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Updated: Apr 8 2022

Plantar Fasciitis

Images bone spur.jpg pf.jpg
  • summary
    • Plantar Fasciitis is a painful heel condition caused by inflammation of the plantar fascia aponeurosis at its origin on the calcaneus.
    • Diagnosis is made clinically with tenderness to palpation at the medial tuberosity of the calcaneus that worsens with dorsiflexion of the toes and foot. 
    • Treatment is a prolonged course of pain control, achilles/plantar fascia stretching, and orthotics. Rarely, surgical management is indicated in the case of progressive symptoms that fail nonoperative management. 
  • Epidemiology
    • Demographics
      • affects men and women equally
    • Anatomic location
      • affects the posteromedial heel
    • Risk factors
      • obesity (high BMI)
      • decreased ankle dorsiflexion in a non-athletic population (tightness of the foot and calf musculature)
      • weight bearing endurance activity (dancing, running)
  • Etiology
    • Pathophysiology
      • pathoanatomy
        • chronic overuse leads to microtears in the origin of the plantar fascia
        • repetitive trauma leads to recurrent inflammation and periostitis
        • abductor hallucis, flexor digitorum brevis, and quadratus plantae share the origin on medial calcaneal tubercle and may be inflamed as well
    • Associated conditions
      • calcaneal apophysitis
      • gastrocnemius-soleus contracture
      • heel pain triad
        • plantar fasciitis
        • posterior tibial tendon dysfunction
        • tarsal tunnel syndrome
      • anatomic variations
        • femoral anteversion
        • pes cavus
        • pes planus
  • 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, often when first getting out of bed
        • may prefer to walk on toes initially
        • worse at the end of the day after prolonged standing
      • relieved by ambulation
      • common to have symptoms bilaterally
    • Physical exam
      • inspection
        • tender to palpation at medial tuberosity of calcaneus
          • dorsiflexion of the toes and foot increases tenderness with palpation
        • limited ankle dorsiflexion due to a tight Achilles tendon
        • tenderness at origin of abductor hallucis
          • small subset of patients
          • indicative of entrapment or irritation of the first branch of the lateral plantar nerve (Baxter's nerve)
  • Imaging
    • Radiographs
      • not necessary on initial visit
        • often normal
        • may show plantar heel spur
      • optional films
        • weight bearing axial and lateral films of hindfoot
          • may show structural changes
    • MRI
      • indications
        • may be useful for surgical planning
    • Bone Scan
      • can quantify inflammation and guide management
      • useful to rule out stress fracture
  • Studies
    • Labs
      • not routinely indicated
      • useful if other causes of heel pain are suspected
        • inflammatory arthritis
        • infection
    • EMG
      • useful to rule out entrapment
  • Treatment
    • Nonoperative
      • pain control, splinting & therapy (stretching) programs
        • indications
          • first line of treatment
        • modalities
          • plantar fascia-specific stretching and Achilles tendon stretching
          • anti-inflammatories or cortisone injections
            • corticosteroid injections can lead to fat pad atrophy or plantar fascia rupture
          • foot orthosis
            • examples include cushioned heel inserts, pre-fabricated shoe inserts, night splints, walking casts
            • short leg casts can be used for 8-10 weeks
        • outcomes
          • 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
          • dorsiflexion night splint most appropriate for chronic plantar fasciitis
          • a non-weight bearing, plantar fascia specific stretching program is more effective than weight bearing Achilles tendon stretching programs
          • stretching programs have equally successful satisfaction outcomes at 2 years
      • shock wave treatment
        • indications
          • second line of treatment
          • chronic heel pain lasting longer than 6 months when other treatments have failed
            • FDA approved for this purpose
        • technique
          • painful for patients
        • outcomes
          • efficacious at 6 month followup
    • Operative
      • gastrocnemius recession
        • indications
          • no clear indications established
      • surgical release with plantar fasciotomy
        • indications
          • perisistent pain after 9 months of failed conservative measures
        • outcomes
          • complications common and recovery can be protracted
      • surgical release with plantar fasciotomy and distal tarsal tunnel decompression
        • indications
          • concomitant compression neuropathy (tibial nerve in tarsal tunnel)
        • technique
          • open procedure must be completed
        • outcomes
          • success rates are 70-90% for dual plantar fascial release and distal tarsal tunnel decompression
  • Technique
    • Surgical release with plantar fasciotomy
      • approach
        • can be done open or arthroscopically
        • open procedure is indicated if tarsal tunnel syndrome is present as well
      • release
        • release medial one-third to two-thirds
          • avoid complete release as it may lead to
            • destabilization of the longitudinal arch
            • overload of the lateral column
            • dorsolateral foot pain
        • consider simultaneous release of Baxter's nerve
          • release the deep fascia of abductor hallucis
          • may improve outcomes
  • Complications
    • Lateral plantar nerve injury
    • Complete release of the plantar fascia with destabilization of medial longitudinal arch
    • Increased stress on the dorsolateral midfoot
    • Chronic pain
    • Heel pad atrophy
    • Plantar fascia rupture
      • risk factors
        • athletes
        • minimalist runners
        • corticosteriod injections
      • treat with cast immobilization
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