Foot

Plantar Fasciitis

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Plantar Fasciitis, Painful Heal Syndrome, Plantar Fasciopathy

  • Epidemiology
  1. Most common cause of plantar Heel Pain
    1. More than 1 Million patient visits per year in U.S.
  2. Peak Incidence ages 40 to 60 years old
  3. More common in women
  4. Lifetime Prevalence in U.S.: 10%
  • Anatomy
  1. Plantar fascia
    1. Connective tissue band
    2. Originates at medial tubercle of Calcaneus
    3. Inserts at proximal phalanges at each Metatarsal head
  2. Plantar fascia forms longitudinal foot arch stabilization
    1. Important for normal gait
    2. Plantar fascia cycles between stretch and contract while standing
    3. More prone to overuse and injury in over-pronation (from limited ankle dorsiflexion)
  • Pathophysiology
  1. Limited ankle dorsiflexion results in foot over-pronation, over-loading the plantar fascia
  2. Repetitive micro-tears of the plantar fascia
  3. Results in collagen degeneration at medial calcaneal tubercle (plantar fascia origin)
  4. Inflammation is not the primary process
    1. Therefore, antiinflammatory approaches are less effective
  • Risk factors
  1. Functional abnormalities
    1. Athletes: Overuse Injury (especially runners)
      1. More time on feet increases risk of repetitive injury
    2. Non-athletes
      1. Limited Ankle Dorsiflexion due to tight or weak muscles or tendons (most common)
        1. Tight Achilles tendon or heel cord (limited ankle dorsiflexion)
        2. Tight or weak gastrocnemius or soleus muscles
      2. Other risks
        1. Body Mass Index >27 kg/m2
        2. Standing or walking for most of workday
    3. Older patients
      1. Mechanism
        1. Weak foot intrinsic muscles
        2. Acquired flat foot
        3. Thinning of heel fat pad (exposes the plantar fascia insertion to compression)
      2. Characteristics of pain
        1. Localized pain in central heel
        2. First steps in morning not provocative
      3. Benefit from heel pads or heel cups
  2. Anatomic abnormalities
    1. Limited ankle dorsiflexion
    2. Over-Pronated foot
    3. Leg Length Discrepancy
    4. Forefoot varus
    5. Lateral tibial torsion
    6. Femoral Anteversion
    7. Abnormal longitudinal foot arch
      1. Low arch: Pes Planus (flat foot)
      2. High arch: pes cavus
  • Symptoms
  1. Characteristic
    1. Dull tooth-ache, throbbing, sharp or burning pain
    2. Stiffness sensation may also be present
  2. Pain Location: Posterior and medial aspect of heel
    1. Medial tubercle of Calcaneus
    2. Medial longitudinal arch
  3. Both heels often affected
  4. Provocative
    1. Pain worse with first few steps in morning
    2. Pain may be worse at days end in severe cases
    3. Worse after recent increase in weight bearing activity
    4. Pain worse with first steps of run
      1. Pain worse during first 5-10 minutes of run
      2. Less pain during remainder of run
      3. Pain worsens after run completed
    5. Pain worse with prolonged standing (weight bearing)
      1. Especially standing in hard shoes on hard floor
  5. Palliative
    1. Improves after first few minutes of activity
  • Signs
  1. Focal point tenderness (and possible thickening, swelling or crepitus)
    1. Calcaneus medial tubercle or tuberosity (anteromedial Calcaneus)
    2. Beneath longitudinal arch at proximal plantar fascia
  2. Provocative maneuvers to strain fascia and elicit pain
    1. Stand on tips of toes
    2. Passive dorsiflexion toes (Windlass Test)
      1. Examiner stabilizes ankle and dorsiflexes toes at MTP joints
  • Differential Diagnosis
  1. See Heel Pain
