plantar fasciitis. This is contrary to the popular belief that the presence of a heel spur is the causative factor in the development of plantar fasciitis. Recent studies, in fact, have suggested that only 50% of patients with heel pain will have heel spurs and even asymptomatic cases (15%) have heel spurs.5 Further, cadaveric dissections have revealed the presence of the spur within the flexor digitorum brevis as well as the abductor hallucis, rather than the plantar fascia itself.6 Thus, although heel spurs do indeed occur with heel pain, they are generally not considered the cause. Some have attributed heel pain to irritation of the medial calcaneal nerve or extensor digiti minimi branch of the lateral plantar nerve as it passes between the abductor hallucis and quadrates plantae. Loose attachment of the heel fat pad and its hyper-mobility, excessive loading of the heel pad, as well as fat pad inflammation and atrophy may also contribute to heel pain symptoms and have been categorized as overload heel pain syndrome.

The condition of plantar “fasciitis” denotes an inflammatory process, but histologic evidence is not in agreement with this notion. Findings demonstrate microtears in the fascia, myxoid degeneration, angiofibroblastic hyperplasia, and collagen necrosis.7 Such changes would suggest a non-inflammatory state of degenerative fasciosis secondary to chronic repetitive microtrauma of the plantar fascia at its originAn inflammatory model of the development of symptomatic plantar fasciitis does, however, gain support in the concept that the inflamed plantar fascia tightens microscopically injured plantar fascia attempts to heal itself via an inflammatory pathway. This leads to tightening of the plantar fascia and a build up of inflammatory mediators when the patient is at rest, especially as the foot and ankle assume a plantarflexed position at night. Upon ambulation, with the foot and ankle in forced into a now neutral and dorsiflexed position, the healing tissue contractsis strained, producing heel pain typically at the origin of the plantar fascia with the first few steps in the morning or after prolonged rest.

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Patients with plantar fasciitis almost universally, give a history of sharp, stabbing inferior heel pain with the first few steps in the morning after getting out of bed. Pain is often also associated with first steps after periods of inactivity such as sitting for lunch or after getting out of car. This pain is localized to the plantar medial aspect of the calcaneal tuberosity (Figure 1). It will often improve after some movement or stretching. However, it will tend to recur and worsen as the day progresses, particularly if the patient has had prolonged periods of significant weight-bearing activities such as walking or standing. The symptomatic patient will deny radiation of pain and will not usually have any associated parasthesia. Pain that is burning is not typical of plantar fasciitis and may suggest nerve irritation as a source of the pain (ex. Baxter’s neurtitis). Validated risk factors for the development of classic plantar fasciitis include: being overweight, a job or lifestyle that requires prolonged standing and walking, and a documented equines contracture.

Figure 1. Common location of plantar fascia pain

The foot and ankle physical exam should be thorough and include inspection of the patient’s stance, foot shape, and gait. A neurologic examination of the lower extremity and back should be done to explain paresthesias or abnormal sensation accompanying pain. The location of the pain, often at the medial plantar aspect of the heel, is important in making the correct diagnosis. However, patients may experience pain more distal to the origin as the plantar fascia extends into the medial arch or branches into the five digital bands. Although possible, variations of the typical clinical finding of plantar medial heel pain should warrant further investigation of other diagnoses. Lastly, the diagnosis can be further identified through dorsiflexion of the toes, which typically exacerbates the pain in patients with symptomatic plantar fasciitis (Figure 2).

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Plantar fasciitis is typically diagnosed based on the patient’s history and physical examination. Plain x-rays are not routinely indicated but can be used to rule out calcaneal tumors, fractures, abscesses, and foreign bodies. A lateral weight-bearing view of the foot will often demonstrate a calcaneal heel spur. Essentially, the same traction phenomena that causes overloading of the plantar fascia and its origin may cause excessive bone formation in the form of a calcaneal heel spur. However, the presence of a heel spur does not directly correlate with symptoms. Many patients have heel spurs on x-rays and are asymptomatic, whereas, many patients have significant plantar fasciitis and do not demonstrate a heel spur on plain x-ray.

