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Plantar fasciitis
Other names	Plantar fasciosis, plantar fasciopathy, jogger's heel, heel spur syndrome
Most common areas of pain in plantar fasciitis
Specialty	Orthopedics, sports medicine, plastic surgery, podiatry
Symptoms	Pain in the heel and bottom of the foot
Usual onset	Gradual
Causes	Unclear
Risk factors	Overuse (long periods of standing), obesity, inward rolling of the foot
Diagnostic method	Based on symptoms, ultrasound
Differential diagnosis	Osteoarthritis, ankylosing spondylitis, heel pad syndrome, reactive arthritis
Treatment	Conservative management
Frequency	~4%

Plantar fasciitis or plantar heel pain is a disorder of the plantar fascia, which is the connective tissue that supports the arch of the foot. It results in pain 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. Pain is also frequently brought on by bending the foot and toes up towards the shin. The pain typically comes on gradually, and it affects both feet in about one-third of cases.

The cause of plantar fasciitis is not entirely clear. Risk factors include overuse, such as from long periods of standing, an increase in exercise, and obesity. It is also associated with inward rolling of the foot, a tight Achilles tendon, and a sedentary lifestyle. It is unclear if heel spurs have a role in causing plantar fasciitis even though they are commonly present in people who have the condition. Plantar fasciitis is a disorder of the insertion site of the ligament on the bone characterized by micro tears, breakdown of collagen, and scarring. Since inflammation plays either a lesser or no role, a review proposed it be renamed plantar fasciosis. The presentation of the symptoms is generally the basis for diagnosis; with ultrasound sometimes being useful if there is uncertainty. Other conditions with similar symptoms include osteoarthritis, ankylosing spondylitis, heel pad syndrome, and reactive arthritis.

Most cases of plantar fasciitis resolve with time and conservative methods of treatment. For the first few weeks, those affected are usually advised to rest, change their activities, take pain medications, and stretch. If this is not sufficient, physiotherapy, orthotics, splinting, or steroid injections may be options. If these measures are not effective, additional measures may include extracorporeal shockwave therapy or surgery.

Between 4% and 7% of the general population has heel pain at any given time: about 80% of these are due to plantar fasciitis. Approximately 10% of people have the disorder at some point during their life. It becomes more common with age. It is unclear if one sex is more affected than the other.

Signs and symptoms

When plantar fasciitis occurs, the pain is typically sharp and usually unilateral (70% of cases). Bearing weight on the heel after long periods of rest worsens heel pain in affected individuals. Individuals with plantar fasciitis often report their symptoms are most intense during their first steps after getting out of bed or after prolonged periods of sitting. Symptoms typically improve with continued walking. Rare, but reported, symptoms include numbness, tingling, swelling, and radiating pain. Typically there are no fevers or night sweats.

If the plantar fascia is overused in the setting of plantar fasciitis, the plantar fascia can rupture. Typical signs and symptoms of plantar fascia rupture include a clicking or snapping sound, significant local swelling, and acute pain in the bottom of the foot.

Risk factors

Identified risk factors for plantar fasciitis include excessive running, standing on hard surfaces for prolonged periods, high arches of the feet, the presence of a leg length inequality, and flat feet. The tendency of flat feet to excessively roll inward during walking or running makes them more susceptible to plantar fasciitis. Obesity is seen in 70% of individuals who present with plantar fasciitis and is an independent risk factor.

Plantar fasciitis is commonly a result of some biomechanical imbalance that causes an increased amount of tension placed along the plantar fascia.

Achilles tendon tightness and inappropriate footwear have also been identified as significant risk factors.

Pathophysiology

The cause of plantar fasciitis is poorly understood and appears to have several contributing factors. The plantar fascia is a thick fibrous band of connective tissue that originates from the medial tubercle and anterior aspect of the heel bone. From there, the fascia extends along the sole of the foot before inserting at the base of the toes and supports the arch of the foot.

