Plantar Fasciitis


Article Author:
Benjamin Buchanan


Article Editor:
Donald Kushner


Editors In Chief:
Dustin Constant
Donald Kushner


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
2/11/2019 9:15:29 PM

Introduction

Plantar fasciitis is the result of degenerative irritation of the plantar fascia origin at the medial calcaneal tuberosity of the heel as well as the surrounding perifascial structures. The plantar fascia plays an important role in the normal biomechanics of the foot and is composed of three segments, all of which arise from the calcaneus. The fascia itself is important in providing support for the arch and providing shock absorption. Despite the diagnosis containing the segment "itis," this condition is notably characterized by an absence of inflammatory cells.[1][2][3]

Etiology

This is often an overuse injury that is primarily due to a repetitive strain causing micro tears of the plantar fascia but can occur as a result of trauma or other multifactorial causes. Some predisposing factors are pes planus, pes cavus, limited ankle dorsiflexion, and excessive pronation or supination. Pes planus can cause increased strain at the origin of the plantar fascia. Pes cavus can cause excessive strain on the heel because the foot does not effectively evert or absorb shock. Tight gastrocnemius, soleus, and/or other posterior leg muscles have also been commonly found in patients with this condition. It is thought that these tight muscles can alter the normal biomechanics of ambulation. Approximately 50% of patients with this condition will also have heel spurs, but the spurs themselves are not the cause. It is often associated with runners and older adults, but other risk factors include obesity, occupations requiring prolonged standing, and weight-bearing. Plantar fasciitis has been found to be associated with various seronegative spondyloarthropathies, but in approximately 85% of cases, there are no known systemic factors.[4][5]

Epidemiology

Plantar fasciitis is the most common cause of heel pain presenting in the outpatient setting. The exact incidence and prevalence of plantar fasciitis by age are unknown, but estimates do show that approximately one million patient visits per year are due to plantar fasciitis. This condition accounts for about 10% of runner-related injuries and 11% to 15% of all foot symptoms requiring professional medical care. It is thought to occur in about 10% of the general population as well, with 83% of these patients being active working adults between the ages of 25 and 65 years old. It may present bilaterally in a third of the cases. Some literature shows prevalence rates among a population of runners to be as high as 22%.[6][7]

Pathophysiology

This condition is primarily a degenerative process. Aside from degenerative changes, histological findings include granulation tissue, micro-tears, collagen disarray, and notably a lack of traditional inflammation. Ultrasound evaluation often reveals calcifications, intrasubstance tears, and thickening and heterogeneity of the plantar fascia. These changes, often seen on ultrasound, suggest a non-inflammatory condition and dysfunctional vasculature.

History and Physical

Patients will often present with a history of progressive pain at the inferior and medial heel, but can, however, radiate proximally in more severe cases. They will often describe the pain as sharp and worst with the first few steps out of bed in the morning. Long periods of standing, or in severe cases, sitting for prolonged periods, will also exacerbate symptoms. Pain often decreases with ambulation or beginning an athletic activity, but then increases throughout the day as activity increases. Pain can usually be reproduced by palpating the plantar medial calcaneal tubercle at the site of the plantar fascial insertion on the heel bone. Pain can also be reproduced with passive dorsiflexion of the foot and toes. Specifically, passive dorsiflexion of the first metatarsophalangeal joint is known as the windlass (or Jack's) test and considered a positive test if pain is reproduced. Secondary findings may include a tight Achilles heel cord, pes planus, or pes cavus. It may also be beneficial to assess a patient's gait to assess for biomechanical factors or predisposing factors mentioned previously. When considering the diagnosis of plantar fasciitis, one should consider fat pad contusion or atrophy, stress fractures, and nerve entrapments such as tarsal tunnel syndrome in the differential.