  2. Paresthesias are typically absent in Plantar Fasciitis (consider entrapment Neuropathy instead)
    1. Baxter neuritis
    2. Medial calcaneal nerve entrapment
    3. Tarsal Tunnel Syndrome
  1. General
    1. Foot XRay is often normal
    2. Indicated for refractory course >3 months
      1. Assess for tumor and other alternative diagnosis (see Heel Pain)
  2. Traction spur or heel spur at Os Calcis (present in 50% of cases)
    1. Spur directed distally
    2. Spur is a response to muscle tension
    3. Seen in asymptomatic foot
    4. No relationship between Heel Pain and spur formation (heel spur is not the cause of pain)
      1. Common in asymptomatic patients
      2. Persists after Plantar Fasciitis resolves
  3. Calcaneus Stress Fracture (Calcaneus)
    1. Assess for in chronic cases
  • Imaging
  • MRI
  1. Indicated in severe refractory cases
  2. Findings
    1. Thickening of the proximal plantar fascia (to 7-8 mm)
    2. Plantar aponeurosis inflammation
    3. Reactive calcaneal marrow edema
    4. Middle or proximal fascial rupture
  1. Plantar fascia thickness >4 mm
  2. Plantar Fasciitis has reduced echogenicity
  • Management
  • Stage 1 Acute
  1. Anticipatory guidance
    1. Prolonged recovery expected: 6-18 months
  2. NSAIDs (Analgesic effect)
    1. Typically a suboptimal response as inflammation is not the primary process
  3. Ice Therapy
    1. See Local Cold Therapy
  4. Relative rest with alternative activities
    1. Consider switch to non-irritating activities
  5. Avoid provocative activities
    1. Avoid prolonged weight bearing
    2. Avoid walking on hard surfaces
  6. Pre-fabricated Orthotics (e.g. Superfeet Orthotics)
    1. As effective as custom Orthotics in Plantar Fasciitis
    2. Landorf (2006) Arch Intern Med 166(12): 1305-10 [PubMed]
    3. Pfeffer (1999) Foot Ankle Int 20:214-21 [PubMed]
  7. Properly fitting, newer Running Shoes
    1. General
      1. Thicker, cushioned mid-sole
      2. Highly dense, vinyl acetate Running Shoe
    2. Motion control shoe for Pes Planus
      1. Lasted construction
      2. External heel counter
      3. Wide flare
      4. Additional medial support
  8. Other measures
    1. Low-Dye Taping
      1. Reduces over-pronation by fixing the subtalar joint
      2. Reduces pain in the first week of application, but effectiveness wanes later
      3. https://www.youtube.com/watch?v=ZwMZ90BdYhw
      4. van de Water (2010) J Am Podiatr Med Assoc 100(1): 41-51 [PubMed]
  1. General
    1. Avoid Stretching the acutely painful foot
    2. Consider early initiation of Posterior Night Splints for 3 weeks (see below)
  2. Dynamic stretches and massage
    1. Roll foot arch over Tennis Ball or 15-oz metal can
    2. Cross friction massage over plantar fascia
  3. Plantar fascia stretch
    1. Sit with affected foot crossed over opposite thigh
    2. Use one hand at base of toes on plantar surface
    3. Pull toes toward shin (dorsiflex) until stretch felt
    4. More effective than achilles tendon stretches
      1. DiGiovanni (2003) J Bone Joint Surg 85-A:1270-7 [PubMed]
  4. Achilles Tendon stretches
    1. Heel Stretching with towel
      1. Maximize passive dorsiflexion
      2. Pull with towel below foot (pull and release)
    2. Calf stretches against wall
      1. Lean forward into wall onto outstretched hands
      2. Extend Stretching leg back behind you
      3. Move other leg forward in front
      4. Gastrocnemius stretch
        1. Legs slightly bent
      5. Soleus muscle stretch
        1. Legs fully extended
    3. Calf stretches using steps or boards
      1. Technique
        1. Toes on edge of step or board
        2. Heel drops down over edge of step
      2. Adjuncts
        1. Stair stretch
        2. Two-by-Four piece or wood