Plantar fasciitis is a non-inflammatory condition of the plantar fascia. Within the last decade, studies have observed microscopic anatomical changes indicating that plantar fasciitis is due to a non-inflammatory structural breakdown of the plantar fascia rather than an inflammatory process.

Many in the academic community have stated the condition should be renamed plantar fasciosis in light of these newer findings. Repetitive microtrauma (small tears) appears to cause a structural breakdown of the plantar fascia. Microscopic examination of the plantar fascia often shows myxomatous degeneration, connective tissue calcium deposits, and disorganized collagen fibers.

Disruptions in the plantar fascia's normal mechanical movement during standing and walking (known as the Windlass mechanism) place excess strain on the calcaneal tuberosity and seem to contribute to the development of plantar fasciitis. Other studies have also suggested that plantar fasciitis is not due to the inflamed plantar fascia but maybe a tendon injury involving the flexor digitorum brevis muscle located immediately deep to the plantar fascia.

Diagnosis

Plantar fasciitis is usually diagnosed by a health care provider after consideration of a person's presenting history, risk factors, and clinical examination. Palpation along the inner aspect of the heel bone on the sole may elicit tenderness during the physical examination. The foot may have limited dorsiflexion due to excessive tightness of the calf muscles or the Achilles tendon. Dorsiflexion of the foot may elicit the pain due to stretching of the plantar fascia with this motion. Diagnostic imaging studies are not usually needed to diagnose plantar fasciitis. Occasionally, a physician may decide imaging studies (such as X-rays, diagnostic ultrasound, or MRI) are warranted to rule out serious causes of foot pain.

Other diagnoses that are typically considered include fractures, tumors, or systemic disease if plantar fasciitis pain fails to respond appropriately to conservative medical treatments. Bilateral heel pain or heel pain in the context of a systemic illness may indicate a need for a more in-depth diagnostic investigation. Under these circumstances, diagnostic tests such as a CBC or serological markers of inflammation, infection, or autoimmune disease such as C-reactive protein, erythrocyte sedimentation rate, anti-nuclear antibodies, rheumatoid factor, HLA-B27, uric acid, or Lyme disease antibodies may also be obtained. Neurological deficits may prompt an investigation with electromyography to check for damage to the nerves or muscles.

An incidental finding associated with this condition is a heel spur, a small bony calcification on the calcaneus (heel bone), which can be found in up to 50% of those with plantar fasciitis. In such cases, it is the underlying plantar fasciitis that produces the heel pain, and not the spur itself. The condition is responsible for the creation of the spur though the clinical significance of heel spurs in plantar fasciitis remains unclear.

Imaging

Medical imaging is not routinely needed. It is expensive and does not typically change how plantar fasciitis is managed. When the diagnosis is not clinically apparent, lateral view X-rays of the ankle are the recommended imaging modality to assess for other causes of heel pain, such as stress fractures or bone spur development.

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. In theory, 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.

Three-phase bone scan is a sensitive modality to detect active plantar fasciitis. Furthermore, a 3-phase bone scan can be used to monitor response to therapy, as demonstrated by decreased uptake after corticosteroid injections.

Differential diagnosis

The differential diagnosis for heel pain is extensive and includes pathological entities including, but not limited to, the following: calcaneal stress fracture, septic arthritis, 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 cancers from elsewhere in the body, hypothyroidism, gout, seronegative spondyloparthopathies such as reactive arthritis, ankylosing spondylitis, or rheumatoid arthritis (more likely if pain is present in both heels), plantar fascia rupture, and compression neuropathies such as tarsal tunnel syndrome or impingement of the medial calcaneal nerve.

A determination about a diagnosis of plantar fasciitis can usually be made based on a person's medical history and physical examination. When a physician suspects a fracture, infection, or some other serious underlying condition, they may order an X-ray to investigate. X-rays are unnecessary to screen for plantar fasciitis for people who stand or walk a lot at work unless imaging is otherwise indicated.

Treatment

Non-surgical

About 90% of plantar fasciitis cases improve within six months with conservative treatment, and within a year regardless of treatment.

