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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 spurand 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). Boxters
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, runners 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
Access this article online
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Journal of Research in Medical Sciences
| August 2012 |
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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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| August 2012 |
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Tahririan,
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.: Plantar fasciitis
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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| August 2012 |
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.: Plantar fasciitis
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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Tahririan,
et al
.: Plantar fasciitis
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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... Plantar heel pain may include different sources of pain, involving various diagnoses, such as myofascial pain syndrome, plantar fasciitis, or heel spur, among others [7]. The diagnosis is usually made based on the patient's history and physical examination, including pain during the first steps in the morning or after prolonged rest, as well as pain during prolonged standing or walking [3,4,6]; more in-depth examinations are used only to rule out other disorders causing inferior heel pain, such as tumors, infections, and neuropathic pain (including tarsal tunnel syndrome) [8,9]. The proper identification of the main cause of pain can be difficult as, usually, this may be multifactorial [10]. ...
... A blinded observer will assess all participants at baseline and at 4,8,12,26, and 52 weeks post-treatment (Fig. 2). ...
... Participants will complete the FHSQ at baseline and at 4,8,12,26, and 52 weeks post-treatment. The FHSQ consists of 13 questions reflecting four foot health-related domains: pain (4 questions), function (4 questions), footwear (3 questions), and general foot health (2 questions). ...
Article
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Background Both manual therapy techniques and dry needling have shown to be effective treatment options for the treatment of plantar heel pain; however, in recent years, other techniques based on dry needling (DN), such as percutaneous needle electrolysis (PNE), have also emerged. Currently, PNE is being used in clinical practice to manage myofascial trigger points, despite the lack of studies comparing the effects of this technique over dry needling. Therefore, the aim of this randomized controlled study is to compare the effectiveness of DN versus PNE for improving the level of pain experienced by patients suffering from plantar heel pain provoked by myofascial trigger points. Methods A randomized controlled trial will be conducted with blinded participants and outcome assessors. A sample of 94 patients with a medical diagnosis of plantar heel pain will be recruited and divided into two treatment groups. Eligible participants will be randomly allocated to either (a) treatment group with DN and a self-stretching home program or (b) treatment group with PNE and a self-stretching home program. Each group will receive one treatment session per week over a period of 4 weeks. The primary outcome measure will be the pain subscale of the Foot Health Status Questionnaire. The secondary outcome measures will be a visual analogue scale for pain (average and highest level of pain experienced during the previous 48 h; level of pain immediately after the treatment session) and health-related quality of life (assessed using the EuroQoL-5 dimensions). Cost-effectiveness data will be extracted based on the EuroQoL-5 dimensions. Follow-up measurements will take place at baseline and at 4, 8, 12, 26, and 52 weeks. Discussion The justification for this trial is the need to improve current understanding regarding the effectiveness of treatments targeting the rehabilitation of plantar heel pain. This study will be the first randomized controlled trial to directly compare the effectiveness of DN and PNE combined with a specific stretching program for the treatment of plantar heel pain provoked by myofascial trigger points. Trial registration Clinical Trials NCT03236779. Registered at clinicaltrials.gov 2 August 2017.
... It affects both sedentary and athletic populations, with more than one million people diagnosed per year in the USA. 1,2 It may be considered that PF emerges due to excessive and prolonged standing or running, which causes an acute inflammation or micro-tears, and degenerative changes at the calcaneal enthesis and plantar fascia. The persistence of these risk factors inhibits the regular repair process thus collagen degeneration occurs, causing the structural changes of the plantar fascia. ...
... It has been known that pes planus is an important risk factor for the development of PF. 1,4,17 In this study, we identified that 24% of the patients had pes planus. This finding is also consistent with the literature. ...
