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Plantar fasciitis

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Description

There are many causes of plantar heel pain, but the most common is plantar fasciitis. Unfortunately, plantar fasciitis is poorly understood and the actual source of pain is still under debate. The most common explanation is that the pain is caused by trauma around the plantar calcaneal tuberosity from traction and shear forces from the plantar fascia. Plantar fasciitis can be a painful and debilitating condition, which often frustrates not only the patient but also the treating physician because of its recalcitrant nature. Typical Plantar fasciitis is a common source of pain along the sole, or plantar surface, of the foot.  The etiology of the condition is thought to be overuse, with traction and shear forces applied to the plantar fascia; it is not an inflammatory condition as the “itis” suffix would suggest.   Typical findings of the condition include pain and palpable tenderness in at the area junction of the plantar -fascia and the medial calcaneal tuberosity, significant “start up pain” when taking   usually worse with the first few steps in the morning , and worsening pain with prolonged weight-bearing. No universally accepted treatment algorithm exists for this condition, however, calf stretching (gastrocnemius) with the knee straight, plantar fascia specific stretching, (so-called “start up pain” ). Helpful treatments include stretching of the calf muscles and the plantar fascia itself and the use of orthotics with a medial arch support, and activity modification have been demonstrated to be effective in improving symptoms in the vast majority of patients.  More than 90% of cases resolve with non-surgical conservative care within 6-8 weeks.1

Structure and function  

The plantar fascia is a multilayered, fibrous aponeurosis located at sheet of fibrous tissue  (technically termed an aponeurosis) running along the sole of the foot that originates from the plantar aspect of the calcaneus. It spreads broadly from the central third of the foot at the medial tuberosity of the calcaneus, then divides into five digital bands at the metatarsalphalangeal joints. Each band inserts into the calcaneus to the base of the proximal phalanges, and with fibers merge merging with the dermis, transverse - metatarsal ligaments, and flexor tendon sheaths . Three distinct compartments of intrinsic plantar muscles are also formed through strong vertical septa that divide the medial, central, and lateral portions of the plantar fascia. The terminal branches of the posterior tibial nerve and artery and the medial calcaneal, medial plantar, and lateral plantar nerves supply cutaneous branches through the plantar aponeurosis.

The plantar fascia can be said to be an anatomic extension of the Achilles tendon. It is essentially an inelastic structure with minimal elongation.2 During the toe-off phase of gait, the metatarsalphalangeal joints are dorsiflexed, which results in high tensile forces at the calcaneal origin of the plantar fascia. This has been referred to as the “windlass effect” of the plantar fascia.The plantar heel fat pad is a complex structure of multiple fibrous septa enclosed by adipose tissue that function as a shock absorber. This protects the underlying bone and soft tissue structures even with the heel absorbing 110% of body weight at heel strike and up to 200% while running.4

There is no widely accepted agreement as to the cause of plantar fasciitis although the end result is chronic microscopic (and sometimes macroscopic) as well.  The plantar fascia is mostly inelastic, with minimal elongation. Although the terminal insertion of the fascia is on the toes, the functional insertion point is at the of the metatarsal, as the phalanges are dorsiflexed relative to the metatarsals, forcing the tissue to curve around the joint. (This relationship is similar to the semitendinosus tendon, which technically inserts on the anterior aspect of the tibia, but flexes the knee as if it attached on the posterior surface.

Weight-bearing forces tend to flatten the medial longitudinal arch as forces are applied to the foot; the plantar fascia prevents this collapse, by maintaining the distance between the calcaneus and the metatarsals.  Note that the insertion of the plantar fascia is on the toes; hence dorsiflexion of the toes pulls on the plantar fascia, winding it under the metatarsals and thereby elevating the arch, a so-called “windlass” effect.

