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Plantar Heel Pain


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Plantar heel pain is a common complaint encountered by orthopedic surgeons, internists, and family practitioners. Although it is most often caused by plantar fasciitis, this is a diagnosis of exclusion. Other mechanical, rheumatologic, and neurologic causes must be considered first. The history and physical examination are typically all that is needed to make the proper diagnosis, but diagnostic adjuncts are available to assist the clinician. When plantar fasciitis is diagnosed, conservative modalities must be tried first. Corticosteroid injections and extracorporeal shock-wave therapy may also be used. After 6 months of failed conservative treatments, surgical intervention should be considered.
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Plantar Heel Pain
Andrew J. Rosenbaum, MD
*, John DiPreta, MD
David Misener, BSc(HK), CPO, MBA
Plantar heel pain is a very common complaint that can cause significant discomfort
and disability. Approximately 1 in 10 people are predicted to develop such heel pain
during their lifetime, with more than 2 million individuals undergoing treatment of it
annually in the United States.
Although 1% of all visits to orthopedic surgeons are
attributed to heel pain, it is also commonly treated by internists and family practi-
The annual cost of the evaluation and treatment of plantar heel pain by these
providers is estimated at approximately $284 million.
The cause, diagnosis, and effective management of plantar heel pain have chal-
lenged practitioners since the early 1800s, when Wood first described plantar fasciitis,
citing an infectious origin.
In the 1930s, gonorrhea, syphilis, tuberculosis, and strep-
tococcal infections were thought to be responsible.
The focus then shifted to plantar
fat pad impingement by heel spurs.
A plethora of conditions are now acknowledged
as causes of plantar heel pain.
A thorough history and physical examination are crucial to the diagnosis of plantar
heel disorders. Although plantar fasciitis is the most common culprit, accounting for
Division of Orthopaedic Surgery, Albany Medical College, 255 Patroon Creek Boulevard,
Apartment 1214, Albany, NY 12206, USA;
Clinical Prosthetics and Orthotics, 149 South Lake
Avenue, Albany, NY 12208, USA
* Corresponding author.
E-mail address:
Plantar heel pain Plantar fascia Plantar fasciitis Windlass mechanism
Heel spur Baxter nerve First branch lateral plantar nerve
Extracorporeal shock-wave therapy
Approximately 1 in 10 people are predicted to develop such heel pain during their lifetime.
Plantar fasciitis is the most common cause of plantar heel pain and is responsible for
80% of the cases.
Plantar heel pain is usually responsive to conservative interventions, including home
stretches, nonsteroidal antiinflammatory drugs, orthoses, night splints, and, at times,
corticosteroid injections and extracorporeal shock-wave therapy.
If conservative measures do not provide pain relief, surgery can be considered.
Med Clin N Am -(2013) --
0025-7125/13/$ – see front matter Ó2013 Elsevier Inc. All rights reserved.
80% of patients with inferior heel pain, the clinician’s differential must always include
other causes. Mechanical, rheumatologic, and neurologic conditions can all manifest
as plantar heel pain. This article reviews the relevant anatomy and biomechanics of the
plantar hindfoot, the cause of plantar heel pain, pertinent components of the physical
examination, useful diagnostic adjuncts, as well as both conservative and operative
treatment modalities.
The plantar fascia is a broad fibrous aponeurosis that spans the plantar surface of the
foot (Fig. 1). It originates from the medial and anterior aspects of the calcaneus and
helps to divide the intrinsic plantar musculature of the foot into 3 distinct compart-
ments: medial, central, and lateral. Distally, the plantar fascia forms 5 digital bands
at the metatarsophalangeal joints. Each digital band then divides to pass on either
side of the flexor tendons, inserting into the periosteum at the base of the proximal
The plantar fascia has a continuous connection with the Achilles tendon, leading to
tightening of the plantar fascia when tensile loads are applied to the tendon. For this
reason, Achilles tendon stretching and night splinting have become effective conser-
vative treatments for plantar fasciitis.
The heel’s fat pad, first described by Teitze in 1921, is also an integral component of
the plantar hindfoot.
It is anchored to both the calcaneus and skin, acting as a shock
absorber for the hindfoot. It helps to dissipate impact forces caused by heel strike dur-
ing ambulation, which generates forces up to 110% of one’s body weight when
walking and 250% of body weight when running.
However, after 40 years of age, it
begins to degenerate, losing some of its overall thickness and height. With this dete-
rioration, softening and thinning of the fat pad occur, which leads to diminished pro-
tection of the heel.
The foot and its ligaments can be thought of as a truss, with the calcaneus, midtarsal
joint, and metatarsals forming the truss’s medial longitudinal arch.
The plantar fascia
acts as a tie-rod, preventing arch collapse via its great tensile strength, particularly
during weight bearing. Preservation of the medial longitudinal arch is crucial for ambu-
lation in a systematic and efficient manner. With arch collapse, the appropriate timing
of pronation and supination during the gait cycle is altered, leading to inefficient foot
The windlass mechanism is a term used to describe the role of the plantar fascia in
dynamic function during gait; a windlass is the tightening of a rope or cable.
As one’s
toes are dorsiflexed, the plantar fascia tightens, shortening the distance between the
calcaneus and metatarsals and elevating the medial longitudinal arch (Fig. 2).
In the
high-arched position, less tension on the truss is required for arch support, as
opposed to a low-arched position. In other words, in a high-arched position, there
is less tension on the plantar fascia.