The recommended first treatment is a four- to six-week course which combines three elements: daily stretching, daily foot taping (using a special tape around the foot for supporting the arch) and individually tailored education on choosing footwear and other ways of managing the condition.

Reduction in pain and stress on the plantar fascia can be done by strengthening the muscles in the foot that support the arches through barefoot exercising, without footwear, compared to exercising in common footwear.

If plantar fasciitis fails to respond to conservative treatment for at least three months, then extracorporeal shockwave therapy (ESWT) may be considered. Evidence from meta-analyses suggests significant pain relief lasts up to one year after the procedure. However, debate about the therapy's efficacy has persisted. ESWT is performed with or without anesthesia though studies suggest giving anesthesia diminishes the procedure's effectiveness. Complications from ESWT are rare and typically benign when present. Known complications of ESWT include the development of a mild hematoma or an ecchymosis, redness around the site of the procedure, or migraine.

The third line of treatment, if shockwave therapy is not effective after around 8 weeks, is using customised foot orthoses which can offer short-term relief from pain.

Affected people use further different treatments for plantar fasciitis but many have little evidence to support their use and are not adequately studied.

Other conservative approaches include rest, massage, heat, ice, and calf-strengthening exercises, weight reduction in the overweight or obese, and nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen. The use of NSAIDs to treat plantar fasciitis is common, but their use fails to resolve the pain in 20% of people.

Corticosteroid injections are sometimes used for cases of plantar fasciitis that have proven resistant to more conservative measures. There is tentative evidence that injected corticosteroids are effective for short-term pain relief up to one month, but not after that.

Another treatment technique is known as plantar iontophoresis. This technique involves 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. Some evidence supports the use of night splints for 1–3 months to relieve plantar fasciitis pain that has persisted for six months. The night splints are designed to position and maintain the ankle in a neutral position, thereby passively stretching the calf and plantar fascia during sleep.

Surgery

Plantar fasciotomy is a surgical treatment and the last resort for refractory plantar fasciitis pain. If plantar fasciitis does not resolve after six months of conservative treatment, then the procedure is considered as a last resort. Minimally invasive and endoscopic approaches to plantar fasciotomy exist but require a specialist who is familiar with specific equipment. The availability of these surgical techniques is limited as of 2012. A 2012 study found 76% of people who underwent endoscopic plantar fasciotomy had complete relief of their symptoms and had few complications (level IV evidence). Heel spur removal during plantar fasciotomy does not appear to improve the surgical outcome.

Plantar heel pain may occur for multiple reasons. In select cases, surgeons may perform a release of the lateral plantar nerve alongside the plantar fasciotomy. Possible 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. Coblation surgery has recently been proposed as an alternative surgical approach for the treatment of recalcitrant plantar fasciitis.

Gastrocnemius recession is a surgical procedure that involves lengthening the gastrocnemius muscle to reduce tension in the Achilles tendon and plantar fascia. This technique improves the ankle's range of motion, reduces pain, and can help patients return to work, sports, and weight-bearing activities more comfortably. The procedure is particularly beneficial for individuals with limited ankle dorsiflexion (upward bending) due to tight calf muscles, which can exacerbate plantar fasciitis symptoms.

Unproven treatments

Botulinum toxin A injections as well as similar techniques such as platelet-rich plasma injections and prolotherapy remain controversial.

Dry needling is also being researched for treatment of plantar fasciitis. A systematic review of available research found limited evidence of effectiveness for this technique. The studies were reported to be inadequate in quality and too diverse in methodology for a firm conclusion.

With a combination of plantar fasciitis stretching and the use of botulinum toxin showed an increase in improvement and functionability in patients.

Epidemiology

Plantar fasciitis is the most common type of plantar fascia injury and is the most common reason for heel pain, responsible for 80% of cases. The condition tends to occur more often in women, military recruits, older athletes, dancers, people with obesity, and young male athletes.

