Plantar fasciitis

Abstract

Heel pain, mostly caused by plantar fasciitis (PF), is a common complaint of many patients who requiring professional orthopedic care and are mostly suffering from chronic pain beneath their heels. The present article reviews studies done by preeminent practitioners related to the anatomy of plantar fasciitis and their histo-pathological features, factors associated with PF, clinical features, imaging studies, differential diagnoses, and diverse treatment modalities for treatment of PF, with special emphasis on non-surgical treatment. Anti-inflammatory agents, plantar stretching, and orthosis proved to have highest priority; corticosteroid injection, night splints and extracorporeal shock wave therapy were of next priority, in patients with PF. In patients resistant to the mentioned treatments surgical intervention should be considered.

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Journal of Research in Medical Sciences
| August 2012 |
799
review article
Plantar fasciitis
Mohammad Ali Tahririan, Mehdi Motifard, Mohammad Naghi Tahmasebi
1
, Babak Siavashi
2
Department of Orthopedics, Kashani Hospital, Medical University of Isfahan,
1
Departments of Orthopedics, Shariati Hospital,
2
Sina Hospital,
Tehran University of Medical Sciences, Iran
Heel pain, mostly caused by plantar fasciitis (PF), is a common complaint of many patients who requiring professional orthopedic care
and are mostly suffering from chronic pain beneath their heels. e present article reviews studies done by preeminent practitioners
related to the anatomy of plantar fasciitis and their histo-pathological features, factors associated with PF, clinical features, imaging
studies, differential diagnoses, and diverse treatment modalities for treatment of PF, with special emphasis on non-surgical treatment.
Anti-inflammatory agents, plantar stretching, and orthosis proved to have highest priority; corticosteroid injection, night splints
and extracorporeal shock wave therapy were of next priority, in patients with PF. In patients resistant to the mentioned treatments
surgical intervention should be considered.
Key words: Plantar fasciitis, plantar heel pain, risk factors, imaging studies, treatment
Address for correspondence: Assistant Prof. Tahririan Mohammad Ali, Department of Orthopedics, Kashani Hospital, Isfahan Medical University.
E-mail: tahririan@med.mui.ac.ir
Received: 31-03-2012; Revised: 27-05-2012; Accepted: 07-06-2012
1980 to 2012), and AMED (from 1985 to 2012). Using the
keywords “heel pain,” “painful heel,” “plantar fasciitis,”
and “heel spur” and combining them with search terms:
“treatment,” and “management,” 51 journal articles
were identied. Of these, 42 were primary articles while
the remaining 9 were review papers.
Patho-anatomical features
The differential diagnosis of PF precedes an
understanding of the local anatomy. The calcaneum is
separated from plantar skin by a complete honeycombed
bro-fay fat pad that acts as a shock absorber.
The posterior tuberosity of calcaneum has medial and
lateral processes. The medial process gives aachment
to the Flexor digitorum brevis (FDB), Abductor hallucis
(AH), and the medial head of Quadratus plante (QP) as
well as the central band of plantar fascia.
The plantar fascia or deep fascia of the sole, proximally
has a direct fibrocartilaginous attachment to the
calcaneum (an enthesis), whose central band is constant
along with medial and lateral band. It has a triangular
shape and develops from the medial process of the
calcaneal tuberosity, and diverges distally at mid-
metatarsal level into five separate strands, which
are aached at the forefoot onto the plantar skin, the
base of proximal phalanges (via plantar plate), the
metatarsophalangeal(MTP) joints via the collateral
ligaments and deep transverse metatarsal ligaments.
[6]
Heel skin is innervated by the medial calcaneal nerve
which may present with heel pain if compressed
proximally (such as in tarsal tunnel syndrome). Boxter’s
INTRODUCTION
Heel pain is a common presenting complaint in the foot
and ankle practice, and plantar fasciitis (PF) is the most
common cause of chronic pain beneath the heel in adults,
making up 11–15% of the foot symptoms requiring
professional care among adults.
