Plantar Fasciitis

Author: Derek Moore

Topic updated on 05/17/13 11:50am

Introduction

Plantar fasciitis is inflammation of the aponeurosis at its origin on the calcaneus
- a chronic overuse condition due to repetitive over-stretching of the plantar fascia
Pathoanatomy
- abductor hallucis, flexor digitorum brevis, and quadratus plantae share the origin on medial calcaneal tubercle and may be inflamed as well
Risk factors
- high BMI
- decreased ankle dorsiflexion in a non-athletic population
- tightness of the foot and calf musculature
- weight bearing endurance activity (dancing, running)
Associated conditions
- calcaneal apophysitis
  - usually occurs with concomitant calcaneal apophysitis

Anatomy

The plantar fascia is a thin layer of connective tissue supporting the arch of the foot

Presentation

Symptoms
- sharp heel pain
  - insidious onset of heel pain when first getting out of bed
  - worse at the end of the day after prolonged standing
- relieved by ambulation, warming up
Physical exam
- tender to palpation at medial tuberosity of calcaneus
- tight Achilles tendon (limited ankle dorsiflexion)

Imaging

Radiographs
- often normal
- may show plantar heel spur
Bone Scan
- useful to rule out stress fracture

Evaluation

EMG
- useful to rule out entrapment

Treatment

Nonoperative
- night splinting & stretching programs
  - indications
    - first line of treatment
  - technique
    - plantar fascia-specific stretching
    - achilles stretching
    - pre-fabricated shoe inserts
  - outcomes
    - stretching programs have equally successful satisfaction outcomes at 2 years
    - pre-fabricated shoe inserts shown to be more effective than custom orthotics in relieving symptoms when used in conjunction with achilles and plantar fascia stretching
- shock wave treatment
  - indications
    - second line of treatment
  - technique
    - painful for patients
  - outcomes
    - efficacious at 6 month f/u
Operative
- surgical release with plantar fasciotomy
  - indications
    - refractory disease
  - technique
    - can be done open or arthroscopically
    - resection of heel spurs does not improve outcomes
  - outcomes
    - complications common and recovery can be protracted

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Qbank (4 Questions)

TAG

(OBQ10.206) For the treatment of new onset plantar fasciitis, which of the following modalities results in the highest patient satisfaction at 8 weeks of follow-up? Topic

Review Topic

1. Achilles tendon–stretching program
2. Corticosteroid injection
3. Extracorporeal shock-wave therapy
4. Plantar fascia–specific stretching program
5. Distal tarsal tunnel decompression and partial plantar fascia release

PREFERRED RESPONSE ▶

DISCUSSION: A plantar fascia-specific stretching program has the highest patient satisfaction at the 8 week follow-up interval. Symptoms of plantar fasciitis include “start-up” inferior heel pain with patients often preferring to walk on their toes for the first few steps when getting out of bed. The pain lessens with ambulation and then increases again with increased activity. Illustration A depicts a patient performing plantar fascia-specific stretching. Illustration B displays a patient performing an achilles tendon–stretching program.

The review article by Neufeld and Cerrato details that stretching programs have been the primary treatment therapy modality for patients with plantar fasciitis. The purpose of plantar fascia–specific stretching is to recreate the windlass mechanism and achieve tissue tension through a controlled stretch of the plantar fascia.

The Level 2 study by Giovanni et al compared these 2 protocols and showed that heel pain was eliminated or improved at 8 weeks in 52% of patients treated with the plantar fascia–specific stretching program versus only 22% of patients participating in the Achilles tendon–stretching program. At 2-year follow-up, the study reported no difference between the two groups with 92% of all patients reporting total satisfaction or satisfaction with minor reservations.
Corticosteroids(Answer 2) should be used rarely as they can cause fat atrophy and even plantar fascia rupture. The FDA has approved extracorporeal shock-wave therapy(Answer 3) for plantar fasciitis lasting greater than 6 months. AAOS Comprehensive Orthopaedic Review states surgical treatment(Answer 5) is indicated for symptoms lasting greater than 9 months despite conservative management.