Plantar fasciitis is thought to be produced by overuse, creating a chronic microscopic injury to the plantar-medial origin of the plantar fascia.  Mechanical derangements and restriction of motion are at least contributory causes of both classic proximal fasciitis and the less-common distal plantar fasciitis. This is contrary to the popular belief that the presence of a heel spur is the causative factor in the development of plantar fasciitis. Recent studies, in fact, have suggested that only  A heel spur is not uncommonly found, but is neither a sensitive nor specific finding. Only 50% of patients with heel pain will have heel spurs and even asymptomatic cases (15%) have heel spurs.5 Furtherabout 15% of people with asymptomatic feet will have them: accordingly, it is likely that the spur is not causing the condition.  Further, cadaveric dissections have revealed the presence of the spur demonstrated that the spur from the calcaneus is within the flexor digitorum brevis as well as the abductor hallucistendons, rather than the plantar fascia itself.6 Thus, although heel spurs do indeed occur with heel pain, they are generally not considered the cause. Some have attributed heel pain to irritation of the medial calcaneal nerve or extensor digiti minimi branch of the lateral plantar nerve as it passes between the abductor hallucis and quadrates plantae. Loose attachment of the heel fat pad and its hyper-mobility, excessive loading of the heel pad, as well as fat pad inflammation and atrophy may also contribute to heel pain symptoms and have been categorized as overload heel pain syndrome.The condition of plantar “fasciitis” denotes an inflammatory process, but histologic evidence is not in agreement with this notion. Findings demonstrate microtears in

Histologic evidence includes  tears in the fascia, myxoid degeneration, angiofibroblastic hyperplasia, and collagen necrosis .7 Such changes would suggest a non-inflammatory state of degenerative fasciosis secondary to chronic repetitive microtrauma of the plantar fascia at its origin. An inflammatory model of the development of symptomatic plantar fasciitis does, however, gain support in the concept that the microscopically injured plantar fascia attempts to heal itself via an inflammatory pathway. This leads to tightening of the plantar fascia and a build up of inflammatory mediators and not inflammation per se. Inflammation could be part of the healing process, however.   

Patient presentation 

Healing of micro-trauma is thought to cause tightening of the plantar fascia  when the patient is at rest, especially as the foot and ankle assume a plantarflexed position at night.  Upon ambulation, with when the foot and ankle forced into a neutral and dorsiflexed position, the healing tissue is strained, producing heel pain typically at the origin of the plantar fascia .  Thus, the classic presentation of plantar fasciitis is an especially sharp  pain with the first few steps in the morning or after prolonged rest.

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Patients with plantar fasciitis almost universally, give a history of sharp, stabbing inferior heel pain with the first few steps in the morning after getting out of bed. Pain is often also associated with first steps after periods of inactivity such as sitting for lunch or after getting out of car. This pain is localized to the plantar medial aspect of the calcaneal tuberosity   (Figure 1). It will often improve after some movement or stretching. However, it will tend to recur and worsen as the day progresses, particularly if the patient has had prolonged periods of significant weight-bearing activities such as walking or standing. The symptomatic patient will deny radiation of pain and will not usually have any associated parasthesia. Pain that is burning is not typical of plantar fasciitis and may suggest nerve irritation as a source of the pain (ex. Baxter’s neurtitis). Validated risk factors for the development of classic plantar fasciitis include: being overweight, a job or lifestyle that requires prolonged standing and walking, and a documented equines contracture.

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Figure 1. Common location of plantar fascia pain

 

The foot and ankle physical exam should be thorough and include inspection of the patient’s stance, foot shape, and gait. A neurologic examination of the lower extremity and back should be done to explain paresthesias or abnormal sensation accompanying pain. The location of the pain, often ; full neurologic evaluation; and identification of any areas of tenderness, especially at the medial plantar aspect of the heel, is important in making the correct diagnosis. However, patients may experience pain more distal to the origin as the plantar fascia extends into the medial arch or branches into the five digital bands. Although possible, variations of the typical clinical finding of plantar medial heel pain should warrant further investigation of other diagnoses. Lastly, the diagnosis can be further identified through . Confidence of the diagnosis is increased if dorsiflexion of the toes , which typically exacerbates the pain in patients with symptomatic plantar fasciitis (Figure 2).via the windlass effect.

 

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Figure 1. Common location of plantar fascia pain

 

Figure 2.Plantar Fascia Specific Stretch

Objective Evidence

Plantar fasciitis is typically diagnosed based on the patient’s by history and physical examination . Plain x-rays are not routinely indicated but can be used to rule out calcaneal tumors, fractures, abscesses, and foreign bodies. A but imaging studies can help rule out other diagnoses.  A lateral weight-bearing view of the foot will often demonstrate a calcaneal heel spur. Essentially, the same traction phenomena that causes overloading of the plantar fascia and its origin may cause excessive bone formation in the form of a calcaneal heel spur. However, though this should be considered an incidental finding ; as noted, the presence of a heel spur does not directly correlate with symptoms. Many patients have heel spurs on x-rays and are asymptomatic, whereas, many patients have significant plantar fasciitis and do not demonstrate a heel spur on plain x-ray.In very rare instances a  