A In very rare instances a triple-phase bone scan may be warranted as an imaging study of choice when trying to differentiate plantar fasciitis from other plantar heel etiologies. This test can provide objective evidence of predictable increased uptake in the medial calcaneal tubercle that can differentiate the diagnosis of plantar fasciitis from calcaneal stress fracture.8

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Sudden increases in activity or training should lead the clinician to further investigate the possibility of a calcaneal stress fracture. Infection or neoplasm are the most likely cause of plantar heel pain when described as unrelenting or nocturnal pain or when accompanied by constitutional symptoms such as unplanned weight loss, fevers or chills.

Red flags

Make sure to offer nonThe sudden onset of hell pain following a fall from a height requires that a fracture be ruled out.  Non-operative treatments for a minimum of six months and usually up to a year before treating a recalcitrant plantar fasciitis with should be tried as the vast majority of patients will get better without surgery.

Treatment options and Outcomes

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The vast majority of patients, 85-90%90+%, will have their symptoms resolve with non-operative treatment over a period of 32-6 months.1,12 The main components of an effective non-operative treatment program are calf and plantar fascia stretching, activity modification to avoid precipitating activities, and comfort shoe wear. Common non-surgical treatments also include short-term NSAID use, formal physical therapy, immobilization via cast or boot, steroid injections, and rarely extracorporeal shock wave therapy.

Calf (gastrocnemius) Stretching

Regular daily gastrocnemius (Figure 3 ) and soleus (Figure 4) -right leg) stretching performed over a 6- to 8-week period will alleviate plantar fasciitis in almost 90% of patients. The stretching should be performed for a total of 3 minutes per day. It should be done with the knee straight so that the gastrocnemius is stretched, as this is the muscle that is tight. It should be performed on both sides. Six sets of 30 seconds per side is one method of achieving this. It is important that the stretch be done daily. 

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Figure 3. Gastrocnemius stretch of the right leg. Note that the back knee is straight and the back foot is internally rotated.

Plantar Fascia Specific Stretching

Equally good results can be obtained with a plantar fascia stretch. Plantar fascia specific stretch has been found to provide symptomatic relief for the majority of patients. This is done in a seated position and includes crossing the affected leg over the other leg. Using the hand on the affected side, dorsiflex the affected foot (Figure 2). This creates tension/stretch in the arch of the plantar fascia. Appropriate stretch position can be confirmed by gently rubbing the thumb of the unaffected side left to right over the arch of the affected foot. The plantar fascia should feel firm, like a guitar string. The stretch position should be held for 10 seconds and repeated 10 times. The timing of when this is performed is important. It should be done prior to the first step in the morning and during the day before standing after prolonged inactivity. Most patients perform the stretch 4-5 times during the day for the first month, and then on semi-regular basis (3-4 times per week). Decreased pain , with improvement of about 25-50% is expected at 6 weeks, with resolution of symptoms over 3-6 months.

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Figure 3. Gastrocnemius stretch. Note that the back knee is straight and the back foot is internally rotated.

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Figure 4. Soleus stretch. Note that the back knee is bent and the back foot is internally rotated.

With resolution of the heel pain symptoms, it is important to continue calf stretching and plantar fascia stretching on a semi-regular basis (3-4 times per week) so as to minimize the risk of recurrence. These treatment modalities treat the symptoms, but do not fully address the underlying biomechanical predisposing factors. Therefore, ongoing management of this condition is essential.

Activity Modification

Any activity that has recently been started, such as a new running routine or a new exercise at the gym that may have increased loading through the heel area, should be stopped on a temporary basis until the symptoms have resolved. At that point, these activities can be gradually started again. Also, any activity changes that will limit the amount of time a patient is on their feet each day may be helpful. If the patient is carrying significant extra weight, losing weight can be helpful in improving the symptoms associated with plantar fasciitis. Essentially, anything that decreases the repetitive loading through the plantar fascia will help to alleviate the symptoms.

Orthotic Insert

A soft, over-the-counter orthotic with an accommodating arch support has proven to be quite helpful in the management of plantar fascia symptoms. Studies demonstrate that it is not necessary to obtain a custom orthotic for the treatment of this problem.

