Updated: 4/8/2022

Plantar Fasciitis

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  • 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
Flashcards (4)
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Questions (10)
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(OBQ18.93) A 48-year-old female presents with acute-on-chronic heel pain. She had been training for a marathon for 3 months when she felt an acute pop near her heel and has been unable to bear much weight since. Prior to this event, pain only occurred during the beginning of her runs and slowly subsided. Her family physician had placed her on a regimen of daily stretching and night-time splinting for 2 months prior to this incident, but also administered a pain shot in this area 3 weeks ago. She denies recurrent ankle sprains. What finding do you expect on physical exam and what is her diagnosis?

QID: 212989

Pain with resisted toe flexion, symptomatic os trigonum



Pes planus, rupture of the plantar fascia



Pes cavus, peroneal tendon subluxation



Pes planus, posterior tibial tendon insufficiency



Lateral ankle swelling, lateral talar process fracture



L 1 A

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(OBQ13.8) A 36-year-old male recreational golfer has been complaining of left plantar heel pain for nearly 6 weeks. His pain is worse with weight-bearing, especially the first steps in the morning or after long periods of rest. To date, he has been treating his pain with anti-inflammatory medications and physical therapy. His pain had improved by approximately 40% with these modalities, but the improvements are starting to plateau. What would you recommend next for treatment of his condition?

QID: 4643

Stop physical therapy and prescribe custom orthotics



Administer bi-weekly extracorporeal shockwave therapy to the heel



Endoscopic plantar fasciotomy



Bipolar radiofrequency to the heel



Night splints



L 2 C

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(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?

QID: 3299

Isolated Achilles tendon–stretching program



Corticosteroid injection



Extracorporeal shock-wave therapy



Plantar fascia–specific stretching program



Distal tarsal tunnel decompression and partial plantar fascia release



L 2 C

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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?

QID: 834

Navicular stress fracture



Freiberg's Infraction



Plantar fasciitis



First branch of the lateral plantar nerve (Baxter's) entrapment



Anterior tarsal tunnel syndrome



L 1 C

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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?

QID: 148

Stretching of the achilles tendon and plantar fascia along with a prefabricated shoe insert



Immobilization in a short leg cast



Steroid injection of the plantar fascia



Custom made orthotic with arch support



Surgical release of the medial third of the plantar fascia origin



L 1 C

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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?

QID: 289

Walker boot immobilization with full weightbearing for 4 weeks



Corticosteroid injection to the plantar fascia



Surgical release of 50% of the plantar fascia



Heel spur resection



Achilles stretching exercises



L 2 D

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Evidence (27)
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