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Objective: The aim of this study was to investigate the thickness of heel fat pad (THP) and to detect the relationship between the plantar fasciitis (PF) and age, occupation, BMI, longitudinal arch, the thickness of heel fat-pad in the patients with PF. Methods: A total of 50 patients (29 women and 21 men; mean age: 46.5 years (range: 22-70)) that were diagnosed with PF were included to this study. Patients' affected side were compared with the healthy opposite side with the angle of medial arch (AMA) and first metatarsophalangeal angle (FMTPA) on the foot radiograms, and THP and thickness of first metatarsal fat pad (TFMFP) using ultrasonography (USG) of both feet. Results: The mean AMAs of feet with pain and without pain were 122.56° and 120.60°, respectively. The mean FMTPAs of feet with pain and without pain were 14.72° and 14.40°, respectively. The mean THPs of feet with pain at the point of the medial calcaneal tubercle and the mean TFMFPs of the feet with pain at the point of the first metatarsal head were 19.45 mm and 6.75 mm, respectively. The mean THPs of feet without pain at the point of the medial calcaneal tubercle and the mean TFMFPs of the feet without pain at the point of the first metatarsal head were 19.94 mm and 6.75 mm, respectively. It was observed that the mean AMA in the heels with pain was significantly higher than that of the heel without pain (p < 0.05) and the mean THP in the heels with pain was significantly thinner than that of the heel without pain (p < 0.05). Conclusion: The results indicate that USG is an accurate and reliable imaging technique for the measurement of THP in the diagnosis of plantar fasciitis and the heel pad was thinner in the painful heels of patients with plantar fasciitis. Level of evidence: Level III, Diagnostic Study.
... Studies have shown that PF can afflict anyone among all age groups, gender and races. The incidence of PF usually peaks at 40 and 60 years of age in the general population and in younger people 14,15 among runners. ...
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... Increasing knowledge of the pathology has led to the widespread application of a large number of conservative treatments for recalcitrant PF including physiotherapy, plantar fascia stretching exercises, ice packs, night splints, prefabricated and custom-made insert shoe modification, and nonsteroidal antiinflammatory drugs (NSAIDs). 4 Local injection modalities are commonly used secondary to conservative therapies in the treatment of patients who have resistant PF. Corticosteroid injections have been used to treat plantar heel pain since the 1950s. ...
Article
Introduction: Chronic plantar fasciitis (PF) is the most common cause of foot complaints making up to 11–15% of the foot symptoms requiring professional care among adults. Also, it is a common problem that affects sport participants as well as inactive middle-aged individuals. The purpose of this study was to compare the effect of steroid and platelet-rich plasma (PRP) in chronic PF. The results were assessed by comparing American orthopedic foot and ankle scale (AOFAS) and visual analogue scale (VAS) before injection, 1, 2, and 6 months after injection in both groups comprising 25 patients in each group. Results: In our study of 50 patients, in steroid group-A, there is significant change in mean VAS from 6.28 ± 0.86 before follow-up injection to 2.8 ± 0.76 in first follow-up visit (1 month after injection) and to 2.92 ± 0.75 in second follow-up visit (2 months after 1st injection) and remained constant at 2.92 + 0.75 at third follow-up (6 months post 1st injection) and significant change in mean AOFAS from 67 ± 10 before injection to 85.76 ± 5.44 in first follow-up visit (1 month after injection) and to 84.16 + 5.94 in second follow-up visit (2 months after first injection) and deteriorated further to 83.92 + 5.84 at third follow-up (6 months after first injection). In 25 patients in group B, there is significant change in mean VAS from 5.8 ± 80.78 before follow-up injection to 1.96 ± 0.45 in first follow-up visit (1 month after injection) and to 1.96 ± 0.45 in second follow-up visit (2 months after first injection) and remained constant at 1.96 ± 0.45 at third follow-up ( 6 months post first injection) and significant change in AOFAS from 68.44 ± 17.78 before injection to 89.56 ± 0.91 in first follow-up visit (1 month after injection) and to 89.84 ± 0.55 in second follow-up visit (2 months after first injection) and improved further to 89.92 ± 0.40 at third follow-up (6 months after first injection)
... [1] The incidence of PF is estimated at 10%, and the PF occurs in 40 to 60 years old population commonly, [2,3] especially including women, soldiers, athletes, and obese individuals. [4,5] Generally, patients suffer pain at the first step in the morning, and feel a little of alleviation from moderate activity, but the symptoms are aggravated due to prolonged weight-bearing activity. [3,6] The argument on the diverse etiologic possibilities of PF is ongoing. ...
