Updated: 6/7/2021

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
    • Plantar fascia rupture
      • risk factors
        • athletes
        • minimalist runners
        • corticosteriod injections
      • treat with cast immobilization
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Questions (9)
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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
FIGURES:
1

Navicular stress fracture

1%

(34/2883)

2

Freiberg's Infraction

1%

(41/2883)

3

Plantar fasciitis

94%

(2710/2883)

4

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

2%

(60/2883)

5

Anterior tarsal tunnel syndrome

1%

(30/2883)

L 1 C

Select Answer to see Preferred Response

(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
1

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

93%

(1511/1623)

2

Immobilization in a short leg cast

4%

(61/1623)

3

Steroid injection of the plantar fascia

1%

(15/1623)

4

Custom made orthotic with arch support

2%

(27/1623)

5

Surgical release of the medial third of the plantar fascia origin

0%

(5/1623)

L 1 C

Select Answer to see Preferred Response

Evidence (26)
VIDEOS & PODCASTS (5)
CASES (1)
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