        3. Slant board
        4. Wobble board
      3. Pointers
        1. Consider using in places of prolonged standing
        2. Examples: By kitchen stove or sink
  5. Strengthening of intrinsic foot muscles
    1. With heel on floor, pick up marbles with toes
    2. Towel curls
      1. Sit in chair with a towel on the floor
      2. Place foot on towel, and keep heel firmly planted
      3. Use toes to pull towel toward body
    3. Toe taps
      1. Keep heel on floor
      2. Raise all toes off floor
      3. Tap floor with great toe 10 to 50 times
      4. Tap floor with 4 lateral toes 10 to 50 times
  • Management
  • Stage 3 Refractory
  1. Reconsider differential diagnosis of Heel Pain
  2. Posterior Night Splints
    1. Indicated if other measures not effective in 2 weeks
    2. Most efficacious if symptoms >12 months
    3. Mixed results for efficacy in studies
      1. Probe (1999) Clin Orthop Relat Res (368):190-5 [PubMed]
      2. Lee (2012) J Rehabil Res Dev 49(10): 1557-64 [PubMed]
  3. Custom Orthotic: Semi-rigid, 3/4 to full length
    1. Modestly effective for Pes Planus, but expensive
    2. Provides longitudinal arch support
    3. Controls over-pronation
    4. Controls first Metatarsal head motion
    5. Prefabricated Orthotics are as effective as custom Orthotics in Plantar Fasciitis
      1. Landorf (2006) Arch Intern Med 166(12): 1305-10 [PubMed]
  4. Over-the-counter arch supports
    1. Indicated for mild Pes Planus
  5. Arch Taping or strapping
    1. Transient support for under 30 minutes of activity
  6. Heel Cup
    1. Low efficacy in Plantar Fasciitis in general
    2. Indications
      1. Short term use for acute injury
      2. Older adults with thinning fat pad
      3. Fat pad syndrome
      4. Heel Bruise
  7. Local Corticosteroid Injection of Plantar Fascia
    1. Effective in short-term, but less long-term benefits
    2. As with NSAIDs, Corticosteroids are expected to be less effective for this non-inflammatory condition
    3. Consider for 3-4 weeks of refractory symptoms
    4. Risk of plantar fascia rupture (2.4% to 10% risk) or Heel Fat Pad Syndrome
      1. Acevedo (1998) Fook Ankle Int 19:91-7 [PubMed]
  8. Short Leg Walking Cast for 6 weeks
  • Management
  • Stage 4 Referral
  1. Podiatry or Orthopedic referral Indications
    1. Failed conservative therapy as above for >6 weeks
  2. Options
    1. Platelet rich plasma injection
      1. Variable efficacy in studies
        1. Hsiao (2015) Rheumatology 54(9): 1735-43 [PubMed]
        2. Franchini 2018 Blood Transfus 16(6):502-13 [PubMed]
      2. Whole blood was as effective as platelet rich plasma in some studies
        1. Vahdatpour (2016) Adv Biomed Res 5:84 [PubMed]
    2. Botulinum Toxin Injection
      1. Improves pain and overall function in small 8 week studies
      2. Ahmad (2017) Foot Ankle Int 38(1): 1-7 [PubMed]
    3. Extracorporeal Shock Wave Therapy
      1. Stimulates neovascularization, growth factors
      2. Reduces Substance P unmyelinated nerve fibers
      3. May be effective if 0.28 J/mm2 force is applied
      4. Lou (2017) Am J Phys Med Rehabil 96(8): 529-34 [PubMed]
      5. Rompe (2003) Am J Sports 31:268-75 [PubMed]
    4. Plantar Fasciotomy (endoscopic without inferior calcaneal exostectomy)
      1. Plantar fascia release at os calcis
      2. Risk of longitudinal arch flattening or collapse (Pes Planus)
      3. Incision scarring
      4. Cottom (2016) Clin Podiatr Med Surg 33(4): 545-51 [PubMed]
  • Prognosis
  1. Slow resolution over 6 to 18 months
  2. Good overall prognosis (esp. if treatment started within 12 months of onset)
    1. Non-operative management resolves Plantar Fasciitis in 80% of patients