A multitude of mechanical, neurologic, and rheumatologic conditions can manifest as
plantar heel pain (Box 1). The mechanical causes include derangements of the plantar
fascia, calcaneal stress fractures, and heel pad disorders. Although heel spurs are
intimately associated with these conditions, they do not directly cause plantar heel
Rosenbaum et al
pain. Neurologic disorders are typically caused by nerve compression, whereas rheu-
matoid conditions may present with systemic manifestations. Infection, which was
once thought to be the primary cause of heel pain, is not as common as previously
Fascial derangements include rupture and fasciitis. Rupture most often occurs
acutely following trauma or athletic competition, whereas plantar fasciitis is a sub-
acute and degenerative process resulting from repetitive and excessive loading of
the fascia.
Fig. 1. The plantar fascia is a thick band of connective tissue that supports the foot’s plantar
arch. It originates at the calcaneal tuberosity of the hindfoot, ultimately inserting into
the periosteum at the base of the toes’ proximal phalanges. (Netter illustration from ÓElsevier Inc. All rights reserved.)
Plantar Heel Pain 3
After the metatarsals, the calcaneus is the most common location in the foot for a
stress fracture.
These injuries most frequently occur in those with osteopenia of
the calcaneus and athletes involved in running and jumping sports. Both benign and
malignant neoplasms can also cause plantar heel pain. Benign lesions include simple
bone cysts, which can weaken bone and cause pathologic fracture. Malignant lesions
include primary tumors, of which Ewing sarcoma is the most common, and metastatic
disease, including endometrial adenocarcinoma, bronchogenic carcinoma, bladder
cancer, and gastric cancer.
The deterioration of the fat pad’s structural integrity, with advancing age and weight
gain, is also thought to contribute to heel pain. Although some think that the progres-
sive thinning of the fat pad is primarily responsible, others have shown an increased
thickness to correlate most closely with pain. Further, some think that a reduced elas-
ticity, not fat pad thickness, is the most significant factor.
found that
pad elasticity was reduced in those with pain and that elasticity decreases with
increasing age and body weight.
Heel spurs are often associated with heel pain; up to 75% of patients with pain have
been shown to have spurs (Fig. 3).
However, spurs are also common in those
Fig. 2. The windlass mechanism occurs with dorsiflexion of the toes, which leads to tight-
ening of the plantar fascia. (From Greisberg J. Foot and ankle anatomy and biomechanics.
In: DiGiovanni CW, Greisberg J, editors. Core knowledge in orthopedics: foot and ankle.
Philadelphia: Elsevier; 2007; with permission.)
Box 1
The differential diagnosis of plantar heel pain
Plantar fasciitis
Fat pad atrophy
Partial or complete plantar fascial rupture
Calcaneal stress fracture
Plantar nerve impingement
Hindfoot deformity (cavus or calcaneus)
Inflammatory enthesopathy
Rosenbaum et al
without heel pain, suggesting that they are not necessarily the cause of pain.
In a
randomly chosen sample of 1000 patients, Shmokler and colleagues
found a
13.2% incidence of heel spurs but only a 5.2% incidence of heel pain. This finding sug-
gests that both spurs and pain may develop from a common underlying pathologic
condition. The work of Kumai and Benjamin
supports this notion because their
cadaveric study identified degenerative changes within the plantar fascia as the cause
of spur formation.
A comprehensive history is imperative when evaluating patients with plantar heel pain.
The patients’ general health and past medical history must be reviewed first, identi-
fying any prior treatments for plantar heel pain (ie, medications, injections, therapy,
orthoses, surgeries) and the presence of comorbidities. Obesity is an independent
risk factor for the development of plantar fasciitis and is present in up to 70% of pa-
tients with this disorder.
It is also important to ask about constitutional symptoms,
such as weight loss, fevers, chills, and night sweats, which are findings that suggest a
neoplastic or infectious process.
The clinician should inquire into patients’ recreational and occupational activities
because work-related weight bearing, like obesity, is an independent risk factor for
plantar fasciitis.
When discussing athletics, the specific sport being played can
help differentiate the diagnosis because those who perform running and jumping ac-
tivities are particularly vulnerable to plantar heel pain. It is also helpful to determine if
the pain occurs during heel strike as opposed to push off; if it occurs at the onset of,
during, or after activity; and the type of shoe and its insole being used when the pain is
A description of the pain and its alleviating and exacerbating factors will assist the
clinician in establishing a diagnosis. With the exception of an acute hindfoot fracture or
plantar fascia rupture, patients will typically describe the pain as gradual in onset. Of
note, those patients with a plantar fascia rupture often have histories of corticosteroid
Pain that is worse with the first steps in the morning or when standing
after prolonged sitting is consistent with plantar fasciitis. These patients may also
Fig. 3. Lateral radiograph of the hindfoot. A heel spur is evident on the inferior aspect of
the calcaneus. (From Berkson EM, Greisberg J, Theodore GH. Heel pain. In: DiGiovanni CW,
Greisberg J, editors. Core knowledge in orthopedics: foot and ankle. Philadelphia: Elsevier;
2007; with permission.)
