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Plantar and Medial Heel Pain: Diagnosis and Management

  • New England Orthopedic Surgeons


Heel pain is commonly encountered in orthopaedic practice. Establishing an accurate diagnosis is critical, but it can be challenging due to the complex regional anatomy. Subacute and chronic plantar and medial heel pain are most frequently the result of repetitive microtrauma or compression of neurologic structures, such as plantar fasciitis, heel pad atrophy, Baxter nerve entrapment, calcaneal stress fracture, and tarsal tunnel syndrome. Most causes of inferior heel pain can be successfully managed nonsurgically. Surgical intervention is reserved for patients who do not respond to nonsurgical measures. Although corticosteroid injections have a role in the management of select diagnoses, they should be used with caution.
Review Article
Plantar and Medial Heel Pain:
Diagnosis and Management
Heel pain is commonly encountered in orthopaedic practice.
Establishing an accurate diagnosis is critical, but it can be challenging
due to the complex regional anatomy. Subacute and chronic plantar
and medial heel pain are most frequently the result of repetitive
microtrauma or compression of neurologic structures, such as plantar
fasciitis, heel pad atrophy, Baxter nerve entrapment, calcaneal stress
fracture, and tarsal tunnel syndrome. Most causes of inferior heel pain
can be successfully managed nonsurgically. Surgical intervention is
reserved for patients who do not respond to nonsurgical measures.
Although corticosteroid injections have a role in the management of
select diagnoses, they should be used with caution.
Heel pain is a common complaint
among orthopaedic patients.
Establishing an accurate diagnosis can
be challenging due to the complex
regional anatomy and the close prox-
imity of potential pain generators. The
differential diagnosis should include
vascular, infectious, oncologic, and
systemic causes. Subacute and chronic
heel pain are most commonly due to
repetitive microtrauma or compres-
sion of neurologic structures.
Typically, diagnosis can be made
based on a detailed history and physical
examination that allow the clinician to
pinpoint the location of maximal ten-
derness (Figure 1). Weight-bearing
plain radiographs should be obtained
to assess alignment and degenerative
changes and to exclude fracture and
other skeletal abnormalities. Advanced
imaging studies and electromyography
(EMG) can be used to confirm or
rule out certain diagnoses and to
provide additional information when
the diagnosis is uncertain.
In general, initial management should
consist of one or more nonsurgical
modalities, including rest, shoe wear
modification, NSAIDs, home stretch-
ing exercises, physical therapy, pre-
fabricated shoe inserts, and custom
orthoses. Such measures are effective in
most patients, especially when both the
patient and physician allow adequate
time for them to work. Corticosteroid
injections should be used sparingly.
Although these are considered by many
to be capable of accelerating recovery,
the current literature demonstrates only
short-term benefit and indicates a con-
stellation of notable potential side
Surgical intervention is indi-
cated for carefully selected patients
with recalcitrant pain whose symptoms
have persisted despite an appropriate
course of nonsurgical measures. Further
study is needed to determine the efficacy
of the relatively new treatment modal-
ities, including platelet-rich plasma
(PRP) injection and extracorporeal
shock wave therapy (ESWT).
Plantar Fasciitis
Epidemiology, Anatomy, and
Plantar fasciitis (PF) represents the
most common cause of heel pain in
372 Journal of the American Academy of Orthopaedic Surgeons
Craig R. Lareau, MD
Gregory A. Sawyer, MD
Joanne H. Wang, BA
Christopher W. DiGiovanni, MD
From the Alpert Medical School, Brown
University, Providence, RI (Dr. Lareau,
Dr. Sawyer, and Ms. Wang), the Rhode
Island Hospital, Providence (Dr. Lareau
and Dr. Sawyer), and Harvard Medical
School and the Massachusetts General
Hospital, Boston, MA (Dr. DiGiovanni).
