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The most common reason for pain in the inferior heel.
PF accounts for more than 1 million patient visits per year in the US, and more than 60% of these visits are in primary care offices.
A disorder of the connective tissue which supports the arch of the foot.
Plantar fasciitis is most common in patients age 45 to 64 years.
It is a disorder of the insertion site of the ligament on the bone characterized by micro tears, breakdown of collagen, and scarring.
About 80% of patients with heel pain, is due to plantar fasciitis.
The pain is in the heel and bottom of the foot that is usually most severe with the first steps of the day or following a period of rest.
Frequency about 4%.
Plantar fasciitis is estimated to affect 1 in 10 people at some point during their lifetime and most commonly affects people between 40–60 years of age.
Approximately 10% of people have the disorder at some point during their life.
Pain is brought on by bending the foot and toes up towards the shin.
The pain typically comes on gradually.
It affects both feet in about one-third of cases.
The pain is typically sharp and usually unilateral in 70% of cases.
It is commonly a result of some biomechanical imbalance that causes an increased amount of tension placed along the plantar fascia.
It is suggested that repetitive mechanical overload can induce microscopic tears, primarily at the plantar medial origin of the plantar fascia.
Such tears may be associated with collagen degeneration, fiber disorientation, increase mucoid ground substance, and calcifications.
The plantar fascia is a band of connective tissue deep to the fat layer at the base of the foot from the medial plantar tuberosity of the calcaneus to the base of the digits.
The plantar fascia is a thick fibrous band of connective tissue that originates from the medial tubercle and anterior aspect of the heel bone.
The fascia then extends along the sole of the foot before inserting at the base of the toes and supports the arch of the foot.
It occurs because of an abnormal force being placed on the plantar fascia.Things that can cause an abnormal force are excessive weight, overuse, or wearing shoes without a supporting arch.
Plantar fascia helps to support the medial longitudinal arch of the foot.
By stretching and contracting, the plantar fascia helps in balance.
Plantar fascia degenerative changes at its origin at the medial tuberosity of the calcaneus.
Plantar fasciitis is a non-inflammatory condition of the plantar fascia, with microscopic anatomical changes indicating that plantar fasciitis is due to a non-inflammatory structural breakdown of the plantar fascia related to repetitive microtrauma
Often, microscopic examination of the plantar fascia show myxomatous degeneration, connective tissue calcium deposits, and disorganized collagen fibers.
Inflammation plays either a lesser or no role.
Between 4% and 7% of the general population has heel pain at any given time.
In the United States alone, more than two million people receive treatment for plantar fasciitis annually, with a cost estimated to be $284 million each year.
Accounts for 10% of injuries connected with running.
Account of 11-15% of all foot symptoms among adults requiring professional healthcare.
Incidence peaks in ages 40-60 years but occurs in runners at a younger age.
Risk factors include obesity, prolonged standing, heel spurs, excessive running, poor running shoes, poor running surfaces, high-arches excessive pronation of the foot, a shortened Achilles tendon, decreased ankle dorsiflexion, and elevated BMI.
There is a step wise increase in the odds of PF as ankle dorsiflexion becomes more limited.
The condition tends to occur more often in women, military recruits, older athletes, dancers, the obese, and young male athletes.
Risk factors: Overuse, long periods of standing, stress on the heel, obesity, inward rolling of the foot, increased exercise, tightness of Achilles tendon, sedentary lifestyle, excessive running, running on hard surfaces, standing on hard surfaces for prolonged periods, high arches of the feet, flat feet,the presence of a leg length inequality, flat feet, not wearing the right footwear or insoles, diabetes,
Standing and walking places excess strain on the calcaneal tuberosity and contributes to the development of plantar fasciitis.
Plantar fasciitis may be due to a tendon injury involving the flexor digitorum brevis muscle located immediately deep to the plantar fascia.
There is a strong association between increased body mass index and plantar fasciitis in the non-athletic population.
The tendency of flat feet to excessively roll inward during walking/running increases susceptible to plantar fasciitis.
Obesity is seen in 70% of individuals who present with plantar fasciitis, an independent risk factor.
Achilles tendon tightness and inappropriate footwear have also been identified as significant risk factors.
Most cases resolve with time and conservative treatment.
About 90% of cases improve within six months with conservative treatment, and within a year regardless of treatment.
Conservative approaches: rest, massage, heat, ice, and calf-strengthening exercises; techniques to stretch the calf muscles, Achilles tendon, and plantar fascia; weight reduction in the overweight or obese; and nonsteroidal anti-inflammatory drugs.
NSAIDs fails to resolve the pain in 20% of people.
Tenderness over the anteromedial aspect of the inferior heel is often found.
Palpation of the inner aspect of the heel bone on the sole may elicit tenderness during the physical examination in plantar fasciitis.
First steps upon rising or after inactivity are painful and lessen with activity.
Usually its onset is insidious can begin following trauma.
Diagnostic imaging usually not needed for diagnosis.
Ultrasound measure of the thickness of the plantar fascia or MRI T2 weighted, hyperintensity in the origin of the plantar fascia and thickening of the plantar fascia can confirm the diagnosis.
Diagnosis is primarily based on medical history and physical exam.
Patients report pain at the plantar heel, which is most severe with the first steps in the morning.