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Background: Emerging evidence suggests that low-level laser therapy (LLLT) for plantar fasciitis (PF) may be beneficial. However, the convincing study investigating its effectiveness for treatment of PF was scarce. Therefore, a systematic review and meta-analysis was conducted to assess whether LLLT significantly relieve pain of patients with PF. Methods: PubMed, EMBASE, EBSCO, Web of Science, China Biological Medicine Database, China National Knowledge Infrastructure, Chinese Wan fang, and Cochrane CENTRAL were searched systematically up to March 2018. Results: A total of 6 randomized controlled trials were included. The meta-analysis indicated that compared with control group, visual analogue scale (VAS) score significantly decreased at the end point of the treatment in LLLT group. In addition, this improvement is continued for up to 3 months. However, no significant difference was observed according to the Foot Function Index-pain subscale (FFI-p). Conclusion: This meta-analysis indicates that the LLLT in patients with PF significantly relieves the heel pain and the excellent efficacy lasts for 3 months after treatment.
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Background: Plantar fasciitis is a degenerative condition that is one of the most common causes of heel and foot pain. Among noninvasive management of plantar fasciitis, extracorporeal shockwave therapy (ESWT) has been extensively studied and found to be effective, but few studies have assessed the effectiveness of kinesiotaping (KT) method. Objective: This study aimed to show the effectiveness of KT compared with ESWT in the management of plantar fasciitis. Methods: A total of 84 patients with plantar fasciitis were enrolled from a single center and randomized into KT and ESWT treatment groups in a 1:1 ratio (i.e., 42 patients in each group); only one foot was considered for each patient. Both KT and ESWT were applied once a week for 6 weeks. Patients' pain, functional status and quality of life were evaluated with the visual analog scale (VAS), Foot Function Index (FFI) and the Short-Form-36 (SF-36) health survey, respectively. Patients' fat pat and plantar fascia thickness were measured using ultrasonography. All evaluations were performed before and immediately after the 6-week intervention. Results: In the KT group, six patients were lost to follow-up; therefore, the final analysis only included 36 patients. After the intervention, there was a statistically significant improvement in the VAS and SF-36 scores of both groups (P = 0.001), but the FFI score improvement was statistically significant only in the KT group (P = 0.001). In both groups, the mean thickness of plantar fascia decreased after treatment and the mean thickness of the fat pat increased; however, the change was not statistically significant (P = 0.935 and P = 0.832, respectively). Conclusion: Both KT and ESWT treatments improved pain levels and quality of life in patients with plantar fasciitis, but KT also improved functionality. Multicentered studies with larger sample size and longer follow-ups are required to further validate these findings.
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Purpose of ReviewChronic foot pain constitutes a large portion of the chronic pain burden in the overall population. Plantar fasciitis is one of the most common and most easily identifiable causes of chronic foot pain. The syndrome has been estimated to cause 11 to 15% of foot pain visits, requiring professional care. Moreover, studies have suggested that 1 in 10 people will develop plantar fasciitis at some point in their life. Conservative management has been shown to be effective and considered first-line treatment. Minimally invasive treatment options are typically reserved for those who fail conservative management. With the advent of new techniques and improvements in current therapeutic options, there has been an expansion of available minimally invasive treatment options. The purpose of this review is to provide a comprehensive update on the current understanding of minimally invasive treatments of plantar fasciitis.Recent FindingsThis review shows that conservative management continues to be the first-line therapy, whereas other treatment options were those who failed conservative management using modern techniques that have shown improving effectiveness, with successful restoration of patient functionality, recovery, and satisfaction. However, a multitude of these minimally invasive treatment options are evolving.Conclusion While conservative management continues to be the mainstay of treatment for plantar fasciitis, multiple minimally invasive treatment options are emerging with potential effectiveness in reducing pain and improving the function.