Plantar fasciitis is estimated to affect 1 in 10 people at some point during their lifetime and most commonly affects people between 40 and 60 years of age. In the United States alone, more than two million people receive treatment for plantar fasciitis. The cost of treating plantar fasciitis in the United States is estimated to be $284 million each year.

Prognosis

According to studies following patients with plantar fasciitis over several years, 20% to 75% of individuals no longer have any symptoms within a maximum of one year after the onset of symptoms.

Having a heel spur (bony protrusion at the heel) in addition to heel pain does not worsen the prognosis of recovery. Individuals with and without heel spurs recover at the same rate.

References

1. ^ Kim J, Mukovozov I (2017). Toronto Notes 2017: Comprehensive Medical Reference and Review for the Medical Council of Canada Qualifying Exam Part I and the United States Medical Licensing Exam Step 2. Toronto Notes for Medical Students Incorporated. ISBN 978-1-927363-34-8.
2. ^ Beeson P (September 2014). "Plantar fasciopathy: revisiting the risk factors" (PDF). Foot and Ankle Surgery. 20 (3): 160–165. doi:10.1016/j.fas.2014.03.003. PMID 25103701.
3. ^ Rosenbaum AJ, DiPreta JA, Misener D (March 2014). "Plantar heel pain". The Medical Clinics of North America. 98 (2): 339–352. doi:10.1016/j.mcna.2013.10.009. PMID 24559879.
4. ^ Goff JD, Crawford R (September 2011). "Diagnosis and treatment of plantar fasciitis". American Family Physician. 84 (6): 676–682. PMID 21916393.
5. ^ Cutts S, Obi N, Pasapula C, Chan W (November 2012). "Plantar fasciitis". Annals of the Royal College of Surgeons of England. 94 (8): 539–542. doi:10.1308/003588412X13171221592456. PMC 3954277. PMID 23131221.
6. ^ Tu P, Bytomski JR (October 2011). "Diagnosis of heel pain". American Family Physician. 84 (8): 909–916. PMID 22010770.
7. ^ Tahririan MA, Motififard M, Tahmasebi MN, Siavashi B (August 2012). "Plantar fasciitis". Journal of Research in Medical Sciences. 17 (8): 799–804. PMC 3687890. PMID 23798950.
8. ^ Lareau CR, Sawyer GA, Wang JH, DiGiovanni CW (June 2014). "Plantar and medial heel pain: diagnosis and management". The Journal of the American Academy of Orthopaedic Surgeons. 22 (6): 372–380. doi:10.5435/JAAOS-22-06-372. PMID 24860133. S2CID 43241954.
9. ^ Zhiyun L, Tao J, Zengwu S (July 2013). "Meta-analysis of high-energy extracorporeal shock wave therapy in recalcitrant plantar fasciitis". Swiss Medical Weekly. 143: w13825. doi:10.4414/smw.2013.13825. PMID 23832373.
10. ^ Jeswani T, Morlese J, McNally EG (September 2009). "Getting to the heel of the problem: plantar fascia lesions". Clinical Radiology. 64 (9): 931–939. doi:10.1016/j.crad.2009.02.020. PMID 19664484.
11. ^ Molloy LA (November 2012). "Managing chronic plantar fasciitis: when conservative strategies fail". JAAPA. 25 (11): 48, 50, 52–48, 50, 53. doi:10.1097/01720610-201211000-00009. PMID 23620924. S2CID 36296481.
12. ^ Monto RR (December 2013). "Platelet-rich plasma and plantar fasciitis". Sports Medicine and Arthroscopy Review. 21 (4): 220–224. doi:10.1097/JSA.0b013e318297fa8d. PMID 24212370. S2CID 5968932.
13. ^ Orchard J (October 2012). "Plantar fasciitis". BMJ. 345 (oct10 1): e6603. doi:10.1136/bmj.e6603. PMID 23054045. S2CID 27948691.
14. Barrett SJ, O'Malley R (April 1999). "Plantar fasciitis and other causes of heel pain". American Family Physician. 59 (8): 2200–2206. PMID 10221305.