Dr. Sawyer or an immediate family
member serves as a paid consultant to
Mitek. Dr. DiGiovanni or an immediate
family member has received royalties
from Extremity Medical; is a member of
a speakersbureau or has made paid
presentations on behalf of BioMimetic
Therapeutics, Extremity Medical, and
Wright Medical Technology; serves as
a paid consultant to BESPA, BioMimetic
Therapeutics, Extremity Medical, and
Wright Medical Technology; has stock
or stock options held in Extremity
Medical and Wright Medical
Technology; has received research or
institutional support from BioMimetic
Therapeutics and Wright Medical
Technology; and has received
nonincome support (such as equipment
or services), commercially derived
honoraria, or other nonresearch-
related funding (such as paid travel)
from CuraMedix and Performance
Orthotics. Neither of the following
authors nor any immediate family
member has received anything of value
from or has stock or stock options held
in a commercial company or institution
related directly or indirectly to the subject
of this article: Dr. Lareau and Ms. Wang.
J Am Acad Orthop
Surg 2014;22:372-380
Copyright 2014 by the American
Academy of Orthopaedic Surgeons.
the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
adults, affecting 2 million persons
annually in the United States.
peak incidence occurs between ages 40
been known to occur in runners who
are younger.
Bilateral involvement,
which occurs in approximately one
third of patients, should prompt con-
sideration of inflammatory disease.
The plantar fascia is a fibrous
aponeurosis that originates from
the plantar medial aspect of the
calcaneal tuberosity and divides
into five slips that insert distally on each
of the proximal phalanges. These fibers
also merge with the surrounding der-
mis, transverse metatarsal ligaments,
and flexor tendon sheaths. Especially at
the first metatarsophalangeal joint,
dorsiflexion activates the windlass
mechanism, which increases plantar
fascial tension and elevates the medial
longitudinal arch.
The plantar fascia
lacks elasticity, exhibiting a maximal
elongation of only 4% of its length in
cadaver specimens.
PF is believed to result primarily from
repetitive microtrauma and excessive
Although it is considered to be
an inflammatory condition based on
historic descriptions, recent studies
suggest that it is a noninflammatory,
degenerative process that may be more
appropriately termed plantar fas-
Histologically, PF involves
myxoid degeneration with disorienta-
tion of collagen fibers, angiofibro-
blastic hyperplasia, and calcification.
Reduced ankle dorsiflexion due to
tightness of either the Achilles tendon
or the gastrocnemius muscle may be
associated with the development of PF;
obesity and weight-bearing professions
are other independent risk factors.
Other risk factors include advanced
age, poor footwear, overtraining, and
reduced subtalar joint mobility.
Presentation and Physical
Patients usually experience start-up
pain, that is, plantar medial heel pain
that culminates either with their first
steps in the morning or subsequent to
prolonged periods of rest. This pain is
typically sharp and does not radiate.
Physical examination reveals tender-
ness at the site of the plantar fascial
insertion on the medial calcaneal
tuberosity. Tenderness may extend
along the plantar fascia, and it in-
creases with maneuvers that stretch
the plantar fascia, including passive
toe dorsiflexion. Restricted ankle
dorsiflexion may be identified due to
contracture of the Achilles tendon or
the gastrocnemius muscle itself. The
Silfverskiöld test can be performed
to differentiate between primary con-
tracture of the gastrocnemius muscle
itself and of the gastrocnemius-soleus
This specific maneuver
involves comparative manual stress
assessment of resultant maximal ankle
dorsiflexion during neutral foot align-
ment when the knee is in full extension
and again when the knee is flexed
90°. When a significant improvement
(approximately 10°or more) in ankle
dorsiflexion can be obtained during
knee flexion compared with knee
extension, this test indicates the
presence of a primary gastrocnemius
muscle contracture. In the event that
no such substantive difference exists
between these two testing conditions
but there is still significant dorsi-
flexion restriction, the patient is likely
to have an Achilles contracture (spe-
cifically, combined gastrocnemius
and soleus muscle tightness).
Typically, advanced imaging is not
necessary to confirm the diagnosis of
PF. However, weight-bearing plain
radiographs usually are obtained to
rule out other skeletal causes of heel
pain. The radiographic finding of
a heel spur, or plantar calcaneal
calcification, should be considered
nonspecific because these are often
present in asymptomatic patients.