Pain may worsen with prolonged standing.
There is generally tenderness to palpation at the plantar medial heel, which may be exacerbated with passive extension of the toes.
Findings of decreased dorsiflexion are associated with plantar fasciitis.
Palpation of the inner aspect of the heel bone on the sole may elicit tenderness during the physical examination in plantar fasciitis.
Because of excessive tightness of the calf muscles or the Achilles’ tendon,
the foot may have limited dorsiflexion.
Dorsiflexion of the foot may cause pain due to stretching of the plantar fascia with this motion.
Diagnosis based on symptoms.
Plantar fasciitis is usually diagnosed by a history, risk factors, and clinical examination.
The plantar fascia has three fascicles-the central fascicle being the thickest at 4 mm, the lateral fascicle at 2 mm, and the medial less than a millimeter thick.
Plantar fasciitis becomes more likely as the plantar fascia’s thickness at the calcaneal insertion increases.
A thickness of more than 4.5 mm ultrasound and 4 mm on MRI are useful for diagnosis.
Other imaging findings, such as thickening of the plantar aponeurosis, are nonspecific and have limited usefulness in diagnosing plantar fasciitis.
If the diagnosis is in doubt, lateral view X-rays of the ankle are the recommended to assess for other causes of heel pain, such as stress fractures or bone spur development.
Three-phase bone scan is a sensitive modality to detect active plantar fasciitis,and can be used to monitor response to therapy, as demonstrated by decreased uptake after corticosteroid injections.
Differential diagnosis: calcaneal stress fracture, calcaneal bursitis, osteoarthritis, spinal stenosis involving the nerve roots of lumbar spinal nerve 5 (L5) or sacral spinal nerve 1 (S1), calcaneal fat pad syndrome, metastasized cancer from elsewhere in the body, hypothyroidism, seronegative spondyloparthopathies such as reactive arthritis, ankylosing spondylitis, or rheumatoid arthritis, plantar fascia rupture, and compression neuropathies such as tarsal tunnel syndrome or impingement of the medial calcaneal nerve.
Bone scan positive in 60-98% of case indicating increased blood flow, pooling and often increased focal activity at the plantar insertion site in the calcaneus bone.Since the disease is self-limiting no clear-cut beneficial treatment plan.
Conservative management
Plantar fasciitis is typically self-limiting be may persist for months to years.
Patients should avoid activities that exacerbate symptoms.
Treatment consist of stretching, orthotics, physical therapy, splints, corticosteroid injections, platelet rich plasma, injections.
Nonsteroidal anti-inflammatory drugs are not efficacious.
Heel spurs are commonly present with plantar fasciitis, but their association is unknown.
An associated incidental finding with this condition is a heel spur.
A ((heel Spurs)), small bony calcification on the calcaneus which can be found in up to 50% of those with plantar fasciitis.
The underlying plantar fasciitis that produces the heel pain, and not the spur.
Initial management is rest, change of activities, pain medications, and stretching.
Other options include physical therapy, orthotics, splinting or steroid injections.
Orthotic devices and taping techniques that reduce pronation of the foot and reduce load on the plantar fascia result in pain improvement.
Foot orthoses replace the install of the patients shoe to decrease train on the plantar fascia and reduce crowned reaction forces beneath the calcaneal tuberosity.
Nightsplints tay dorsflex the ankle and extend the toes during sleep can result in an improvement.
The evidence to support the use of foot orthoses is mixed.
Extracorporeal shockwave therapy is considered for persistent symptoms.
PRP injections for plantar fasciitis may be more effective in long-term corticosteroids.
Corticosteroid injections are sometimes used for refractory cases: injected corticosteroids are effective for short-term pain relief only.
Additional effort, if the above measures are not adequate, may include extrcorporeal shockwave therapy or surgery.
Plantar iontophoresis a technique of applying anti-inflammatory substances such as dexamethasone or acetic acid topically to the foot and transmitting these substances through the skin with an electric current may be helpful.
Some evidence suggests the use of night splints for 1–3 months to maintain the ankle in a neutral position passively stretching the calf and plantar fascia during sleep, may be helpful.
Plantar fasciotomy is a reserved treatment for refractory plantar fasciitis that does not resolve after six months of conservative treatment.
76% of people who undergo endoscopic plantar fasciotomy have complete relief of their symptoms.
Heel spur removal during plantar fasciotomy does not appear to improve the surgical outcome.
Complications of plantar fasciotomy include: nerve injury, instability of the medial longitudinal arch of the foot, fracture of the calcaneus, prolonged recovery time, infection, rupture of the plantar fascia, and failure to improve the pain.
Plantar fasciitis is the most common type of plantar fascia injury.
Extracorporeal shockwave therapy is associated with greater reduction in pain tam placebo.
Surgery reserved for patients who have not responded to conservative treatment after 6-12 months.
Surgical procedures include partial plantar fascialectomy. partial plantar release, gastrocnemius release, without specific benefit for one surgical option.
Complications include injection site pain, which is the most common complication of corticosteroid injection.
Plantar fascial rupture occurs in approximately 2.4% of patients injected with corticosteroids, more commonly following multiple injections.
Complications of plantar fascia release include wound complications and dorsal foot mid foot pain.
Gastrocnemius release can cause sural nerve damage and plantarflexion weakness.