[1-4]
It is estimated that 1
in 10 people will develop PF during their lifetime.
[5]
PF,
which is more common in middle-aged obese females
and young male athletes, has a higher incidence in the
athletic population though not all suffering require
medical treatment. In the literature, PF has been described
as painful heel syndrome, chronic plantar heel pain, heel
spur syndrome, runner’s heel, and calcaneal periostitis.
[6,7]
Search strategy
Peer-reviewed journal articles that predominantly focus
on plantar heel pain are included in this review, which
of course does not included non-English language
reports. Studies have been identied using the following
databases: PubMed (from 1980 to 2012), Ovid Medline
(from 1980 to 2010), Web of Science (from 1980 to 2012),
EMBASE (from 1980 to 2012), CINAHL (from 1982 to
2012), Cochrane Database of Systematic Reviews (1980 to
2012), Cochrane Central Register of Controlled Trials (from
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Tahririan,
et al
.: Plantar fasciitis
nerve (the rst branch of lateral plantar nerve) may be at
risk of compression between AH and medial belly of the
QP muscle.
[6,8]
Despite the high prevalence of PF, information about its
pathogenesis is still limited, and its histological changes
are suggestive of degeneration rather than inammation.
The fascia is usually markedly thickened and griy. These
pathologic changes are more consistent with fasciosis
(degenerative process) than fasciitis (inflammatory
process), but fasciitis remains the accepted description in
the literature.
[9]
Histological evidence shows that spur formation can occur
in loose connective tissue, surrounding brocartilage which
may not be aligned with the direction of traction, and spur
trabeculae commonly forms perpendicular to its long
axis. Additionally, clinical studies have shown that spur
development is unrelated to medial arch height and can
occur aer surgical release of the plantar fascia.
[6,9,10]
Factors associated with PF
Identifying factors associated with PF will help identifying
at risk individuals and development of new and improved
preventative and treatment strategies. Obesity is present in
up to 70% of patients with PF. According to the literatures,
there is a strong association between increased body
mass index (BMI) and PF in a non-athletic population.
The evidence suggests that unlike weight, height has no
association with PF. More specically, increased weight is
associated with PF, but not necessarily with reduced height.
Interestingly, there is no correlation between PF and weight,
height or BMI in an athletic population.
[11]
Heel spurs have commonly been implicated as a risk factor
for PF. Current studies demonstrate a highly signicant
association between calcaneal spur and PF. Besides, there
is a weak association between increasing age, prolonged
standing, decreased rst MTP joint extension, decreased
ankle dorsiexion, and PF.
[10,11]
According to Kibler et al., decits in exibility of the plantar
exor muscles may contribute to a greater fascia stretching.
[12]
Cheung et al. contend that intense muscle contractions of the
plantar exor muscles cause indirect stretching of the fascia,
increasing the risk of developing the PF.
[13]
Some reports suggest that 81–86% of patients with PF have
excessive pronation.
[14]
Despite the fact that the pronated
foot posture and over-pronation during gait are commonly
cited as causative factors for PF, there is conicting evidence
with regard to the association of static foot posture and
dynamic foot motion with PF.
[15,16]
Clinical features and diagnosis
The diagnosis of PF is usually clinical and rarely needs to
be investigated further.
[17,18]
The patient complains of pain
in the medial side of the heel, most noticeable with initial
steps aer a period of inactivity and usually lessens with
increasing level of activity during the day, but will tend
to worsen toward the end of the day.
[19]
Symptoms may
become worse following prolonged weight bearing, and
oen precipitated by increase in weight bearing activities.
Paresthesia is uncommon.
[16]
PF is usually unilateral, but up
to 30% of cases have a bilateral presentation.
[7]
Tightness
of Achilles tendon is found in almost 80% of cases.
[2]
Occasionally the pain may spread to the whole of the foot
including the toes. Tenderness can be elicited over the medial
calcaneal tuberosity and may exaggerate on dorsiexion of
the toes or standing tip toe.