A triple-phase bone scan may be warranted as an imaging study of choice when trying to differentiate plantar fasciitis from other plantar heel etiologies. This test can provide objective evidence of predictable increased uptake in the medial calcaneal tubercle that can differentiate the diagnosis of or MRI can plantar fasciitis from calcaneal stress fracture. 8Magnetic resonance imaging (MRI) is seldom used for the confirmation of plantar fasciitis due to its low specificity. It will typically show increased signal intensity, thickening of the plantar fascia, and edema of surrounding structures. However, if symptoms fail to resolve after a concerted treatment effort an MRI may be ordered An MRI may be used also to rule out other causes of heel pain such as tumors and infection.9  Ultrasound is less expensive than an MRI and has been shown to be equally as effective as using a triple-phase bone scan in the diagnosis of plantar fasciitis.10 Ultrasound is also very quick and provides no radiation exposure , but is unfortunately user dependentbut requires specific expertise that many physicians lack. Typical ultrasound findings include a thickened, hypoechoic plantar fascia with soft-tissue edema.

Laboratory , electromyography (EMG), and nerve conduction velocity (NCV) studies can provide additional information for the clinician but are not routinely ordered. Laboratory studies are usually normal in the patient with plantar heel pain, but serum hematologic and immunologic testing can detect other systemic causes. HLA-B27, complete blood count, erythrocyte sedimentation rate, rheumatoid factor, antinuclear antibodies, and uric acid can be considered in patients with bilateral or atypical heel pain. 2 EMGEMG/NCV studies are effective in identifying a spinal radiculopathy, peripheral neuropathy, as well as local nerve entrapment.

 

Epidemiology

Plantar fasciitis is the most common cause of heel pain.   Patients are usually 40-60  about 50 years of age.  It is primarily unilateral, accounting for 70% of all cases of the condition.11 Bilateral heel pain however, in conjunction with multiple sites of enthesopathy and joint pain, suggests a systemic rheumatologic disorderPlantar fasciitis  is bilateral heel in about 30% of primary conditions.

Differential diagnosis

Plantar fasciitis is the most common likely cause of heel pain but there are less common causes other entities such as overload heel pain syndrome, heel pad atrophy, entrapment of the first branch of the lateral plantar nerve (Baxter’s nerve), tarsal tunnel syndrome, calcaneal stress fracture , periosteal inflammation, and seronegative arthritis-induced inflammation. Sudden increases in inflammatory disease might be responsible.

Pain after a sudden increase in the patient’s level of activity or training should lead the clinician to further investigate the possibility of prompt a work-up to rule out a calcaneal stress fracture. Infection or neoplasm are the most likely cause of more likely when the plantar heel pain when described as unrelenting or nocturnal pain or when accompanied by constitutional symptoms such as is present at night, especially when accompanied by unplanned weight loss, fevers or chills. These are, in general, unlikely diagnoses.

Red flags

The sudden onset of hell pain following a fall from a height requires that a fracture be ruled out.  Non-operative treatments for a minimum of six months and usually up to a year should be tried as the vast majority of patients will get better without surgery.Burning pain is not typical of plantar fasciitis and may suggest nerve irritation as a source of the pain: Baxter’s neurtitis (compression of the inferior calcaneal nerve); peripheral neuropathy or radiculopathy.

 

Red flags

Any deviation from the classic history for plantar fasciitis  (eg pain that is worse with the first steps, then better, and then maybe worse as the day goes on if there is a lot of standing) should be a red flag to consider other diagnoses. 

Treatment options and Outcomes

Non-operative Treatments

The vast majority of patients , 90+%, will will have their symptoms resolve with non-operative or without treatment over a period of 2- 6 months. 1,12 The main components of an effective non-operative treatment program are Recovery can be accelerated with a program of calf and plantar fascia stretching, activity modification to avoid precipitating activities, and comfort shoe wear. Common non-surgical treatments also include short-term NSAID use, formal  Formal physical therapy, immobilization via cast or boot, steroid injections, and rarely extracorporeal shock wave therapy may also be employed.