Plantar Heel Pain 5
experience decreased pain with progressive activity, only to have it return later in the
day. Constitutional symptoms in the setting of night and/or rest pain suggest either a
neoplastic or infectious process. Bilateral plantar heel pain, particularly in conjunction
with joint pain and pain at multiple sites of tendon/ligament insertion, suggests that the
pain may be related to a rheumatologic process, such as ankylosing spondylitis or
Reiter syndrome. With nerve entrapment, patients may describe burning, tingling, or
The physical examination is another critical component of the workup because
determination of the location of the pain will facilitate the proper diagnosis. The ex-
amination includes a visual assessment of the foot, which may identify swelling,
skin breakdown, bruising, or deformity. Palpation of the foot’s bony prominences
and tendinous insertions near the heel and midfoot must also be done, noting
any defects or tenderness; Achilles tendon tightness can contribute to the pain.
Observation of ankle and hindfoot range of motion as well as of the foot’s posture
and arch during weight bearing should also be performed. The physician should
also evaluate the patients’ spine because an L5-S1 radiculopathy can cause plantar
heel pain.
With proximal plantar fasciitis, tenderness over the medial aspect of the calcaneal
tuberosity is present. Conversely, distal plantar fasciitis produces pain in the distal
aspect of the plantar fascia. Passive dorsiflexion of the toes exacerbates the pain in
both the proximal and distal types because this stretches the entire plantar fascia.
When a rupture of the plantar fascia occurs, a palpable defect may be evident at
the calcaneal tuberosity, along with localized swelling and ecchymosis.
suggestive of plantar fibromatosis include pain along the plantar fascia in conjunction
with palpable nodules.
A calcaneal stress fracture is diagnosed on physical examination by the squeeze
test in which diffuse heel pain is elicited with medial and lateral heel compression.
Swelling and warmth may also be present. Neoplastic processes must be considered
in the setting of persistent heel pain that is refractory to conservative treatment.
Tarsal tunnel syndrome is a compression neuropathy involving the posterior tibial
nerve as it traverses the tunnel. Percussion of the nerve within the tarsal tunnel, as
well as simultaneous dorsiflexion and eversion, may reproduce symptoms, which
include pain and numbness that radiate to the plantar heel. The findings seen with
plantar fasciitis are often similar. However, unlike tarsal tunnel syndrome, patients
with plantar fasciitis will have pain with passive toe dorsiflexion. Patients may also pre-
sent with entrapment of the first branch of the lateral plantar nerve (Baxter nerve,
FBLPN). Because of its close proximity to the medial calcaneal tubercle, it is usually
present with plantar fasciitis and difficult to distinguish.
Pain that is attributed to the fat pad is centered more proximally than the plantar fas-
cia’s origin. It is often associated with erythema and inflammation at the plantar heel.
On palpation, it is often softened and flattened.
The history and physical examination will often reliably diagnose the cause of plantar
heel pain. However, when the diagnosis remains unclear, imaging modalities and lab-
oratory studies can be obtained. Plain radiographs provide information about the
foot’s bony structures and alignment. Weight-bearing anteroposterior and lateral
views are standard, with axial and 45medial oblique views included at times. Heel
spurs are commonly seen on the lateral radiographs of patients with plantar heel
pain (see Fig. 3). A calcaneal lucency, referred to as the saddle sign often
Rosenbaum et al
accompanies the spur, visible just proximal to it on the radiograph.
Although soft tis-
sues are poorly visualized on plain radiographs, tumors, osteomyelitis, stress frac-
tures, and fat pad atrophy are sometimes visible.
When a calcaneal stress fracture is suspected, a triple-phase bone scan will have
increased uptake. With plantar fasciitis, this too will occur.
However, the
increased uptake in this setting will be localized to the inferomedial aspect of the
heel, enabling this test to distinguish the two processes.
Magnetic resonance imaging (MRI) has become a frequently used adjunct in the
evaluation of plantar heel pain because it provides great detail of soft tissue structures
through its multiplanar capability. Fascial thickening and increased signal intensity
within the plantar fascia are typical MRI findings seen with plantar fasciitis. Admittedly,
these findings are nonspecific, making MRI most useful for excluding other causes
of heel pain. It has been shown that plantar fibromatosis, tumors, infection, and nerve
entrapment are all reliably diagnosed with MRI.
Ultrasound can identify fascial thickenings and soft tissue edema in the plantar heel
and is becoming a commonly used diagnostic tool. In the setting of plantar fasciitis,
ultrasound will reveal thickened, hypoechoic fascia. Although the quality of images
obtained is operator dependent, some studies suggest that it is superior to MRI,
with fat pad edema and degeneration being detected earlier via this modality. Ultra-
sound is also inexpensive and fast, further distinguishing it from MRI.
When bilateral or recalcitrant heel pain is present, clinicians should order a complete
blood count, erythrocyte sedimentation rate, rheumatoid factor, antinuclear anti-
bodies, uric acid, and human leukocyte antigen-B27 studies. These tests may help
identify a rheumatologic or autoimmune disorder, such as a seronegative spondy-
loarthropathy, Behc¸ et syndrome, or inflammatory bowel arthritis.
Nerve conduction velocity and electromyography testing can objectively delineate
the severity of a compression neuropathy around the foot and ankle as well as diag-
nose a spinal radiculopathy or peripheral neuropathy. However, these studies are of
more benefit in the diagnosis of tarsal tunnel syndrome than plantar nerve entrapment
because the FBLPN is difficult to examine with these tests.
Conservative Modalities
Mechanical, rheumatologic, and neurologic sources of plantar heel pain require, and
are usually responsive to, a trial of conservative measures. Interventions include
home stretching programs and physical therapy, nonsteroidal antiinflammatory drugs
(NSAIDs), injections, heel pads, orthoses, night splints, and extracorporeal shock-
wave therapy (ESWT). In a work by Wolgin and colleagues,
82 of 100 patients’
plantar heel pain improved with conservative therapy, and an additional 15 patients
were able to work and perform activities despite having mild symptoms. Callison
found that 73% of patients treated with nonoperative modalities had significant
improvement within 6 months of treatment, whereas only 20% failed to improve.