[20]
The clinical course for most
patients is resolution of symptoms within a year.
[21]
Imaging studies
Imaging studies are typically not necessary for diagnosis
of PF.
[9,17]
In the clinical management of chronic heel pain,
diagnostic imaging can provide objective information. This
information can be particularly useful in cases that do not
respond to rst-line interventions, or when considering
more invasive treatments (e.g. corticosteroid injection).
• Lateral radiograph of the ankle should be the rst imaging
study. It is a good modality for assessment of heel spur,
thickness of plantar fascia, and the quality of fat pad. Stress
fractures, unicameral bone cysts, and giant cell tumors are
usually identied with plain radiography.
[18,19,22]
• Ultrasound examination is operator-dependent,
but it proves to be signicant when the diagnosis is
unclear.
[23,24]
In the literature, normal thickness of the
plantar fascia when measured in ultrasound varies in
range (mean 2–3 mm). People with chronic heel pain are
likely to have a thickened plantar fascia with associated
uid collection, and that thickness values >4.0 mm are
diagnostic of plantar fasciitis.
[6]
• Plantar fascia thickness values have also been used to
measure the eect of treatments and there is a signicant
correlation between decreased plantar fascia thickness
and improvement in symptoms.
[25-27]
• MRI can be used in questionable cases, which fail
conservative management or are suspected of other
causes of heel pain, such as tarsal tunnel syndrome, so
tissue and bone tumors, osteomyelitis, subtalar arthritis,
and stress fracture.
[17,18]
Dierential diagnosis
Although PF is the most common cause of chronic plantar
heel pain, there are multiple dierential diagnoses [Table 1],
most of which can be excluded following a comprehensive
history and physical examination.
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Treatment
The natural history of PF is oen self-limited. However, the
typical resolution time is anywhere from 6 to 18 months
and sometimes longer,
[20]
which can lead to dissatisfaction
of patient and physician. Most experts agree that early
recognition and management of PF leads to short course of
treatment and greater chance of success with conservative
therapies.
[6]
Numerous interventions have been described for treatment
of PF, which include: rest, heat, ice pack, non-steroidal anti-
inammatory drugs (NSAIDS), heel pads, magnetic insole,
night splints, walking cast, taping, plantar and Achilles
stretching, ultrasound, steroid injection, extra-corporeal
shock wave therapy, platelet-rich plasma injection, pulsed
radiofrequency electromagnetic eld therapy, and surgery.
Unfortunately, few high-quality randomized, controlled
trials have been made to support these therapies. All in all,
a trial of conservative treatment is generally advised before
more invasive interventions are aempted.
Stretching
Stretching may be in calf or plantar region. Numerous
authors have recommended that calf stretching should be
one of the interventions used for patients with PF.
[7,17,18,28]
A calf stretch is performed with the patient stands with
staggered legs facing toward a wall, with both hands
stretched out.
According to Porter et al. the dosage for calf stretching can
be either three minutes at a time, three times a day or ve
20-s intervals, twice daily, as both have the same eect.
[29]
The continuity of the connective tissue between the Achilles
tendon and the plantar fascia as well as the fact that decreased
ankle dorsiexion is a risk factor in the development of plantar
fasciitis provides some justication for calf stretching.
[19]
DiGiovanni et al. were the rst to publish that tissue specic
plantar fascia-stretching exercise is more eective than calf
stretching in a randomized clinical trial.
[30]
Moreover, it
seems that plantar fascia-stretching exercise is more eective
than low dose shock wave therapy in acute phase of PF.
[31]
Night splints
The design of night splinting is to keep the patient’s ankle in
a neutral position overnight, passively stretching the calf and
plantar fascia during sleep. There is no dierence between
the various types of the night splints whose purpose is to
allow the fascia to heal.
[32,33]
There is moderate evidence that
night splints are useful in improving symptoms of PF, which
are recommended to be used for 1–3 months and should be
considered as an intervention for patients with symptoms
greater than 6 months in duration.