Calf

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Regular daily gastrocnemius (Figure 3 -right leg) stretching performed over a 6- to 8-week period will alleviate plantar fasciitis in almost 90% of patients. The stretching should be performed for a total of 3 minutes per day. It should be done with  with the knee straight so that the gastrocnemius (which originates on the femur) is stretched, as this is the muscle that is tight. It should be performed on both sides. Six sets of 30 seconds per side is one method of achieving this. It is important that the stretch be done daily . 

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Figure 3. Gastrocnemius stretch of the right leg. Note that the back knee is straight and the back foot is internally rotated.

Plantar Fascia Specific Stretching

is recommended.  Equally good results can be obtained with a plantar fascia stretch. Plantar fascia specific stretch has been found to provide symptomatic relief for the majority of patients. This   This is done in a seated position and includes crossing the affected leg over the other leg. Using the hand on the affected side, dorsiflex the affected foot (Figure 2). This creates tension/stretch in the arch of the plantar fascia. Appropriate stretch position can be confirmed by gently rubbing the thumb of the unaffected side left to right over the arch of the affected foot. The plantar fascia should feel firm, like a guitar string. The stretch position should with the heel on the ground. The patient then places an object (eg, a sock, the contralateral foot) under the metatarsals and steps on it. This produces tension in the plantar fascia.  The stretch position should be held for 10 seconds and repeated 10 times. The timing of when this is performed is important. It should be done prior to the first step in the morning and during the day before standing after prolonged inactivity. Most patients perform the stretch 4-5 times during the day for the first month, and then on semi-regular basis (3-4 times per week). Decreased pain is expected at 6 weeks, with resolution of symptoms over 3-6 months.

With resolution of the heel pain symptoms, it is important to continue calf stretching and plantar fascia stretching on a semi-regular basis (3-4 times per week) so as to minimize the risk of recurrence. These treatment modalities treat the symptoms, but do not fully address the underlying biomechanical predisposing factors. Therefore, ongoing management of this condition is essential.

Activity Modification

Any activity that has recently been started, such as a new running routine or a new exercise at the gym that may have increased loading through the heel area, should be stopped on a temporary basis until the symptoms have resolved. At that point, these activities can be gradually started again. Also, any activity changes that will limit the amount of time a patient is on their feet each day may be helpful.  If the patient is carrying significant extra weight, losing weight can be helpful in improving the symptoms associated with plantar fasciitis. Essentially, anything that decreases the repetitive loading through the plantar fascia will help to alleviate the symptoms.

Orthotic Insert

A soft, over-the-counter orthotic with an accommodating arch support has proven to might be quite helpful in the management of plantar fascia symptoms. Studies demonstrate that it is not necessary to obtain a custom orthotic for the treatment of this problem.

Comfort Shoes

Shoes . Evidence supporting the need for a custom orthotic is lacking. Shoes with a stiff sole and rocker-bottom contour combined with an over-the-counter orthotic or a padded heel can off-load the plantar fascia at its origin and be very helpful in the treatment of plantar fasciitis.likewise may be effective

Anti-inflammatory

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A short course of over-the-counter anti-inflammatory medications (NSAIDS) may be helpful in managing plantar fasciitis symptoms provided the patient does not have any contra-indications such as a history of stomach ulcers.

Corticosteroid Injection

For recalcitrant plantar fasciitis, some physicians will recommend a local injection of corticosteroids. This can be helpful in breaking the cycle of pain and give temporary relief but it provides minimal long-term beneficial effect in most patients.13 In order to avoid atrophy of the fat pad from corticosteroids, injection should be from the medial side. Injections will not change the underlying biomechanics, so they typically need to be combined with the stretching protocols that have been previously described. Some physicians have advocated using plasma-rich protein injections to increase the concentration of growth factors at the site of injury and augment the natural healing process of chronic plantar fasciitis. The research evidence for the use of this technique is limited.

Plantar Fascia Night Splint

A night splint (Figure 5), which medication may ameliorate symptoms, but does not address the pathology (as again, despite the “itis” suffix, inflammation is not the cause).

Corticosteroid Injection can give temporary relief but may lead to atrophy of the fat pad. Data on the salubrious effects of  plasma-rich protein injections are  limited.

A splint (Figure 5) that keeps the ankle in a neutral position (right angle) while the , perpendicular to the foot,  while the patient sleeps, can be helpful in alleviating the significant morning symptoms. This splint is worn nightly for 1-3 weeks until the cycle of pain is broken. Furthermore, this splinting can be reinstituted for a short period of time if symptoms recur.