A study by Davies and colleagues
also supports nonoperative interventions because
they showed that less than 50% of patients who had a surgical procedure for heel pain
were completely satisfied with the results.
A home stretching program is the first-line treatment of plantar heel pain. Both
plantar fascia–specific and Achilles tendon–based protocols are available. Plantar fas-
cia–specific stretching attempts to recreate the windlass mechanism, whereas Achilles
tendon programs attempt to optimize the length of the gastrocnemius-soleus complex.
DiGiovanni and colleagues
compared these protocols and showed that heel pain
Plantar Heel Pain 7
was resolved or improved at 8 weeks in 52% of patients treated with a plantar fascia–
specific program versus 22% of those performing Achilles tendon exercises. However,
at the 2-year follow-up, no difference was evident between the two groups.
NSAIDs are an appropriate treatment of plantar heel pain but are typically
prescribed in conjunction with another intervention, such as stretching. The true effec-
tiveness of NSAIDs is, thus, unclear because they are infrequently the sole treatment
modality. Although up to 76% of patients report successful outcomes with their use,
no study to date has examined their efficacy alone.
Corticosteroid injections are a commonly used treatment of plantar fasciitis, with
one study identifying 170 of 233 orthopedic surgeons polled as using steroid injections
for heel pain.
However, there is limited evidence to suggest that this intervention is
effective at providing sustained pain relief. Crawford and colleagues
found improved
symptoms at 1 month but not at 6 months as compared with a control group. Compli-
cations of steroid injection include rupture of the plantar fascia and fat pad atrophy.
One’s injection technique can reduce the incidence of these complications; the needle
should be placed superior to the fascia, from the medial side. This placement spreads
the solution across the fascial layer, avoiding the fat pad and plantar nerves.
The injection of botulinum toxin A (BTX-A) is also being used to treat plantar foot
pain. Its analgesic and antiinflammatory properties make it an intriguing intervention.
In a placebo-controlled, double-blinded study, Babcock and colleagues
BTX-A injections with significant improvements in pain relief and foot function at both
3 and 8 weeks following treatment. Elizondo-Rodriguez and colleagues
have also
found BTX-A to be an effective treatment of plantar fasciitis. In their prospective, ran-
domized, double-blinded, and controlled clinical trial, the effectiveness of BTX-A
injected into the gastrocnemius-soleus complex was compared with steroid injection
into the medial plantar fascia. Over the 6 months that the patients were followed after
receiving one of the two aforementioned injections, the group who received the BTX-A
was found to have faster and more sustained symptom relief.
Heel pads, foot orthoses, and shoe modifications are adjunctive modalities often
used in the treatment of plantar heel pain. From a biomechanical perspective, foot or-
thoses are designed to place the foot and lower extremity in a more advantageous po-
sition by minimizing the existing stresses to the static and dynamic soft tissues of the
foot and lower limb; orthoses off-load the plantar fascia, recreate the shape of the heel
pad, and decrease excessive pronation.
Commonly used orthoses include prefabricated silicone or rubber heel cups and
arch supports, felt pads, custom arch supports, the University of California Biome-
chanics Laboratory orthosis (UCBL), and the supramalleolar ankle foot orthosis
(SMO). The UCBL shoe insert is a maximum control foot orthotic that was named after
the location in which it was developed, the University of California Berkeley Laboratory
in 1967 (Fig. 4). It has since been defined as a deep-seated foot orthosis. The UCBL
differs from other foot orthoses in that it fully encompasses the heel, which in turn
holds the heel, or hindfoot, in a neutral, vertical position. While correcting and holding
the heel in a neutral position, the UCBL also controls the inside arch of the foot and the
outside border of the forefoot. These 3 corrective forces keep the foot held in a neutral
The SMO, as with other orthoses, gets its name for the part of the body for which it
encompasses (Fig. 5). This orthosis supports the leg just above the medial and lateral
malleoli. The SMO is designed to maintain a vertical or neutral heel while also support-
ing the 3 arches of the foot, which can help improve standing balance and walking.
This design also allows for more control of the ankle and foot. It is more supportive
than a UCBL but less supportive than a standard ankle foot orthosis (AFO).
Rosenbaum et al
Shoes are integral to the success of an orthosis because they help to stabilize the
orthosis within the shoe and around the foot. A proper shoe provides stability and
shock absorption. How a shoe is built also makes a difference in its fit and function.
Neutral-arched feet should be placed in shoes with firm midsoles, straight to semi-
curved lasts, and moderate hindfoot stability. Low-arched or flat feet should be placed
in shoes with a straight last and with motion control to help stabilize the feet. High-
arched feet require cushioning and moderate hindfoot stability to compensate for
the lack of natural shock absorption.
Ample evidence exists based on subjective pain relief, symptom resolution, and pa-
tient satisfaction for the success of orthosis.
In a randomized study by Pfeffer and
236 patients were randomized into 5 treatment groups: 1 control and 4
with different shoe inserts. Those treated with prefabricated inserts had the largest
improvement in heel pain.