[19]
Orthosis
The rationale for use of foot orthoses was to decrease
abnormal foot pronation that was thought to cause
increased stress on the plantar fascia, but to date based
on Ribeiro et al. results, the pain reduction mechanism
obtained by the use of insoles would be mostly related to
its supporting function of the longitudinal arch and not to
the overload reduction over the plantar surface.
[34]
There
appears to be no dierence between prefabricated or custom
foot orthoses in the results of treatment which is strongly
recommended to be used to provide short-term (3 months)
reduction in pain and improvement in function.
[35]
There is
inconclusive evidence with regard the long-term(12 months)
use of orthotic devices.
[6,19,36]
Local injection of steroids
When more conservative management is unsuccessful,
steroid injection is a preferred option. There is no gold
standard regarding the types and doses of local injection of
corticosteroids. It is recommended that steroid injection should
be performed with precise determination of the location,
which can be easily achieved by using ultra-sonographic
guidance.
[37]
Generally, the medial approach is likely to be
less painful than a direct plantar approach. Injecting deep
to the plantar fascia ensures adequate spread of the steroid
preparation and reduces the risk of fat pad atrophy.
[6,38]
Siavashi et al. compared the ecacy of the corticosteroid
injection with plantar stretching and believe there is no
dierence aer 8 weeks between these two methods in
patient’s symptoms.
[39]
Corticosteroid injection has been shown to signicantly
reduce plantar fascia thickness as early as two weeks
and one month following treatment. Additionally, there
is a significant correlation between decreased plantar
fascia thickness and improvement in symptoms. Results
Table 1: Differential diagnoses of plantar fasciitis
Plantar fascia rupture: Sudden, acute, knife-like pain, ecchymosis,
which is more proximal and may be associated with a palpable gap.
MRI or ultrasound confirms the diagnosis.
Fat pad syndrome: Atrophy of heel pad, common in elderly
and diabetic patients, pain is usually centrally located and is not
characterized with morning pain.
Calcaneal stress fracture: Pain with weight-bearing, worsens with
prolonged weight-bearing, diffuse heel tenderness
Tumor: Pain is typically achy, constant, nocturnal, and even present
without weight bearing and at rest, constitutional symptoms late in the
course
Calcaneal bursitis (Policeman’s heel): Burning, aching or throbbing
type of pain, swelling, and erythema of posterior heel
Boxter’s nerve entrapment: Pain is more proximal and dorsal, no
sensory disturbance
Medial calcaneal nerve compression: Occurs in tarsal tunnel,
positive Tinnl’s sign and altered sensation of medial side of the heel.
Seronegative arthropathies: Usually bilateral, history of back pain,
urethritis, uveitis, elevated blood inflammatory markers, etc.
Spinal stenosis and L5-S1 nerve root irritation
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of a Cochrane review show that corticosteroid injection
therapy has short-term benet compared to control, and
the eectiveness of treatment is not maintained beyond
six months.
[27,40,41]
Complications of steroid injection are
not common. Reported complications of palpation-guided
steroid injection are plantar fascial rupture, fat pad atrophy,
lateral plantar nerve injury secondary to injection, and
calcaneal osteomyelitis.
[42,43]
However, these complications
have not been reported following ultrasonographic-guided
injections.
[37]
Extra-corporeal shock wave therapy
Extra-corporeal shock wave therapy (ESWT) can be of high
or low energy. It has been claimed that the deep tissue
cavitation eect causes micro rupture of capillaries, leakage
of chemical mediators, and promotion of neovascularization
of the damaged tissue.
[6]
It is usually applied under
intravenous sedation with or without local inltrative
anesthesia.
[44,45]
ESWT is indicated if there is failure of other
conservative modalities such as stretching exercises, casting
or night splinting, and symptoms lasting for more than
6 months. As this is a relatively safe procedure, it could
be considered before any surgical treatment and may be
preferable to try before local steroid injection.
[46]
Bilateral
cases can be treated under a single anesthetic and full weight
bearing may be started immediately. Prior steroid injections
of over three times appear to be a poor prognostic factor for
good recovery following ESWT.
