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Plantar Fasciitis

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Topic updated on 08/25/16 10:58am
Introduction
  • A condition caused by inflammation of the aponeurosis at its origin on the calcaneus
  • Epidemiology
    • demographics
      • affects men and women equally
    • 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)
  • 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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Qbank (7 Questions)

TAG
(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? Topic Review Topic

1. Stop physical therapy and prescribe custom orthotics
2. Administer bi-weekly extracorporeal shockwave therapy to the heel
3. Endoscopic plantar fasciotomy
4. Bipolar radiofrequency to the heel
5. Night splints

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic

1. Achilles tendon–stretching program
2. Corticosteroid injection
3. Extracorporeal shock-wave therapy
4. Plantar fascia–specific stretching program
5. Distal tarsal tunnel decompression and partial plantar fascia release

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A   B        

1. Navicular stress fracture
2. Freiberg's Infraction
3. Plantar fasciitis
4. First branch of the lateral plantar nerve (Baxter's) entrapment
5. Anterior tarsal tunnel syndrome

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic

1. Stretching of the achilles tendon and plantar fascia along with a prefabricated shoe insert
2. Immobilization in a short leg cast
3. Steroid injection of the plantar fascia
4. Custom made orthotic with arch support
5. Surgical release of the medial third of the plantar fascia origin

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Walker boot immobilization with full weightbearing for 4 weeks
2. Corticosteroid injection to the plantar fascia
3. Surgical release of 50% of the plantar fascia
4. Heel spur resection
5. Achilles stretching exercises

PREFERRED RESPONSE ▶
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