Roos and colleagues
also found foot orthoses to be
effective in both the short- and long-term treatment of plantar fasciitis. In this prospec-
tive randomized trial, those who used orthoses experienced a 62% decrease in pain at
1 year as compared with patients treated with night splints. Admittedly, other studies
have questioned the effectiveness of foot orthoses, identifying only small benefits.
Despite this, heel pads and orthoses are powerful tools in the clinician’s armamen-
tarium for the treatment of plantar heel pain.
Night splints are designed to prevent shortening of the plantar fascia during long pe-
riods of rest, with the goal of alleviating morning start-up pain. The night splint AFO
Fig. 4. The UCBL orthosis. (Courtesy of David Misener, BSc, CPO, MBA, Albany, NY.)
Fig. 5. The SMO. (Courtesy of David Misener, BSc, CPO, MBA.)
Plantar Heel Pain 9
should be placed in 5of dorsiflexion. Wapner and Sharkey
reported that 11 of their
14 patients improved when splinted in this position. Conversely, Probe and col-
found no significant benefit in adding night splinting to a standard NSAID
and stretching protocol. Casting has also been used to unload the heel and immobilize
the plantar fascia, hoping to reduce the repetitive microtrauma associated with plantar
ESWT is indicated for patients who have had at least 6 months of plantar fasciitis
heel pain recalcitrant to at least 3 nonsurgical interventions (Fig. 6). The powerful
shock waves break up scar tissue, stimulate angiogenesis, promote new bone forma-
tion, disrupt calcific deposits, and increase cytokine diffusion. Good or excellent re-
sults in the setting of chronic heel pain have been reported in 57% to 80% of
ESWT is often performed under conscious sedation with regional anes-
thesia. It is well tolerated by patients. The contraindications include patients with
hemophilia, coagulopathies, malignancy, and skeletal immaturity.
Surgery is indicated in the treatment of plantar heel pain that has failed a minimum
of 6 months of conservative modalities (Box 2). An open partial release of the plantar
fascia is the standard intervention. Although both open and endoscopic techniques
have been described, there is no consensus as to the best choice; no studies have
been conducted that directly compare these two techniques. Because entrapment
neuropathy of the FBLPN presents similarly to plantar fasciitis, decompression of
this nerve is frequently performed concurrently. Watson and colleagues
that 93% of their patients had satisfactory outcomes with partial medial plantar fas-
ciectomy and nerve decompression. When nerve decompression is to be performed,
an open approach is advocated because the risk of nerve injury may be higher with
endoscopic procedures.
Resection of heel spurs is also performed at times, most commonly in conjunc-
tion with the aforementioned procedures. However, Manoli and colleagues
ported calcaneal fractures secondary to extensive resection, an unwelcome
complication of this procedure. Additionally, the notion that the subcalcaneal
spur is the cause of plantar pain has lost popularity in recent years; therefore,
this supplementary procedure is being performed less frequently. Fallat and col-
retrospectively compared percutaneous plantar fasciotomy with open
fasciotomy and heel spur resection, determining that the percutaneous procedure
Fig. 6. ESWT. (From Berkson EM, Greisberg J, Theodore GH. Heel pain. In: DiGiovanni CW,
Greisberg J, editors. Core knowledge in orthopedics: foot and ankle. Philadelphia: Elsevier;
2007; with permission.)
Rosenbaum et al
was as effective at relieving the plantar fasciitis pain and that those patients had a
faster return to full activity.
Gastrocnemius recession is another procedure that may be indicated for the treat-
ment of plantar fasciitis recalcitrant to conservative interventions. Because limited
ankle dorsiflexion, specifically isolated gastrocnemius contracture, is frequently asso-
ciated with plantar fasciitis, the release of the gastrocnemius can be an effective treat-
Abbassian and colleagues
found proximal medial gastrocnemius release to
provide complete or significant pain relief in 81% of their patients treated with this.
Additionally, none of their patients reported worsening of their symptoms.
Plantar heel pain is a frequently encountered phenomenon that transcends multiple
medical specialties, including orthopedic surgery and primary care. Plantar fasciitis
is the most common cause. However, other mechanical, rheumatologic, neurologic,
and infectious causes exist; a comprehensive history and physical examination is
pivotal to making the correct diagnosis. When the cause remains unclear after the
evaluation, diagnostic adjuncts are available and include triple-phase bone scan,
MRI, ultrasound, and laboratory studies. Regardless of diagnosis, nonoperative inter-
ventions are the mainstay of treatment and include but are not limited to stretching,
NSAIDs, orthoses, and steroid injections. Operative intervention is only indicated after
6 months of failed conservative modalities.
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Box 2
Algorithm for the treatment of plantar fasciitis
If history and physical examination consistent with plantar fasciitis, begin
Home stretching program multiple times daily (either plantar fascia specific or Achilles
tendon stretching)
Wear shoes with good support and a premade or custom-made orthotic
Trial of NSAIDs
If no improvement
Reexamine patient and consider alternative diagnoses
If still consistent with plantar fasciitis, add alternative treatment, such as night splints and
corticosteroid injection
If symptoms persist more than 6 months
Consider shock-wave therapy
Consider surgery
Plantar Heel Pain 11
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Rosenbaum et al
... Heel pain (HP) affects 10-44% of patients from the general population, and 80% of cases caused by plantar fasciitis (PF) (1,2). Calcaneal spurs found in 45% of patients with (3) and in 10-60% without PF or HP (3)(4)(5), and not found in 46% of patients with painful heel (4), at age 40-60, aggravated while taking the initial few steps after long period of inactivity (6). ...