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Background: Plantar fasciopathy is a common cause of plantar heel pain, with a reported prevalence of up to 10%. The choice of best practice in these patients is debated. Two randomised studies reported that radial extracorporeal shock wave therapy is effective, but a meta-analysis concluded that due to methodological limitations, the evidence is questionable. There are few studies reporting the effect of exercise programs with high-load strength training, despite widespread use. The objective of this placebo-controlled, observer-blinded and partly patient blinded trial is to compare rESWT, sham-rESWT, standardised exercise programme and usual care for alleviating heel pain at 6 and 12 months follow-up. Methods/design: A double-blind, randomised, sham-controlled trial is conducted at a hospital outpatient clinic of physical medicine and rehabilitation. Patients with chronic (> 3 months) pain due to plantar fasciopathy, aged 18 to 70 years old, are eligible for inclusion in the trial. Patients will be randomly allocated in 1:1 ratio to receive rESWT, sham-rESWT, standardised exercises or usual care. The sample size is estimated to 200 patients, 50 in each group. rESWT or sham-rESWT will be given once a week for 3 weeks. A physiotherapist will supervise the exercises, with a total of 8 sessions over 12 weeks. The patients in the usual care group will receive information, advice and foot orthosis only. All patients, regardless of group, will receive the same information and get an individual customised foot orthosis made by an orthopaedic technician. The primary outcome measure is heel pain intensity during activity in the last week, using a numeric rating scale (NRS, 0 to 10) at the 6 months follow-up adjusted for baseline pain intensity. The secondary outcomes are at the 6- and 12-month follow-up and include Foot Functional Index Revised Short Version (FFI-RS), Patient Global Impression of Change Scale (7-point Likert scale), RAND-12 Health Status Inventory (RAND-12), NRS during rest and NRS during activity (12 months). The patients receiving rESWT/sham-rESWT and the outcome assessor will be blinded to the group assignment. Discussion: This trial is designed in order to provide results important for future clinical practice. Trial registration: ClinicalTrials.gov NCT03472989 . Registered on 14 March 2018.
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Background and aims: Plantar fasciitis (PF) is the leading cause of heel pain in adults. This study was designed to evaluate the effect of hyaluronic acid (HA) injection in reducing the symptoms of PF, compared with corticosteroid (CS) injection as a conventional treatment. Methods: In this triple-blind, randomized, clinical trial, 75 patients who had the symptoms of PF for at least 3 months were randomly divided into two groups of 38 and 37 individuals. Then, each patient received either a single injection of high molecular weight (>2000 kDa) HA (1 mL HA 20 mg + 1 mL lidocaine 2%) or CS (1 mL methylprednisolone 40 mg + 1 mL lidocaine 2%) under the ultrasonography (US) guidance. Visual analog scale (VAS), foot ankle ability index (FAAI), pressure pain threshold (PPT), functional foot index (FFI), and plantar fascia thickness (PFT) were measured using US at baseline, 6 weeks and 24 weeks after the injection. Eventually, at the end of the treatment period, the patients' satisfaction was measured. Intention to treat analysis was used to assess the results. Results: After 24 weeks of follow-up, results from 60 subjects were fully obtained; however, results of 73 patients included into intention to treat analysis in the sixth-week follow-up. In both groups, VAS, PFT and FFI decreased, while FAAI and PPT increased significantly (P <0.001). At the baseline and at the 24th-week, no significant difference between the two groups was observed in any of the variables. However, a comparison between the baseline and the sixth-week results shows a prominent decrease in PPT and PFT in the CS group compared to the HA group (P = 0.004 and P = 0.011). Finally, there were no statistical differences between the two groups in treatment satisfaction (P = 0.618). Conclusion: Both CS and HA were effective modalities for PF and can improve pain and function with no superiority in 24th-week follow-ups, although CS seems to have a faster trend of improvement in the short term.