Evaluation

Plantar fasciitis is a clinical diagnosis and imaging is not necessary. A provider may consider obtaining x-rays or ultrasound evaluation if history or physical exam indicate other injuries or conditions or the patient fails to improve after a reasonable amount of time. X-rays and/or ultrasound evaluation may show calcifications in the soft tissues or heel spurs on the inferior aspect of the heel. Additionally, ultrasound may show thickening and swelling of the plantar fascia which is a typical feature. If the patient is not responding to conservative therapy after longer periods of time, then the provider may consider ordering an MRI to evaluate for tears, stress fractures, or osteochondral defects.[8][9]

Treatment / Management

Relative rest from offending activity as guided by the level of pain should be prescribed. Ice after activity as well as oral or topical NSAIDs can be used to help alleviate pain. Deep friction massage of the arch and insertion has been shown to help. Shoe inserts or orthotics and night splints can be prescribed in conjunction with the previously mentioned therapies. Providers should educate patients on proper stretching and rehab of the plantar fascia, Achilles' tendon, gastrocnemius, and soleus. If pain does not respond to conservative measures, then consider more advanced or invasive techniques such as extracorporeal shock-wave therapy, botulinum toxin A, or various injections that could include autologous platelet-rich plasma, dex prolotherapy, or steroids. The more advanced and invasive techniques should be combined with conservative therapies. Surgery should be the last option if this process has become chronic and other less invasive therapies have failed. [10][11][12]

Differential Diagnosis

  • Calcaneus injury
  • Infection
  • Sickle cell bony pain
  • Bone contusion
  • Neuropathic pain
  • Tendinitis
  • Osteoporosis
  • Malignancy

Pearls and Other Issues

  • After diagnosis, thorough patient education, and a prescription for conservative treatment, patients can typically follow-up as needed.
  • It is usually a self-limited condition, and with conservative therapy, symptoms are usually resolved within 12 months of initial presentation and often sooner.
  • Sometimes more chronic cases of this condition will need additional follow-up to consider more advanced therapies and evaluation of gait and biomechanical factors that can potentially be corrected through gait retraining.
  • Corticosteroid injections have been shown to be beneficial in the short-term (less than four weeks) but ineffective in the long term.
  • Evidence of the efficacy of platelet rich plasma, dex prolotherapy, and extra-corporeal shockwave therapy is conflicting. 

Enhancing Healthcare Team Outcomes

A multidisciplinary approach at plantar fasciitis

Plantar fasciitis affects many people, usually young people and athletes. The condition can be disabling if not appropriately managed. The key is the education of the patient. The nurse, pharmacists, physical therapist and rehabilitation specialist play a vital role in the recurrence of symptoms. Patients need to be told that the symptoms may take weeks or months to improve. In addition, the patient may have to enroll in a physical therapy program and even wear a night splint. Patients have to be taught how to stretch the plantar fascia with basic home exercises. In addition, a podiatry consult may be required to get the appropriate shoes with adequate arch support. Patients should be educated on avoiding long periods of standing. Further, losing weight and stretching before starting an exercise program is important. Those with acute symptoms should be told to avoid walking barefoot and limit repetitive exercises that traumatize the heel. If all these maneuvers fail, the last resort is a referral to an orthopedic surgeon.[13][14][15] (Level V)

Outcomes

Plantar fasciitis may be a benign disorder but if not adequately managed can be disabling and associated with moderate to severe pain. About 70-80% of patients with plantar fasciitis see symptom reduction in 9-12 months, but at least 5-10% require surgical release of the plantar fascia. Plantar fasciitis in athletes is associated with high morbidity and even when managed appropriately recurrences are not uncommon. The morbidity of plantar fasciitis is due to pain in the foot, difficulty with ambulation, limitation in exercise and inability to weight bear. Sometimes, the uneven ambulation can also leas to an injury of the knee and hip joints. Among people who have to stand for long hours, plantar fasciitis is one of the most common causes of worker's compensation claims.[2][16] (Level V)


  • Image 1611 Not availableImage 1611 Not available
    Contributed by Scott Dulebohn, MD
Attributed To: Contributed by Scott Dulebohn, MD

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Plantar Fasciitis - Questions

Take a quiz of the questions on this article.

Take Quiz
A 25-year-old medical student complains of worsening heel pain over the past month. He has been on a surgical rotation. The pain is worse first thing in the morning and after standing for extended periods of time. The patient is obese. He has normal gait and a normal neurologic exam. The bottom of the foot is tender just distal to the calcaneus. There is no deformity or erythema. What is the most likely diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following statements about plantar fasciitis is not correct?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is not part of the initial treatment for plantar fasciitis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which symptom is most diagnostic of plantar fasciitis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following causes plantar fasciitis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
An obese female complains of heel pain of several weeks duration. She had started a jogging program but has had to stop. The pain is worst with the first step in the morning. Her foot is tender over the inferior medial heel. Select the most appropriate way to arrive at the correct diagnosis.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What will B mode and power Doppler ultrasound examinations in patients with plantar fasciitis reveal?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which location for ultrasound-guided injection of corticosteroids is more effective?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the consequence of repeated corticosteroid injections for treatment of the plantar fasciitis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Plantar Fasciitis - References