Comfort Shoes

Shoes with a stiff sole and rocker-bottom contour combined with an over-the-counter orthotic or a padded heel can off-load the plantar fascia at its origin and be very helpful in the treatment of plantar fasciitis.

Anti-inflammatory Medication

A short course of over-the-counter anti-inflammatory medications (NSAIDS) may be helpful in managing plantar fasciitis symptoms provided the patient does not have any contra-indications such as a history of stomach ulcers.

Corticosteroid Injection

For recalcitrant plantar fasciitis, some physicians will recommend a local injection of corticosteroids. This can be helpful in breaking the cycle of pain and give temporary relief but it provides minimal long-term beneficial effect in most patients.13 In order to avoid atrophy of the fat pad from corticosteroids, injection should be from the medial side. Injections will not change the underlying biomechanics, so they typically need to be combined with the stretching protocols that have been previously described. Some physicians have advocated using plasma-rich protein injections to increase the concentration of growth factors at the site of injury and augment the natural healing process of chronic plantar fasciitis. The research evidence for the use of this technique is limited; however, it does show compelling promise for clinical use if deemed successful by future clinical studies..

Plantar Fascia Night Splint

A night splint (Figure 5), which keeps the ankle in a neutral position (right angle) while the patient sleeps, can be helpful in alleviating the significant morning symptoms. This splint is worn nightly for 1-3 weeks until the cycle of pain is broken. Furthermore, this splinting can be reinstituted for a short period of time if symptoms recur.

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Figure 5. Plantar fasciitis night splint

Casting and Extra-corporeal Shockwave Therapy

In the small percentage of patients with continued symptoms despite the therapies discussed above, casting and extracorporeal shock wave therapy (ESWT) can be beneficial. Application of a short leg walking cast or boot for 4-6 weeks may minimize repetitive microtrauma by unloading the heel and immobilizing the plantar fascia. The efficacy of immobilization in relieving plantar fasciitis has been supported in several retrospective studies.14,15 ESWTis often performed under anesthesia and high-intensity shock waves are focused on the plantar fascia insertion. This creates a controlled injury to the plantar fascia breaking up scar tissue and causing inflammation. With the new blood supply entering this area as a healing response, the symptoms are often improved. There is a propensity for symptoms to gradually recur, although reasonable results have been reported at 6 month and 2-year follow-ups. ESWT therapy is well tolerated by most patients but should not be a treatment choice for patients with coagulopathies, hemophilia, malignancy, or open physes.


Operative TreatmentsTreatment

Surgery is a treatment option for patients with persistent symptoms, but is not recommended unless a patient has failed a rarely required to treat plantar fasciitis.  Only patients who have persistent symptoms despite religiously adhering to the nonoperative treatment for a minimum of 6-9 months of appropriate non-operative treatment. The surgery often should be considered for surgery.  Surgical treatment of plantar fasciitis does not fully address the underlying reason why the condition occurred, therefore the surgery may not be completely effective. There is also a risk of accidental injury of the medial calcaneal nerve which may produce neuroma and sensory impairment.

Partial Plantar Fasciectomy

Endoscopic or open partial plantar fasciectomy involves removal of the injured area of the plantar fascia. Decompression of the first branch of the lateral plantar nerve can be done along with partial plantar fascia release if suspicion of entrapment of the calcaneal branches of the tibial nerve exists. This is then followed by a 6-week period of relative rest and stretching. Although this procedure has produced good results, it can increase the risk of a rupture of the plantar fascia with resulting profound flatfoot deformity and an increase in symptoms. Complete release of the plantar fascia leads to flat foot and subsequent problems. Therefore, it is recommended that less than 40% of the plantar fascia be released. Complications from release of the plantar fascia include prolonged healing and rehabilitation times, alteration of the biomechanics of the foot leading to a decrease in arch height, increased strain of the plantar ligament's cuboid attachment areas, and increased stress to the midfoot and metatarsal bones. Postoperatively, patients may experience acute plantar fasciitis, heel numbness, neuroma formation, and infection.