... Calcaneal spurs found in 45% of patients with (3) and in 10-60% without PF or HP (3)(4)(5), and not found in 46% of patients with painful heel (4), at age 40-60, aggravated while taking the initial few steps after long period of inactivity (6). Several factors can affect PF/HP as long standing (7)(8), Neuromuscular deficit (9), High body mass index (10), Fascial thickening (11), foot pronation, high arch and tight Achilles tendon (12,13), Plantar nerve entrapment (2), Heel pad atrophy (14). Causal relation of spur to pain is contradicted by several studies and findings. ...
... Wearing et al. (17)(18)(19) stated that there is extremely little proof that any one of numerous recognized risk elements are in fact the reason for HP/PF, yet instead, these variables act to modulate the pain levels once it exists. pain and spurs might establish from an usual underlying pathologic condition (2). These studies doubt that spur or fascial thickening are primary cause of HP and other source of pain may be masked (i.e., spine), as lumbosacral radiculopathy (LSR) that may lead to neuro-muscular impairments in lower limb that lead to overloading soft tissues of foot leading to fascial thickening and the spur. ...
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Background: Persistence of painful calcaneal spur (PCS) and loss of long-term effect may be related to unrecognized low back pain (LBP), dysfunction and/or lumbosacral radiculopathy (LSR), but prevalence of LBP in PCS patients has not been established. Purpose: to determine the prevalence of LBP among individuals with and without PCS. Methods: A cross-sectional study of individuals with (n = 26) and without (n=27) PCS. X-ray used to determine calcaneal spur. MRI and X-ray (as available), and clinical tests used to determine LBP/pathology/LSR. Results: A greater percentage of individuals with PCS had LBP (88.5% vs. 33% in controls), lumbar pathology (58 vs. 19), and LSR (54 vs. 15). Conclusion: Individuals with painful calcaneal spur had a greater prevalence of LBP/lumbar pathology/LSR. Treatment to address impairments related to lumbar spine may be necessary to enhance the treatment of PCS.
... Plantar fasciitis is the most common cause of heel pain in approximately 80% of patients with inferior heel pain [1]. Obesity, loss of ankle dorsiflexion, and extensive work-related weight-bearing are the main risk factors for patients with plantar fasciitis, which occurs in up to 70% of those cases [2]. ...
... Pain that is worse with the first steps in the morning or standing after prolonged sitting is characteristic of plantar fasciitis [3]. This pain may decrease with progressive activity, but only to return later in the day [1]. ...
Background Injectable therapies have been increasingly investigated to treat plantar fasciitis in randomized controlled trials (RCT) where normal saline injections are frequently used as placebo. The purpose was to quantify the effect of saline injections and compared against available minimal clinically important difference criteria (MCID) specific for plantar fasciitis to assess if changes were clinically meaningful. Methods RCT including a placebo group (normal saline) and reporting changes in pain and functional outcomes in plantar fasciitis were identified through a search in MEDLINE, Embase, Web of Science, and Scopus to February 2022. PRISMA guidelines and a registered protocol (PROSPERO: CRD42020214035) were followed to conduct the study. Results Pooled analysis of 13 RCT (379 subjects) included for analysis revealed a significant improvement on pain (P <.00001) and functional scores (P <.00001) after normal saline injections. These changes exceeded the established MCID criteria. Conclusions Normal saline injections in plantar fasciitis showed a therapeutic effect with statistically and clinically meaningful improvement when administered in the setting of an RCT for up to 12 months. The control of potential confounders influencing the effect of saline injections is required for future research.
... Since plantar heel pain is a serious problem in modern society, how to treat plantar heel pain quickly and efficiently has been a hot topic in medical research. There are numerous conservative approaches for treating plantar heel pain, including stretching, night splint, physical therapy, extracorporeal shockwave therapy, nonsteroidal anti-inflammatory drugs, and foot orthoses [4]. In order to optimize the treatment effect for plantar heel pain, there is an essential need to further investigate the underlying mechanism of each treatment approach. ...
... Hence, a pathological condition involving plantar fascia such as plantar fasciitis can cause severe adverse effects on the biomechanics of the foot and locomotion. There are several conservative treatment options for plantar fasciitis, including corticosteroid injection, anti-inflammatory medication, extracorporeal shock wave therapy, stretching, night splint, physical therapy, and foot orthoses [4,42,44]. The plastic heel cup investigated in the present study is just one of the treatment options. ...
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The plastic heel cup has been adopted to treat plantar heel problems for years. However, its mechanisms and biomechanical effects are yet to be fully understood. The purpose of this study was to investigate the effects of the plastic heel cup on the microchamber and macrochamber layers of the heel pad by comparing the stiffness (in terms of the shear wave speed) and thickness of these two layers with and without a plastic heel cup during static standing. Fifteen patients with unilateral plantar fasciitis were recruited. The shear wave speed and thickness of the microchamber and microchamber layers of each symptomatic heel pad during standing measured by ultrasound shear wave elastography were compared between conditions with and without a plastic heel cup. It was found that a plastic heel cup reduced the shear wave speed of the microchamber layer to 55.5% and increased its thickness to 137.5% compared with the condition without a plastic heel cup. For the microchamber layer, the shear wave speed was reduced to 89.7%, and thickness was increased to 113.6% compared with the condition without a plastic heel cup. The findings demonstrate that a plastic heel cup can help to reduce the stiffness and increase the thickness for both layers of the heel pad during standing, suggesting that the mechanism of a plastic heel cup, and its resulting biomechanical effect, is to reduce the internal stress of the heel pad by increasing its thickness through confinement.