References

Becker BA,Childress MA, Common Foot Problems: Over-the-Counter Treatments and Home Care. American family physician. 2018 Sep 1     [PubMed]
Ling Y,Wang S, Effects of platelet-rich plasma in the treatment of plantar fasciitis: A meta-analysis of randomized controlled trials. Medicine. 2018 Sep     [PubMed]
Lee YK,Lee M, Treatment of infected Achilles tendinitis and overlying soft tissue defect using an anterolateral thigh free flap in an elderly patient: A case report. Medicine. 2018 Aug     [PubMed]
Finkenstaedt T,Siriwanarangsun P,Statum S,Biswas R,Anderson KE,Bae WC,Chung CB, The Calcaneal Crescent in Patients With and Without Plantar Fasciitis: An Ankle MRI Study. AJR. American journal of roentgenology. 2018 Aug 30     [PubMed]
Arnold MJ,Moody AL, Common Running Injuries: Evaluation and Management. American family physician. 2018 Apr 15     [PubMed]
Cotchett M,Lennecke A,Medica VG,Whittaker GA,Bonanno DR, The association between pain catastrophising and kinesiophobia with pain and function in people with plantar heel pain. Foot (Edinburgh, Scotland). 2017 Aug     [PubMed]
Tschopp M,Brunner F, [Diseases and overuse injuries of the lower extremities in long distance runners]. Zeitschrift fur Rheumatologie. 2017 Jun     [PubMed]
Lai TW,Ma HL,Lee MS,Chen PM,Ku MC, Ultrasonography and clinical outcome comparison of extracorporeal shock wave therapy and corticosteroid injections for chronic plantar fasciitis: A randomized controlled trial. Journal of musculoskeletal     [PubMed]
Kim M,Choi YS,You MW,Kim JS,Young KW, Sonoelastography in the Evaluation of Plantar Fasciitis Treatment: 3-Month Follow-Up After Collagen Injection. Ultrasound quarterly. 2016 Dec     [PubMed]
McClinton S PT, PhD, OCS, FAAOMPT,Heiderscheit B PT, PhD,McPoil TG PT, PhD,Flynn TW PT, PhD, OCS, FAAOMPT, Physical therapist decision-making in managing plantar heel pain: cases from a pragmatic randomized clinical trial. Physiotherapy theory and practice. 2018 Jul 6     [PubMed]
Lee TL,Marx BL, Noninvasive, Multimodality Approach to Treating Plantar Fasciitis: A Case Study. Journal of acupuncture and meridian studies. 2018 Aug     [PubMed]
Roerdink RL,Dietvorst M,van der Zwaard B,van der Worp H,Zwerver J, Complications of extracorporeal shockwave therapy in plantar fasciitis: Systematic review. International journal of surgery (London, England). 2017 Oct     [PubMed]
McClinton SM,Flynn TW,Heiderscheit BC,McPoil TG,Pinto D,Duffy PA,Bennett JD, Comparison of usual podiatric care and early physical therapy intervention for plantar heel pain: study protocol for a parallel-group randomized clinical trial. Trials. 2013 Dec 3     [PubMed]
Wyatt LH, Conservative chiropractic management of recalcitrant foot pain after fasciotomy: a retrospective case review. Journal of manipulative and physiological therapeutics. 2006 Jun     [PubMed]
Wynne MM,Burns JM,Eland DC,Conatser RR,Howell JN, Effect of counterstrain on stretch reflexes, hoffmann reflexes, and clinical outcomes in subjects with plantar fasciitis. The Journal of the American Osteopathic Association. 2006 Sep     [PubMed]
Uğurlar M,Sönmez MM,Uğurlar ÖY,Adıyeke L,Yıldırım H,Eren OT, Effectiveness of Four Different Treatment Modalities in the Treatment of Chronic Plantar Fasciitis During a 36-Month Follow-Up Period: A Randomized Controlled Trial. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons. 2018 Sep - Oct     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Surgery-Podiatry Cert Medicine. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Surgery-Podiatry Cert Medicine, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Surgery-Podiatry Cert Medicine, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Surgery-Podiatry Cert Medicine. When it is time for the Surgery-Podiatry Cert Medicine board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Surgery-Podiatry Cert Medicine.