Plantar fasciitis continues to be widely used for the clinical syndrome of undersurface heel pain. However, the use of 'itis' denotes an inflammatory disorder. This is a misnomer as the pathology is not the result of excessive inflammation. Pathological changes are degenerative (but partially reversible) in nature, probably due to repetitive trauma.
The plantar fascia is a thick, fibrous band of connective tissue. Its origin is the medial plantar tubercle of the calcaneum. It runs along the sole of the foot like a fan, being attached at its other end to the base of each of the toes. It is a tough, resilient structure that has a number of critical functions during running and walking:
- It stabilises the metatarsal joints during impact with the ground.
- It acts as a shock absorber for the entire leg.
- It forms the longitudinal arch of the foot and helps to lift the arch to prepare it for the 'take-off' phase of the gait cycle.
By Ryxi10, via Wikimedia Commons
- The plantar fascia is a sturdy structure but the degree of stress that it takes makes it susceptible to injury. A force equal to almost three times the body's weight passes through the foot with each step. On running, this typically happens about 90 times a minute.
- Plantar fasciitis is thought to be a traction and overuse injury. Damage to the plantar fascia is usually in the form of micro-tears. It is a degenerative rather than an inflammatory process.
- Damage tends to occur near the heel, where stress on the fibres is greatest and where the fascia is the thinnest. The fascia broadens as it extends toward the toes.
- Plantar fasciitis is often associated with calcaneal spurs. These are depositions of calcium where the fascia suffers most damage. Spurs are most commonly on the medial side at the origin of the fascia from the calcaneum. Spurs are the result of the process of plantar fasciitis and not the cause of the pain.
- It can present bilaterally.
- Plantar fasciitis is a common problem.
- There is no sex predilection.
- About 5-10% of running injuries are plantar fasciitis.
- Participants in sports that involve some degree of running and jumping - eg, basketball, tennis, step aerobics, dancing.
- Non-athletic people who spend much of each day on their feet.
- It may appear in someone who suddenly becomes more active after a period of relative inactivity.
- Running on hard ground increases the risk, as does an increase in hill training.
- Worn-out trainers increase risk as they lose their shock absorption properties.
- Obesity increases risk. There is increased stress placed through the fascia.
- Other mechanical risk factors include flat feet (pes planus) and having a high arch (pes cavus).
- Pregnancy is associated with a temporary and physiological gain in weight. Hormones also cause relaxation of ligaments, predisposing to flat feet.
- There may be an association with human leukocyte antigen (HLA) B27 associated spondyloarthropathies.
- The principal complaint is heel/plantar pain. Most often this is 1 or 2 cm distal to the medial calcaneal tuberosity.
- Ask about the onset of the symptoms and any precipitating, aggravating or relieving factors. What brings it on? What makes it worse?
- It is often at its most severe during the first few steps after prolonged inactivity, such as sleeping or sitting.
- Sitting with the foot elevated usually relieves the pain.
- For those who are on their feet all day, pain is worst at the end of the day.
- Walking barefoot, on toes, or up stairs can precipitate pain.
- Ask about running or jogging and other sports.
- Ask about footwear and when it was last replaced.
- Ask about previous trauma to the foot.
- Look at the foot. Note any obvious deformities, skin changes, or congenital conditions. Look for pes planus or pes cavus.
- There is often tightness of the Achilles tendon and ankle dorsiflexion may be limited.
- Palpate the plantar surface over the medial calcaneal tuberosity and along the course of the plantar fascia, pressing quite hard. The reproduction of the pain is the most important physical sign to confirm the diagnosis.
- Pain may be reproduced by asking the patient to stand on their toes or by passive dorsiflexion of the toes.
- Palpate the back of the heel and ankle to exclude Achilles tendonitis.
- Subcalcaneal bursitis produces a tender swelling underneath the calcaneum. It is not aggravated by dorsiflexing the toes. There is usually little or no swelling in plantar fasciitis.
- Referred pain from an S1/S2 lesion should be excluded. Perform the straight leg raising test as for examination of the back. Check the ankle tendon reflex (S1) and calf strength. This is easily performed by asking the patient to walk on toes or stand on one leg and raise the heel off the floor. These tests should be normal.
- Exclude tarsal tunnel syndrome: the posterior tibial nerve passes under the flexor retinaculum which runs between the medial malleolus and the calcaneum. Percuss over the nerve below and posterior to the medial malleolus. This can reproduce pain, numbness and burning on the medial side of the foot, ankle or calf if there is tarsal tunnel syndrome.
- Press together the heads of the 2nd and 3rd metatarsals and then the 3rd and 4th. Reproduction of the pain suggests Morton's neuroma, with entrapment of the common digital nerve between the metatarsal heads.