15. ^ Yin MC, Ye J, Yao M, Cui XJ, Xia Y, Shen QX, et al. (August 2014). "Is extracorporeal shock wave therapy clinical efficacy for relief of chronic, recalcitrant plantar fasciitis? A systematic review and meta-analysis of randomized placebo or active-treatment controlled trials". Archives of Physical Medicine and Rehabilitation. 95 (8): 1585–1593. doi:10.1016/j.apmr.2014.01.033. PMID 24662810.
16. Dubner S. "These Shoes Are Killing Me!". Freakonomics. Retrieved 12 June 2020.
17. Buchbinder R (May 2004). "Clinical practice. Plantar fasciitis". The New England Journal of Medicine. 350 (21): 2159–2166. doi:10.1056/NEJMcp032745. PMID 15152061.
18. Cole C, Seto C, Gazewood J (December 2005). "Plantar fasciitis: evidence-based review of diagnosis and therapy". American Family Physician. 72 (11): 2237–2242. PMID 16342847.
19. Ehrmann C, Maier M, Mengiardi B, Pfirrmann CW, Sutter R (September 2014). "Calcaneal attachment of the plantar fascia: MR findings in asymptomatic volunteers". Radiology. 272 (3): 807–814. doi:10.1148/radiol.14131410. PMID 24814176.
20. League AC (March 2008). "Current concepts review: plantar fasciitis". Foot & Ankle International. 29 (3): 358–366. doi:10.3113/fai.2008.0358. PMID 18348838. S2CID 6734497.
21. Pelletier-Galarneau M, Martineau P, Gaudreault M, Pham X (2015). "Review of running injuries of the foot and ankle: clinical presentation and SPECT-CT imaging patterns". American Journal of Nuclear Medicine and Molecular Imaging. 5 (4): 305–316. PMC 4529586. PMID 26269770.
22. ^ American College of Occupational and Environmental Medicine (February 2014), "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation, American College of Occupational and Environmental Medicine, archived from the original on 11 September 2014, retrieved 24 February 2014, which cites
    • Haas N, Beecher P, Easly M, et al. (2011). "Ankle and foot disorders". In Hegmann KT (ed.). Occupational medicine practice guidelines : evaluation and management of common health problems and functional recovery in workers (3rd ed.). Elk Grove Village, IL: American College of Occupational and Environmental Medicine. p. 1182. ISBN 978-0615452272.
23. ^ "A best practice guide for managing plantar heel pain". NIHR Evidence (Plain English summary). National Institute for Health and Care Research. 2022-07-21. doi:10.3310/nihrevidence_52045. S2CID 251780089.
24. ^ Morrissey D, Cotchett M, Said J'Bari A, Prior T, Griffiths IB, Rathleff MS, et al. (October 2021). "Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values". British Journal of Sports Medicine. 55 (19): 1106–1118. doi:10.1136/bjsports-2019-101970. PMC 8458083. PMID 33785535.
25. Kamalakannan M, Dass D (2019). "Efficacy of Bare foot Exercise Versus Common Footwear Exercise in Subjects with Plantar Fasciitis". Research Journal of Pharmacy and Technology. 12 (3): 1039. doi:10.5958/0974-360X.2019.00171.9. ISSN 0974-3618. S2CID 181730696.
26. Aqil A, Siddiqui MR, Solan M, Redfern DJ, Gulati V, Cobb JP (November 2013). "Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: a meta-analysis of RCTs". Clinical Orthopaedics and Related Research. 471 (11): 3645–3652. doi:10.1007/s11999-013-3132-2. PMC 3792262. PMID 23813184.
27. ^ Wang CJ (March 2012). "Extracorporeal shockwave therapy in musculoskeletal disorders". Journal of Orthopaedic Surgery and Research. 7 (1): 11. doi:10.1186/1749-799X-7-11. PMC 3342893. PMID 22433113.