Cadaver dissection has shown that
these spurs are localized to the flexor
Figure 1
Clinical photographs of the medial (A) and plantar (B) aspects of a left foot
demonstrating locations of tenderness for five diagnoses of heel pain: heel pad
atrophy (1), plantar fasciitis (2), Baxter nerve entrapment (3), calcaneal stress
fracture (4), and tarsal tunnel syndrome (5).
Craig R. Lareau, MD, et al
June 2014, Vol 22, No 6 373
the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
digitorum brevis (FDB) origin and
do not lie in the true substance of the
plantar fascia itself.
MRI is rarely required for the diag-
nosis of PF. It is perhaps better used to
rule out alternative pathologies, such as
calcaneal stress fracture. In the patient
with PF, MRI usually demonstrates
thickening of the plantar fasciaone
study showed it to be twice the
thickness of healthy controlsand
edema within the soft tissues.
in the medial calcaneal tuberosity,
however, is only variably present on
In all cases, initial management should
be nonsurgical. Rest, structured phys-
ical therapy, home stretching exercises,
heel cushions, orthoses, ice, NSAIDs,
and weight loss all have been linked to
the successful nonsurgical manage-
ment of PF.
Barefoot activities and
wearing shoes with inadequate cush-
ioning and support should be avoid-
Shoe wear modifications, such
as use of a rocker sole, have been
shown to reduce dorsiflexion of the
first metatarsophalangeal joint and
thereby decrease the peak tensile strain
of the plantar fascia.
specific to the plantar fascia has
recently been shown to provide supe-
rior pain relief when compared with
Achilles tendon stretching at 8 weeks;
however, no significant difference was
seen at 2-year follow-up.
In a level I
study, celecoxib was shown to provide
short-term pain reduction compared
with placebo.
Other management options include
night splinting, prescription orthoses,
and a period of immobilization.
Night splints are designed to prevent
and correct passive contracture of
the plantar fascia and gastrocnemius-
soleus complex. In one study, foot
orthoses were found to improve pain
and function at 3 months but not
at 12 months.
Prefabricated shoe
inserts have been shown to be as
effective as more costly custom
Following a dedicated
trial of such treatment measures, 90%
to 95% of patients experience reso-
lution of symptoms within 1 year.
For the small number of refractory
patients, more invasive techniques,
such as injection and ESWT, may be
In level I trials, corticosteroid in-
jections have resulted in significantly
improved pain relief in patients with
PF at 4 weeks compared with pla-
These same studies, however,
also suggest that corticosteroid in-
jections may only provide short-term
pain relief; injection did not provide
significant pain relief compared with
placebo at 3-month follow-up.
Corticosteroid injections are associ-
ated with a risk of plantar fascia rup-
This finding was observed in
2.4% of patients whoreceivedcorti-
costeroid injections.
members of the American Orthopae-
dic Foot and Ankle Society, this
complication was found to occur an
average of 1.5 times per provider over
fascia rupture itself is not believed to be
a common sequela of injection. Long-
term consequences of rupture include
longitudinal arch strain, lateral and
dorsal midfoot strain, lateral plantar
nerve dysfunction, stress fracture, and
hammer toe deformity.
potential side effects of corticosteroid
injection include skin and fat atrophy
at the injection site, postinjection
flare, inadvertent intraneural/intra-
vascular injection, hyperglycemia in
patients with diabetes, tendon rup-
ture, infection, and facial flushing.
Of these, postinjection flare, facial
flushing, and skin and fat atrophy are
the most common. Systemic compli-
cations are rare.
ESWT uses acoustic waves that elicit
an inflammatory response; in theory,
this leads to neovascularization and
Level I and II evidence,
however, have not convincingly dem-
onstrated it to be superior to placebo
in the management of PF. Of eight
double-blind placebo-controlled ran-
domized clinical studies, four con-
cluded that ESWT significantly
improved some short-term outcome
The remainder dem-
onstrated no significant differences in
any outcome measure.
study demonstrated that plantar fas-
cial stretching exercises were superior
to ESWT.
Level I studies investigating pulsed
radiofrequency electromagnetic field
and botulinum toxin A
for the management of PF
have failed to demonstrate a significant
difference compared with placebo.