Illustrations: A

REFERENCES:

1. Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treatment. J Am Acad Orthop Surg. 2008 Jun;16(6):338-46. Review PMID:18524985 (Link to Abstract)

2. Digiovanni BF, Nawoczenski DA, Malay DP, Graci PA, Williams TT, Wilding GE, Baumhauer JF. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. J Bone Joint Surg Am. 2006 Aug;88(8):1775-81 PMID:16882901 (Link to Abstract)

Question Authors:

Michael Hughes MD,

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(OBQ07.173) A 34-year-old female has an insidious onset of heel pain when first getting out of bed and at the end of the day after prolonged standing. She works as a waitress and recently had bariatric surgery with a current BMI of 35. She has a gastrocnemius contracture noted on Silverskiold testing. AP and oblique radiographs are shown in Figure A and lateral radiograph is shown in Figure B. What is the most likely diagnosis? Topic

Review Topic

FIGURES: A

1. Navicular stress fracture
2. Freiberg's Infraction
3. Plantar fasciitis
4. First branch of the lateral plantar nerve (Baxter's) entrapment
5. Anterior tarsal tunnel syndrome

PREFERRED RESPONSE ▶

DISCUSSION: Classic symptoms of plantar fasciitis include “start-up” inferior heel pain with patients often preferring to walk on their toes for the first few steps when getting out of bed. The pain lessens with ambulation and then increases again with increased activity. None of the other options have this classic constellation of symptoms. Figures A and B do not show any evidence of fracture or osteonecrosis.

The Level 3 case-control study by Riddle et al found that reduced ankle dorsiflexion was the strongest independent risk factor for development of plantar fasciitis with an odds-ratio(OR) of 23. BMI >30 (OR=5)and work-related weight-bearing(OR=3) are independent risk factors for plantar fasciitis.

REFERENCES:

1. Garrick JG: Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Acadmey of Orthopaedic Surgeons, 2004, pp 249-261

2. Riddle DL, Pulisic M, Pidcoe P. Risk Factors For Plantar Fasciitis: A matched case-control study. J Bone Joint Surg Am 2003; 85: 872-877 PMID:12728038 (Link to Abstract)

Question Authors:

Michael Hughes MD, Ben Taylor MD,

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(OBQ06.37) A 44-year-old recreational runner began training for a half marathon 6 weeks ago. Over the last week he has developed heel pain that is worse in the morning upon awakening and when he arises from his desk at the end of the workday. Physical exam is notable for tenderness with direct palpation of the anteromedial heel. Which of the following is the best initial management? Topic

Review Topic

1. Stretching of the achilles tendon and plantar fascia along with a prefabricated shoe insert
2. Immobilization in a short leg cast
3. Steroid injection of the plantar fascia
4. Custom made orthotic with arch support
5. Surgical release of the medial third of the plantar fascia origin

PREFERRED RESPONSE ▶

DISCUSSION: The clinical presentation is consistent with plantar fasciitis. Initial treatment includes stretching of the plantar fascia and achilles tendon. Shoe inserts and heel cups may be beneficial in relieving symptoms as well. Symptoms often take up to 6 months or a year to resolve and surgical release of the plantar fascia should be reserved for the exceptionally recalcitrant cases. Pfeffer et al conducted a level 1 study of 236 patients with plantar fasciitis. All patients were treated with achilles tendon and plantar fascia stretching. The patients were then randomized to a custom orthotic or prefabricated insert. The patients who received a prefabricated insert demonstrated significantly greater improvement in clinical symptoms at 8 weeks. Harty et al conducted a biomechanical study of foot loading on live subjects. Lack of knee extension was associated with prolonged loading of the forefoot. The authors concluded that through the windlass mechanism of the plantar fascia, hamstring tightness may predispose the foot to development of plantar fasciitis. Illustration A demonstrates the proper technique of plantar fascia stretching through stabilization of the hindfoot and hyperextension of the toes. Illustration B demonstrates an achilles tendon stretch that also incorporates eccentric loading of the gastroc-soleus.

Illustrations: A

REFERENCES:

1. Pfeffer G, Bacchetti P, Deland J, Lewis A, Anderson R, Davis W, Alvarez R,Brodsky J, Cooper P, Frey C, Herrick R, Myerson M, Sammarco J, Janecki C, Ross S,Bowman M, Smith R. Comparison of custom and prefabricated orthoses in the initialtreatment of proximal plantar fasciitis. Foot Ankle Int. 1999 Apr;20(4):214-21. PMID:10229276 (Link to Abstract)

2. Richardson EG: Heel pain, in Coughlin MJ< Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St. Louis, MO, Mosby, 1999, pp 1090-1209.