[17]
This modality is contra-
indicated in bleeding diatheses.
[18]
The outcome of ESWT is not dependent on the presence of
calcaneal spur where it does not change the radiographic
appearance of the spur.
[47]
Presence of calcaneal bone marrow edema on MRI has been
found to be a good predictive indicator for a satisfactory
clinical outcome following ESWT.
[48]
There are inconclusive data whether to use local steroids or
ESWT. Sorrentino et al. suggest in patients with idiopathic
PF, perifascial edema seems to be a useful criterion to
address the therapy to the high resolution ultrasonographic-
guided steroid injection treatment, while in cases without
edema, treatment could be address to ESWT.
[49]
According
to Saber et al, both local steroid injection and ESWT are
proved to be eective in treatment of PF, but as steroid
injection is more cost eective and has more reproducible
results regardless of machine or operator, it is preferred.
However, ESWT should be considered prior to any surgical
treatment for recalcitrant PF.
[25]
Autologous platelet rich plasma (PRP)
There is substantially growing enthusiasm for the use
of growth factor containing harvested blood/ platelet
concentrate which, unlike steroids, can stimulate the reparative
process.
[50,51]
Current studies have revealed that local injection
of PRP provides signicant relief of pain and improvement
of function, and the results seems to be comparable, and
sometimes superior to local steroid injection.
[50]
However,
available data are limited by quality and size of the study, as
well as length of follow-up, and are currently insucient to
recommend this modality for routine clinical use.
Surgery
Recalcitrant cases where symptoms persist for more than
6–12 months, even aer adequate conservative treatment
are usually selected for surgery.
[17]
Before surgery nerve
conduction and electromyographic studies should be
considered to determine if the posterior tibial nerve is
compressed.
Open or endoscopic plantar fascia release may be done.
Some advantages of endoscopic plantar fasciotomy include:
minimal so tissue dissection, excellent visualization of
the plantar fascia, minimal post operative pain, and earlier
return to work, However, the American Orthopaedic Foot
and Ankle Society recommends that in case of suspected
nerve compression, endoscopic release should be avoided.
[52]
All in all, still, the procedure of choice is open partial plantar
fascia release with simultaneous release of rst branch of
lateral plantar nerve.
[6]
A large cohort study indicates that
70% of patients showed improvement following surgery
but only 50% of patients displayed complete satisfaction.
Following complete division of the plantar fascia, the
development of pes planus, secondary hallux valgus, or
hammer toes are expected, and therefore orthotics are
required lifelong post- operatively.
[18]
CONCLUSION
PF is the most common cause of inferior heel pain in adults.
The patient usually complains of gradual onset of pain along
the medial side of the heel. The pain is worse when arising in
the morning which becomes less severe aer the few steps.
The diagnosis of PF is usually clinical and rarely needs to be
investigated by imaging or electromyographically.
In most patients with PF, conservative treatment usually
is sucient. Initially, a period of rest accompanied by anti-
inammatory agents (ice pack/heat, NSAID’s), stretching,
and an orthosis is recommended. There is no dierence in
which types of orthosis is used, although plantar stretching
seems to be more eective. If the patient remain symptomatic,
corticosteroid injection and night splint (especially in patients
with symptoms greater than 6 months in duration) may be
reasonable. ESWT should be considered prior to any surgical
intervention in patients with refractory PF.
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In a good majority of the patients, these modalities are
sucient and the patient will become symptom free.
However, if aer 6–12 months of conservative treatment,
the patient still has sucient symptoms that interfere with
their activities of daily life, surgical intervention should be
considered. Moreover, newer treatment modalities such as
local injection of PRP which may play more important roles
in near future should also be considered.
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How to cite this article: Tahririan MA, Motifard M, Tahmasebi MN, Siavashi
B. Plantar fasciitis. J Res Med Sci 2012;17:799-804.
Source of Support: Nil, Conict of Interest: None declared.
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