Gastrocnemius Recession (Strayer or Volpius Procedure)

Recently there have been a few studies which suggest that gastrocnemius recession (Strayer or Volpius procedure) can help resolve the symptoms associated with plantar fasciitis as gastrocnemius contracture is a known risk factor for the development plantar fasciitis. This operation involves making an incision in the lower calf in order to releasing the tendon of the gastrocnemius at the point where it inserts just above the Achilles tendon. Following the surgery, patients need a six week period of relative rest. The gastrocnemius can have noticeable residual weakness that usually resolves in 6-12 months. At this time there are only limited studies assessing the long-term effectiveness of this procedure.

Radio frequency Ablation

A new, less-invasive surgical technique has been described that utilizes bipolar radiofrequency microtenotomy (Topaz Procedure) to treat recalcitrant plantar fasciitis.16 Studies indicate that the radiofrequency in wound healing could lead to increased angiogenesis. Patients have reported a rapid recovery with pain relief though 24 months. Unfortunately, this technique has not been subject to prospective, randomized trials and further studies need to be undertaken to solidify its efficacy.

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Risk factors for plantar fasciitis include excessive standing, increased body weight, increasing age, a change in activity level, Achilles tightness, and a stiff calf muscle (gastrocnemius)A pes planus or pes cavus foot deformity can increase loading through the plantar fascia and increase the risk of developing plantar fasciitis. However, any foot type can develop this condition. Seronegative spondyloarthropathies and Paget may be risk factors as well. 

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Key terms 

plantar fascia, plantar fasciitis, calcaneous, Achilles tendon

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Learn how to instruct patients on stretching the plantar fascia , Achilles tendon, gastrocnemius, and soleusand gastrocnemius.

References

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  2. Donley BG, Moore T, Sferra J, et al: The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: A randomized, prospective, placebo controlled study. Foot Ankle Int 2007; 28:20-23.
  3. Levy JC, Mizel MS, Clifford PD, et al: Value of radiographs in the initial evaluation of nontraumatic adult heel pain. Foot Ankle Int 2006; 27:427- 430.
  4. Tisdel CL: Heel pain, in Orthopaedic Knowledge Update: Foot and Ankle
  5. Davies MS, Weiss GA, Saxby TS: Plantar fasciitis: How successful is surgical intervention? Foot Ankle Int 1999; 20:803-807.
  6. Forman WM, Green MA: The role of intrinsic musculature in the formation of inferior calcaneal exostoses. Clin Podiatr Med Surg 7(2):217-223, 1990.
  7. Landorf KB, Keenan A, Herbert RD: Effectiveness of foot orthoses to treat plantar fasciitis: A randomized trial. Arch Intern Med 2006; 166:1305-1310.
  8. Saxena A, Fullem B: Plantar fascia ruptures in athletes. Am J Sports Med 2004; 32:662-665.
  9. Snook GA, Chrisman OD: The management of subcalcaneal pain. Clin Orthop 82:163-168, 1972.
  10. Kenzora JE: The painful heel syndrome: An entrapment neuropathy. Bull Hosp J Dis Orthop Inst 47:178-189, 1987.
  11. Buchbinder R: Clinical practice: Plantar fasciitis. N Engl J Med 2004;350: 2159-2166.
  12. Wolgin M, Cook C, Graham C, et al: Conservative treatment of plantar heel pain: Long-term follow-up. Foot Ankle Int 1994;15:97-102.
  13. Mizel MS, Marymont JV, Trepman E: Treatment of plantar fasciitis with a night splint and shoe modification consisting of a steel shank and anterior rocker bottom. Foot Ankle Int
  14. Chen HS, Chen LM, Huang TW: Treatment of painful heel syndrome with shock waves. Clin Orthop Relat Res 2001; 387:41-46.
  15. Gill LH: Plantar fasciitis: Diagnosis and conservative treatment. J Am Acad Orthop Surg 1997; 5:109-117.
  16. Ogden JA, Alvarez R, Levitt R, et al: Shock wave therapy for chronic proximal plantar fasciitis. Clin Orthop Relat Res 2001; 387:47-59.

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