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Background Intense therapeutic ultrasound (ITU) is an innovative ultrasound-based therapy where sound waves are concentrated into select musculoskeletal tissue. These focused waves generate thermal coagula at a controlled depth and space while preserving surrounding tissues. A multicenter study was conducted evaluating the efficiency, safety, and patient tolerance of ITU for the treatment of chronic plantar fasciitis (CPF) pain. Methods Seventy-four CPF patients, having failed conservative and/or minimally invasive treatment, participated in the study. Randomized participants either received 2 ITU treatments or 2 sham ITU treatments in addition to standard-of-care therapy. Plantar fascia pain was assessed pretreatment and at 4, 8, 12, and 26 weeks after treatment. Diagnostic ultrasonographic images were analyzed to examine hypoechoic, perifascial lesions whose volumes were calculated until week 12. Function and patient satisfaction were measured using self-reported outcome measures. Results The treated group reported significant average pain reduction (–26%, –33%, –43%) and hypoechoic lesion volume (–33%, –53%, –68%) at weeks 4, 8, and 12 compared to baseline. Although the control/sham group reported insignificant pain changes at the same time points (–5%, +8%, and +2%) and increased hypoechoic lesion volume (+15%, +28%, +58%). Treated patients reported a significant increase in daily living activities (+28%, +42%, +47%, +40%) compared to the sham/control group (+0.12%, +12%, +3%, +21%). Patient satisfaction remained more than 80% at weeks 8, 12, and 26 for all treatment groups. Conclusion ITU is an effective pain relief treatment for CPF, which is refractory to either conservative measures or minimally invasive treatments. Level of Evidence Level II.
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This study was conducted to compare and evaluate the therapeutic effects of ultrasound guided local steroid injection versus medium frequency shock wave therapy in plantar fasciitis treatment among Egyptian population.
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Objective: Plantar Fasciitis is the common foot complaint that outbreaks as a result of an inflammation of plantar fascia. The purpose of this study was to compare the effectiveness of three orthoses, silicon heel pad, thermoplastic custom-made arch support and Tension Night splint, how they relived pain in plantar fasciitis. Materials & Methods: In this quasi experimental study that was done on 16 patients who were referred from Shariati Hospital Orthopedic ward to Saba Orthotics & Prosthetics Center; age, sex, BMI, occupation and activity level were not inclusion criteria, systemic diseases and also surgery on foot in past were as exclusion criteria. The patients were assigned one by one to three treatment groups who were ready to admit them. Subject's pain was assessed for 3 months, at 2nd, 6th and 12th week, by Numerical Rating Scale and Verbal Rating Scale through phone. Data were analyzed with ANOVA, Pierson’s and Spearman’s correlation coefficients, Kruskal-Wallis test and Repeated Measurement test. Results: The coefficient correlation of Numerical score pain and rating score pain were 0.80. The average of morning (P=0.87), evening (P=0.198) and the worse pain (P=0.113) before entering the study were similar in three groups. The repeated measurement test defined that all the three orthoses were effective for the morning, evening and as so for the worse pain (P<0.001). There was not significant difference among the three groups in decrease of morning (P=0.483), evening (P=0.462) and worse pain (P=0.948). Conclusion: Taking advantage of the three orthoses without any treatment was effective for the Plantar Fasciitis pain in this study. keywords:Plantar fasciitis / Silicon heel pad / Arch support / Tension night splint
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Plantar heel pain development reflects an interaction among multiple extrinsic and intrinsic risk factors. Intrinsic risk factors include biomechanical factors such as limb length discrepancy, increased eversion at the subtalar joint, range of motion at the ankle joint, arch height, foot type and heel pad thickness. Extrinsic risk factors such as footwear have been identified as influencing the incidence of plantar heel pain. The type of design may also have an impact on risk factor identification and on the strength and validity of a study. With the current emphasis on injury prevention, a study designed to identify and quantify risk factors is needed to provide valuable data in diagnosing, assessing and planning treatment for athletes.
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The Heel Pain-Plantar Fasciitis Guidelines link the International Classification of Functioning, Disability, and Health (ICF) body structures (Ligaments and fascia of ankle and foot, and Neural structures of lower leg) and the ICF body functions (Pain in lower limb, and Radiating pain in a segment or region) with the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD) health condition (Plantar fascia fibromatosis/Plantar fasciitis). The purpose of these practice guidelines is to describe evidence-based orthopaedic physical therapy clinical practice and provide recommendations for (1) examination and diagnostic classification based on body functions and body structures, activity limitations, and participation restrictions, (2) prognosis, (3) interventions provided by physical therapists, and (4) assessment of outcome for common musculoskeletal disorders.