3. Harty J, Soffe K, O'Toole G, Stephens MM. The role of hamstring tightness inplantar fasciitis. Foot Ankle Int. 2005 Dec;26(12):1089-92. PMID:16390645 (Link to Abstract)

Question Authors:

John Badylak MD,

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(OBQ06.103) A 40-year-old female presents to the physician for an initial visit with a 5-month history of plantar medial heel pain. She notices it immediately on getting out of bed in the morning, but the pain improves after a few steps. The pain is exacerbated throughout her workday to the point where she is unable to finish her work shift. Figure A shows a lateral radiograph of the affected heel. Which of the following is the most appropriate initial management? Topic

Review Topic

FIGURES: A

1. Walker boot immobilization with full weightbearing for 4 weeks
2. Corticosteroid injection to the plantar fascia
3. Surgical release of 50% of the plantar fascia
4. Heel spur resection
5. Achilles stretching exercises

PREFERRED RESPONSE ▶

DISCUSSION: This is the classic history of plantar fasciitis. The typical patient is 40-70 years of age and can point almost directly to the plantar medial heel as the source from where the pain emanates. It is a degenerative process associated with micro-tears of the plantar fascia. Figure A shows a calcaneal spur. It is widely accepted that heel spurs can occur concomitantly with plantar fasciitis, but they are not the etiology of the disorder. Treatment is predominantly aimed at intrinsic toe stretching (Illustration B) combined with achilles stretching (Illustration A) as gastrocnemius contractures are often found concomitantly. Night splints have also been found to help. If surgery is required because conservative management fails after 6-12 months, only the medial third of the plantar fascia is released so that the medial longitudinal arch is not compromised.

Illustrations: A

REFERENCES:

1. Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 249-261

2. DeLee JC, Drez D Jr, Miller MD: Heel pain, in DeLee JC, Drez D Jr, Miller MD (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 2446-2474.

Question Authors:

Michael Hughes MD,

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Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. Includes Poll

Digiovanni BF, Nawoczenski DA, Malay DP, Graci PA, Williams TT, Wilding GE, Baumhauer JF
J Bone Joint Surg Am. 2006 Aug;88(8):1775-81. PMID: 16882901 (Link to Pubmed)

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Evidence & References Show References

Level of Evidence 1 (Randomized Control Trial)

Pfeffer G, Bacchetti P, Deland J, Lewis A, Anderson R, Davis W, Alvarez R,Brodsky J, Cooper P, Frey C, Herrick R, Myerson M, Sammarco J, Janecki C, Ross S,Bowman M, Smith R. Comparison of custom and prefabricated orthoses in the initialtreatment of proximal plantar fasciitis. Foot Ankle Int. 1999 Apr;20(4):214-21. PMID:10229276 (Link to Abstract)

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

Harty J, Soffe K, O'Toole G, Stephens MM. The role of hamstring tightness inplantar fasciitis. Foot Ankle Int. 2005 Dec;26(12):1089-92. PMID:16390645 (Link to Abstract)
Riddle DL, Pulisic M, Pidcoe P. Risk Factors For Plantar Fasciitis: A matched case-control study. J Bone Joint Surg Am 2003; 85: 872-877 PMID:12728038 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Richardson EG: Heel pain, in Coughlin MJ< Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St. Louis, MO, Mosby, 1999, pp 1090-1209.
Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treatment. J Am Acad Orthop Surg. 2008 Jun;16(6):338-46. Review PMID:18524985 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
DeLee JC, Drez D Jr, Miller MD: Heel pain, in DeLee JC, Drez D Jr, Miller MD (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 2446-2474.
Digiovanni BF, Nawoczenski DA, Malay DP, Graci PA, Williams TT, Wilding GE, Baumhauer JF. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. J Bone Joint Surg Am. 2006 Aug;88(8):1775-81 PMID:16882901 (Link to Abstract)
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 249-261
Garrick JG: Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Acadmey of Orthopaedic Surgeons, 2004, pp 249-261

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Plantar Fasciitis

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