... At present, plantar fasciitis (PF) is considered to be one of the main foot disorders, with an estimated prevalence of 7% in the general population [1], and among athletes, PF disturbance is more prevalent in runners, being present in up to 17.4% of the running population [2]. According to its etiology, PF has been described as a degenerative soft tissue condition, related to pain, functionality disorders and stiffness alterations in the plantar fascia [3]. Heel pain was the primary symptom reported by the patients in one study [4]. ...
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Objective: The primary aim of the present study was to compare the echo intensity (EI) and echovariation (EV) of the intrinsic foot muscles (IFMs) between individuals with and without plantar fasciitis (PF), using ultrasound imaging. The secondary objective was to study the intra-rater reliability of the echotexture variables. Methods: A case-control study was conducted with 64 participants, who were divided into the following two groups: A, the PF group (n = 32); B, the healthy group (n = 32). Results: The comparison between the two groups did not identify significant differences (p > 0.05) between the flexor hallucis brevis (FHB), flexor digitorum brevis (FDB), quadratus plantae (QP) and abductor hallucis brevis (AHB) variables for the EI and EV. Moreover, excellent intra-rater reliability was reported for the following ultrasound imaging EI variables: ABH (ICC = 0.951), FHB (ICC = 0.949), FDB (ICC = 0.981) and QP (ICC = 0.984). Conclusions: The muscle quality assessment using the EI and EV variables did not identify differences in the FHB, FDB, AHB and QP muscles between individuals with and without PF through USI evaluation. The reliability of all the IFM measurements was reported to be excellent.
Tendinopathy is a chronic injury that affects both the athletic and general population. Recalcitrant tendinopathy is both frustrating for patients and providers once typical conservative treatments have been exhausted. Current research in orthobiologics shows that they are safe and could improve pain and function in recalcitrant cases. Unfortunately, many studies show inconsistency in the content of the orthobiologic injectate and approach in treatment protocols. There are robust data to support the use of platelet-rich plasma for the treatment of recalcitrant common extensor tendinopathy and plantar fasciopathy, but high-quality random control trials are needed before drawing definitive conclusions for other tendinopathies.
The key to successful ankle and foot regenerative procedures is predicated on correct diagnosis and detailed anatomic knowledge, which will allow the clinician to perform accurate ultrasound-guided interventions. Additionally, it is important to understand the available evidence for these relatively new treatment options to set appropriate expectations for the patient. This chapter reviews the pertinent anatomy, current literature on regenerative therapies about the foot and ankle, and author’s preferred technique for application of these interventions.KeywordsAnkleFootInjectionRegenerative medicinePlatelet-rich plasmaProlotherapyUltrasound guidance
Objectives: To assess the advantage of the addition of shear wave elastography (SWE) to gray-scale sonography in the diagnosis of plantar fasciitis. Methods: 30 subjects between 18-60 years of age with unilateral heel pain who were clinically suspected of having plantar fasciitis were included in this study. Their affected feet were taken as cases; while their contralateral feet served as controls. On gray-scale ultrasound, the thickness of plantar fascia, its echopattern, presence of hypoechoic areas, and perifasicular collections were recorded. SWE was done by placing seven ROIs within the plantar fascia; and the mean of their Young's modulus was taken in kPa. Results: Plantar fascial thickening more than 4 mm had 70% sensitivity and 66.7% specificity, echopattern had 90% sensitivity and 96.7% specificity, hypoechoic areas had 80% sensitivity and 96.7% specificity, and perifascial edema had 26.7% sensitivity and 100% specificity for diagnosing plantar fasciitis. Using the ROC curve, the cut-off value of Young's modulus for the diagnosis of plantar fasciitis was found to be ≤ 99.286 kPa. This predicted plantar fasciitis with 97% sensitivity and 100% specificity. The primary diagnostic feature of ultrasound of plantar fascia thickness more than 4 mm detected 21 out of 30 cases of plantar fasciitis; whereas elastography detected an additional 8 cases which would have been missed on B-mode ultrasound alone. Conclusions: SWE is a useful supplement and improves the diagnostic accuracy of gray-scale ultrasound in plantar fasciitis.
El objetivo de este artículo es analizar las distintas opciones de tratamiento. Se realizó una encuesta virtual a diferentes traumatólogos especialistas en pierna y pie, sobre el tratamiento de la fascitis plantar. Los resultados fueron variados, lo que demuestra que no hay una respuesta concreta ante el tratamiento crónico. Conclusiones: La fascitis plantar es un cuadro doloroso frecuente. Su origen es desconocido, pero está relacionada con múltiples factores. Se han recomendado muchas modalidades terapéuticas, como fármacos, fisioterapia, ortesis y cirugía, pero no existe un estudio que analice la eficacia de cada una de ellas por separado ni que confirme categóricamente su utilidad.