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In a prospective study of 435 patients with chronic proximal plantar fasciitis, 283 (65%) had an inferior calcaneal bone spur of variable size evident prior to treatment with electrohydraulic high-energy extracorporeal shock waves (ESW). This included 308 patients who received extracorporeal shock wave treatments and 127 placebo (sham control) patients. At both initial (3 months) and final (12 months) evaluations after receiving ESW, no patient who received shock wave applications had significant disappearance or change in the radiographic appearance of the heel spur. Clinical outcome after ESW was satisfactory in 168 patients (82%) with a radiographically demonstrable inferior heel spur and in 81 patients (79%) without such a heel spur. The results showed no correlation between the presence or absence of the heel spur and the eventual treatment outcome.
Article
In a prospective study of 435 patients with chronic proximal plantar fasciitis, 283 (65%) had an inferior calcaneal bone spur of variable size evident prior to treatment with electrohydraulic high-energy extracorporeal shock waves (ESW). This included 308 patients who received extracorporeal shock wave treatments and 127 placebo (sham control) patients. At both initial (3 months) and final (12 months) evaluations after receiving ESW, no patient who received shock wave applications had significant disappearance or change in the radiographic appearance of the heel spur. Clinical outcome after ESW was satisfactory in 168 patients (82%) with a radiographically demonstrable inferior heel spur and in 81 patients (79%) without such a heel spur. The results showed no correlation between the presence or absence of the heel spur and the eventual treatment outcome.
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Plantar heel pain (PHP) is a common orthopaedic presentation, but our understanding of this symptom is still limited. Multiple risk factors have been proposed but few substantiated. Obesity and foot pronation are known risk factors, whilst running or standing for long periods probably also contribute. There, however, is no relationship between heel spurs and PHP. As well as plantar fasciopathy, a number of different conditions can also give rise to PHP. It may be helpful to consider the differential diagnoses in terms of the structures that are symptomatic: the plantar aponeurosis, other soft tissues, the calcaneum and the peripheral nerves. The pathophysiology of PHP is still unclear but could be multi-factorial. Histological specimens show evidence of degeneration in the plantar aponeurosis but not inflammation. Seronegative arthritis should be excluded in cases of bilateral PHP. A number of different treatment options have been tried but very few have been rigorously investigated. Indeed, the overwhelming majority of cases will improve on conservative treatment. Shock wave therapy and surgery may be of use in selected subsets of patients who do not respond to other modes of conservative treatment.
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Plantar fasciitis is a common cause for heel pain and is the result of a degenerative process of the plantar fascia at its calcaneal attachment. Age, obesity, excessive weight bearing and tight Achilles tendon are the common predisposing factors. Though this is a self-limiting condition, the time for resolution of symptoms is highly variable. Commonly used treatments are rest, analgesics, heat and cold application, stretching exercises, splints and orthoses. Local infiltration with steroids, radiotherapy, extracorporeal shock wave treatment and surgery are used in more resistant cases. We review the current understanding and concepts in the treatment of this condition.
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Plantar fasciitis is a common diagnosis in patients presenting with heel pain. The presence of co-existing calcaneal spurs has often been reported but confusion exists as to whether it is a casual or significant association. The lateral heel radiographs of nineteen patients with a diagnosis of plantar fasciitis and nineteen comparison subjects with a lateral ankle ligament sprain matched for age and sex, were reviewed independently by two observers. Objective measurements of calcaneal spur length and a subjective grading of spur size were recorded. There was a significantly higher prevalence of calcaneal spurs in the cases than the comparison group (89% versus 32%; McNemar chi-square=9.09, df=2, p=0.00257). There was good inter- and intra-observer agreement. The current study has demonstrated a significant association between plantar fasciitis and calcaneal spur formation. Further research is warranted to assess whether the association is causal.