28. "Plantar Fasciitis and Bone Spurs". American Academy of Orthopaedic Surgeons. 2010. Archived from the original on 16 June 2014. Retrieved 24 June 2014.
29. David JA, Sankarapandian V, Christopher PR, Chatterjee A, Macaden AS (June 2017). "Injected corticosteroids for treating plantar heel pain in adults". The Cochrane Database of Systematic Reviews. 2017 (6): CD009348. doi:10.1002/14651858.CD009348.pub2. PMC 6481652. PMID 28602048.
30. ^ Thomas JL, Christensen JC, Kravitz SR, Mendicino RW, Schuberth JM, Vanore JV, et al. (May–June 2010). "The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010". The Journal of Foot and Ankle Surgery. 49 (3 Suppl): S1-19. doi:10.1053/j.jfas.2010.01.001. PMID 20439021. S2CID 3199352.
31. Tweed JL, Barnes MR, Allen MJ, Campbell JA (September–October 2009). "Biomechanical consequences of total plantar fasciotomy: a review of the literature". Journal of the American Podiatric Medical Association. 99 (5): 422–430. doi:10.7547/0990422. PMID 19767549.
32. Arshad Z, Aslam A, Razzaq MA, Bhatia M (April 2022). "Gastrocnemius Release in the Management of Chronic Plantar Fasciitis: A Systematic Review". Foot & Ankle International. 43 (4): 568–575. doi:10.1177/10711007211052290. PMC 8996295. PMID 34766860.
33. Monto RR (April 2014). "Platelet-rich plasma efficacy versus corticosteroid injection treatment for chronic severe plantar fasciitis". Foot & Ankle International. 35 (4): 313–318. doi:10.1177/1071100713519778. PMID 24419823. S2CID 206652513.
34. Cotchett MP, Landorf KB, Munteanu SE, Raspovic A (January 2011). "Effectiveness of trigger point dry needling for plantar heel pain: study protocol for a randomised controlled trial". Journal of Foot and Ankle Research. 4 (1): 5. doi:10.1186/1757-1146-4-5. PMC 3035595. PMID 21255460.
35. ^ Cotchett MP, Landorf KB, Munteanu SE (September 2010). "Effectiveness of dry needling and injections of myofascial trigger points associated with plantar heel pain: a systematic review". Journal of Foot and Ankle Research. 3 (1): 18. doi:10.1186/1757-1146-3-18. PMC 2942821. PMID 20807448.
36. Elizondo-Rodriguez, Jorge; Araujo-Lopez, Yariel; Moreno-Gonzalez, J. Alberto; Cardenas-Estrada, Eloy; Mendoza-Lemus, Oscar; Acosta-Olivo, Carlos (January 2013). "A Comparison of Botulinum Toxin A and Intralesional Steroids for the Treatment of Plantar Fasciitis: A Randomized, Double-Blinded Study". Foot & Ankle International. 34 (1): 8–14. doi:10.1177/1071100712460215. ISSN 1071-1007. PMID 23386757.
37. ^ Hansen L, Krogh TP, Ellingsen T, Bolvig L, Fredberg U (March 2018). "Long-Term Prognosis of Plantar Fasciitis: A 5- to 15-Year Follow-up Study of 174 Patients With Ultrasound Examination". Orthopaedic Journal of Sports Medicine. 6 (3): 2325967118757983. doi:10.1177/2325967118757983. PMC 5844527. PMID 29536022.
38. Buchanan BK, Kushner D (2023). Plantar Fasciitis. Treasure Island (FL): StatPearls Publishing. PMID 28613727. Retrieved 2023-07-15. {{cite book}}: |work= ignored (help)

Further reading

• Lee SY, McKeon P, Hertel J (February 2009). "Does the use of orthoses improve self-reported pain and function measures in patients with plantar fasciitis? A meta-analysis". Physical Therapy in Sport. 10 (1): 12–18. doi:10.1016/j.ptsp.2008.09.002. PMID 19218074.

External links

• "Plantar fasciitis and bone spurs". American Academy of Orthopedic Surgeons.

• Disorders of fascia
• Foot diseases
• Inflammations
• Overuse injuries
• Soft tissue disorders