Introduction: Plantar fasciitis is a painful ailment that causes frustration to both the patient and physician. Stretching exercises targeting the plantar fascia are an excellent therapy option for plantar fasciitis. Objective: To compare the outcome of a gastrocnemius-soleus stretching program versus tendo Achilles stretching exercises for the management of chronic plantar fasciitis. Methods: Patients aged 30-70 years of either gender with chronic plantar fasciitis were included and randomly divided into two groups. In group A, the gastrocnemius-soleus stretching program was applied, whereas in group B, the tendo Achilles stretching exercises were adopted. The pain score was determined at baseline and after eight weeks, and the change in pain score was calculated. All information was noted in the proforma and then entered and analyzed in the Statistical Package for the Social Sciences (SPSS) software version 21 (International Business Machines (IBM), New York, United States). An independent-samples t-test was conducted to compare the mean change in pain score in both groups. A P value of <0.05 was considered significant. Results: The mean age of the patients in the gastrocnemius-soleus stretching group was 48.70 ± 9.80 years, whereas that in the tendo Achilles stretching exercises group was 48.63 ± 8.43 years. Group A included 16 (53.3%) men and 14 (46.7%) women, whereas in group B, there were 15 (50%) men and 15 (50%) women. The mean change in pain score in group A was 2.57 ± 1.01, whereas that in group B was 1.77 ± 0.57. The difference in both groups was significant (P < 0.05). Conclusion: Gastrocnemius-soleus stretching exercises are more effective for reducing the symptoms of plantar fasciitis in the adult population.
Background The use of shear wave elastography (SWE) seems to be an important imaging method in the diagnosis of plantar fasciitis (PF). Purpose To compare patients diagnosed with PF with similar and young healthy control groups in terms of B-mode ultrasound (US) and SWE results and to evaluate the elasticity of the plantar fascia. Material and Methods A total of 140 feet of 70 participants were evaluated, including 30 patients and 40 healthy individuals as the control. Clinical, B-mode US, and SWE evaluations were performed for each patient. In addition, American Orthopedic Foot and Ankle Score (AOFAS) was calculated to evaluate pain and foot function in both groups. Results Of the patients in the PF group, 40 (88%) were women and the healthy control groups had similar sex distributions ( P = 0.23). The AOFAS score was lower in feet with PF compared to the other groups ( P < 0.001). Of 30 patients with PF, 15 (50%) had bilateral PF and 15 (50%) unilateral PF. In addition, ≥4 mm thickness measurement, which was used as a diagnostic criterion for PF as a US finding, could be shown in 11 (73.3%) patients with unilateral PF and 6 (40%) patients with bilateral PF. Conclusion In conclusion, the evaluation of the diagnosis of PF with clinical findings and regular follow-up of measurements with SWE can provide measurement results with higher sensitivity in the diagnosis of PF.
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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.
A sample of 60 subjects took part in a study of the mechanical role played by the very rigid plantar fascia, and the changes that occurred during active contraction of the toe flexor muscles, and when traction is applied to the plantar fascia by active dorsiflexion of the hallux. The data show that dorsiflexion of the hallux leads to a marked change in the height of the medial arc of the foot. The number of cases of plantar fasciitis treated today in sports clinics calls attention to the mechanical behaviour and function of this structure. The authors believe that it is indeed submitted to intense traction stress during running and jumping activities, when the hallux is constantly held in dorsiflexion.
Babcock MS, Foster L, Pasquina P, Jabbari B: Treatment of pain attributed to plantar fasciitis with botulinum toxin A: A short-term, randomized, placebo-controlled, double-blind study. Am J Phys Med Rebabil 2005;84:649–654. Objective: To investigate the effect of botulinum toxin A on associated pain and functional impairment of refractory plantar fasciitis. Design: This is a randomized, double-blind, placebo-controlled study of 27 patients (43 feet) with plantar fasciitis. Block randomization was performed using computer software. In patients with bilateral symptoms of comparable severity, botulinum toxin A was injected in one foot and saline in the other foot. The treatment group received a total of 70 units of botulinum toxin A divided into two sites per foot. One of the two sites was the tender area in the medial aspect of the heel close to the calcaneal tuberosity (40 units), and the other was in the arch of the foot between an inch anterior to the heel and middle of the foot (30 units). The placebo group received the same volume of normal saline. Main outcome measures included: Pain Visual Analog Scale, Maryland Foot Score, Pain Relief Visual Analog Scale, and pressure algometry response. Patients were assessed before injection, at 3 wks, and at 8 wks. Results: The study revealed statistically significant changes in the treatment group. Compared with placebo injections, the botulinum toxin A group improved in all measures: Pain Visual Analog Scale (P < 0.005), Maryland Foot Score (P = 0.001), Pain Relief Visual Analog Scale (P < 0.0005), and pressure algometry response (P = 0.003). No side effects were noted. Conclusions: Botulinum toxin A injection for plantar fasciitis yields significant improvements in pain relief and overall foot function at both 3 and 8 wks after treatment.
Minimally invasive surgery for the treatment of recalcitrant heel pain is a relatively new approach. To compare the 2 approaches, a retrospective chart review was conducted of 53 patients (55 feet) who had undergone surgical treatment of plantar fasciitis by either open fasciotomy with heel spur resection or percutaneous medial fascial release. The outcomes measures included perioperative pain and the interval to return to full activity. Pain was measured on a subjective 10-point visual analog scale. Of the 55 fasciotomies performed, 23 were percutaneous and 32 were open, with adjunctive heel spur resection. The percutaneous group experienced a mean pain reduction of 5.69 points at the first postoperative visit, whereas open fasciotomy group experienced a mean pain reduction of 3.53 points. At 12 months postoperatively, no statistically significant difference was found in the pain levels between the 2 groups. The results also showed that the percutaneous group returned to normal activity an average of 2.82 weeks (p < .001) faster than the open group. In the patient cohorts studied, percutaneous medial fascial release was as effective at resolving recalcitrant plantar fasciitis pain as the open procedure and involved less postoperative pain and a faster return to full activity.