- A stress fracture of the calcaneum will cause tenderness over the calcaneum rather than anterior to it.
- Achilles tendonitis.
- Subcalcaneal bursitis.
- S1 radiculopathy or referred pain.
- Tarsal tunnel syndrome.
- Morton's neuroma.
- Sever's disease (children and adolescents).
- Stress fracture of calcaneum.
- Blood tests are not helpful.
- Weighing and measuring the patient may reinforce that the BMI needs attention if obesity is a contributory factor.
- X-ray: should not be performed as a matter of routine but may be indicated if you suspect another diagnosis. A lateral view may show soft tissue calcifications or a calcified spur on the anterior aspect of the calcaneus. X-ray may also help to exclude stress fracture, although stress fractures may not always be evident.
- Ultrasound: this may show a thicker heel aponeurosis in plantar fasciitis.
- Bone scans and MRI: these have also been used in diagnosis.
There is no one treatment with very strong evidence of efficacy; however, there are several treatment options with moderate levels of evidence, including stretching, orthotics, shock-wave therapy and injections. Treatments should be offered in sequence, depending on the individual patient's circumstances and likelihood of response.
- Resting of the foot as much as possible.
- Loss of weight if obese.
- Correction of pes planus if present.
- Advice to run on a softer surface.
- A laced sports shoe gives good support. Update shoes regularly.
- If the patient is an athlete, discuss training schedules. Cardiovascular fitness may be built by a shift, even temporarily, to swimming, cycling, a step machine in a gym or other low-impact exercise.
- Non-steroidal anti-inflammatory drugs and ice may be useful.
- Patients should be counselled that with any conservative management plan they should not expect to note a significant improvement in symptoms before 6-8 weeks.
Physiotherapy and stretching exercises
- Stretching exercises are often advised for the plantar fascia, calf muscles and the Achilles tendon. Again, hard evidence for their use is lacking.However, benefit has been shown in some studies. The patient may be taught to do these exercises independently.
- Deep massage of the sole of the foot also stretches the plantar fascia.
- A physiotherapist may also recommend ultrasound, laser treatment, or iontophoresis with dexamethasone to assist pain relief and reduce inflammation. Again, evidence for these treatments is limited.
Orthotics, splinting and casting
- A heel and arch support may help. However, a review showed that even though there is some evidence to support the use of foot orthoses in the prevention of lower limb overuse injuries, there is limited evidence for their use in the treatment. Another study showed that they had short-term but not long-term treatment benefits. A Cochrane review suggested that there was silver level evidence for their use. Various pads and shoe inserts can be bought to cushion and raise the heel and give good arch support. Inserts should be worn in both shoes, even if pain is only in one foot.
- Night splints to keep the ankle dorsiflexed and the toes extended can help to stretch the plantar fascia and may induce faster healing.
- The evidence for steroid injection shows that it may provide some short-term benefit but the evidence for its effectiveness in the long term is lacking. Counsel the patient accordingly.
- A posterior tibial nerve block before injection has been suggested to reduce pain of the injection.
- Ultrasound guidance has been used to facilitate accurate injection.[11, 12]
- Plantar fascia rupture may also be a complication of steroid injection.
- Use a maximum of three injections in six months.
- Extracorporeal shock-wave therapy: a meta-analysis has shown this to be a safe and effective treatment which may be preferable to steroid injection. However, the National Institute for Health and Care Excellence (NICE) states that, although the evidence on extracorporeal shock-wave therapy for refractory plantar fasciitis raises no major safety concerns, current evidence on its efficacy is inconsistent.
- Botulinum toxin A injections: may produce some benefit in the short term.
- Autologous blood injection: the idea is that growth factors promote healing of the plantar fascia by stimulating fibroblast activity and vascular growth. There is currently a lack of long-term evidence for this technique.In one study it was shown to be effective in lowering pain and tenderness in chronic plantar fasciitis but corticosteroid injections were found to be superior in terms of speed and probably extent of improvement.
- Radiotherapy has been shown to provide effective pain relief.
- Surgery: this has also been used in patients with refractory symptoms. The procedure releases the plantar fascia from the bone. It may also include calcaneal spur excision. Open or endoscopic approaches may be used. Complications include increased pain, nerve injury, fascial rupture and infection.
- Pain may be long-standing and can last for some years. However, plantar fasciitis generally resolves over time with minimally invasive management.
- 80% show spontaneous response within 12 months.
- Regularly changing footwear used for running and walking.
- Wearing shoes with good cushioning in the heels and good arch support.
- Losing weight if overweight.
- Avoiding exercising on a hard surface.
- Regular stretching exercises for the plantar fascia and Achilles tendon.
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