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Figure 5. Plantar fasciitis night splint

Casting and Extra-corporeal Shockwave Therapy

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Operative Treatment

Surgery   Avoiding the position of plantar flexion can prevent some of the shortening of the fascia that occurs at night.

 Surgery is rarely required to treat plantar fasciitis.  Only   Only patients who have persistent symptoms despite religiously adhering to the nonoperative non-operative treatment for a minimum of 6 -9 months should be considered for surgery.  Surgical treatment of plantar fasciitis does not fully address the underlying reason why the condition occurred, therefore the surgery may not be completely effective. There is also a risk of accidental injury of the medial calcaneal nerve which may produce neuroma and sensory impairment.

Partial Plantar Fasciectomy

  Endoscopic or open partial plantar fasciectomy involves removal of the injured area of the plantar fascia. Decompression of the first branch of the lateral plantar nerve can be done along with partial plantar fascia release if suspicion of entrapment of the calcaneal branches of the tibial nerve exists. This is then followed by a 6-week period of relative rest and stretching. Although  Although this procedure has produced good results , it can increase the risk of a rupture of the plantar fascia with resulting profound flatfoot deformity and an increase in symptoms. Complete in some cases, complete release of the plantar fascia leads to flat foot and subsequent even worse problems. Therefore, it is recommended that less than 40% of the plantar fascia be released Complications from release of the plantar fascia include prolonged healing and rehabilitation times, alteration of the biomechanics of the foot leading to a decrease in arch height, increased strain of the plantar ligament's cuboid attachment areas, and increased stress to the midfoot and metatarsal bones. Postoperatively, patients may experience acute plantar fasciitis, heel numbness, neuroma formation, and infection.

Gastrocnemius Recession (Strayer or Volpius Procedure)

Recently there have been a few studies which suggest that gastrocnemius recession (Strayer or Volpius procedure) can (though an appropriately conservative release may limit the effectiveness of the procedures. A recession of the gastrocnemius theoretically should help resolve the symptoms associated with plantar fasciitis as ,  as gastrocnemius contracture is a known risk factor for the development plantar fasciitis. This operation involves making an incision in the lower calf in order to releasing the tendon of the gastrocnemius at the point where it inserts just above the Achilles tendon. Following the surgery, patients need a six week period of relative rest. The gastrocnemius can have noticeable residual weakness that usually resolves in 6-12 months. At this time there There are only limited studies assessing the long-term effectiveness of this procedure.

Radio frequency Ablation

A new, less-invasive surgical technique has been described that utilizes bipolar radiofrequency microtenotomy (Topaz Procedure) to treat recalcitrant plantar fasciitis.16 Studies indicate that the radiofrequency in wound healing could lead to increased angiogenesis. Patients have reported a rapid recovery with pain relief though 24 months. Unfortunately, this technique has not been subject to prospective, randomized trials and further studies need to be undertaken to solidify its efficacy.

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Figure 3. Gastrocnemius stretch of the right leg. Note that the back knee is straight and the back foot is internally rotated.

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Figure 5. Plantar fasciitis night splint

 

 

Risk factors and prevention

Risk factors for plantar fasciitis include excessive standing, increased  greater body weight, increasing age, a change in activity level, Achilles tightness, and a stiff calf muscle (gastrocnemius).  A  A flat foot or a high arch deformity (pes planus or and pes cavus foot deformity , respectively) can increase loading through  of the plantar fascia and increase the risk of developing plantar fasciitis.  However However, any foot type can develop this condition. Seronegative spondyloarthropathies and Paget may be risk factors as well. 

Miscellany

Many big-name professional athletes have been affected by plantar fasciitis. The long list of athletes include but are not limited to Los Angeles Angels first basemenAlbert Pujols, Tampa Bay Rays third baseman Evan Longoria, Los Angeles Dodgers starting pitcher Clayton Kershaw, San Diego Chargers tight end Antonio Gates, Giants quarterback Eli Manning, Pau Gasol of the Los Angeles Lakers, and Joakim Noah of the Chicago Bulls.Fascia and political Fascism are related words. A fascia is of course connective tissue, typically that wraps around muscle fibers.  Fascism comes from the Italian word fasci, political groups or guild, itself derived from the Latin word fascis, meaning "bundle"

Key terms 

plantar fascia, plantar fasciitis, calcaneous, Achilles tendon

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