Neither has PRP injection demon-
strated comparative superiority over
corticosteroid injection in the man-
agement of PF.
Surgery for recalcitrant disease most
often entails partial plantar fas ciotomy
without heel spur resection. In the past
two decades, endoscopic techniques
have gained in popularity due to
the purported advantage of a more
rapid postoperative recovery.
plantar fasciotomy, the traditional
mainstay of surgical management,
has been shown to provide pain relief
in 76% of patients.
In a recent level
IV study, endoscopic plantar fas-
ciotomy completely relieved symp-
toms in 76% of patients and was
associated with a low complication
Gastrocnemius recession may be
considered for the patient with PF
and a concomitant gastrocnemius
contracture. In a retrospective series,
25 patients with PF and isolated
gastrocnemius contracture experi-
enced significant pain relief after
gastrocnemius recession, with the
average visual analog scale score
decreasing from 8.1 to 1.9.
2012, Abbassian et al
that proximal gastrocnemius release
resulted in complete or significant
pain relief for 81% of patients; 58%
of patients experienced relief within
2 weeks of surgery.
Plantar and Medial Heel Pain: Diagnosis and Management
374 Journal of the American Academy of Orthopaedic Surgeons
the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Heel Pad Atrophy
Anatomy and
The heel pad, which is located beneath
the calcaneus, consists of adipose tis-
sue within a highly organized and
specialized confluence of fibrous sep-
tae that extend from the skin to the
calcaneal periosteum. These septae are
arranged into a stiff superficial micro-
chamber and a deep macrochamber
that undergoes substantial deforma-
tion with loading.
The heel pad
serves as a shock absorber, allowing
the heel to tolerate high loads and
repetitive load bearing. Heel pad
atrophy typically begins in the fifth
decade of life and likely is the result of
loss of water, collagen, and elastic
The heel pad becomes less
elastic in both the elderly and in per-
sons with diabetes, and these patients
are particularly prone to heel pad
atrophy. Prichasuk
defined the heel
pad compressibility index as the ratio
of the heel pad thickness in loaded
and unloaded positions. An increase
in the heel pad compressibility index
indicates loss of elasticity.
Presentation and Physical
Heel pad atrophy results in deep, non-
radiating pain that typically involves
the central weight-bearing portion of
the calcaneal tuberosity. It is com-
monly misdiagnosed as PF. Symptoms
of heel pad atrophy are usually exac-
erbated by walking barefoot or on
hard surfaces and are relieved by
the absence of heel pressure. Physical
examination typically elicits centrally
located tenderness over the plantar
aspect of the calcaneal tuberosity;
this tenderness can be associated with
varying degrees of swelling. Usually,
pain is not reproducible with passive
motion of the ankle or toes or
with side-to-side compression of the
Although radiographic studies are not
required to either make or confirm the
diagnosis of heel pad atrophy, imaging
should be considered to rule out alter-
native pathology. Heel pad thickness
is typically greater in men than in
This thickness is measured
on the weight-bearing lateral view as
the distance between the ground and
the plantar aspect of the calcaneal
tuberosity. The relationship between
this measurement and the presence of
symptoms remains unclear because
not all patients with heel pad atrophy
are symptomatic. MRI is usually
unnecessary, but it may demonstrate
edema and atrophy of the heel pad.
Resolution of symptomatic heel pad
atrophy can be challenging. Manage-
ment may include NSAIDs, properly
padded shoes, and customized ortho-
ses or over-the-counter silicone heel
cups. Given that the inherent nature of
this pathology is mechanical, lower-
impact and offloading activities can be
very helpful. Corticosteroid injection
should be avoided because it can result
in further atrophy of the plantar fat.
Surgical management is not rec-
ommended. There are no proven
techniques capable of adequately
recreating or replacing the normal
heel pad architecture. Furthermore,
the plantar skin is prone to problems
with wound healing, and infection in
this region can be difficult to manage.
Baxter Nerve Entrapment
Anatomy and
The first branch of the lateral plantar
nerve, that is, the Baxter nerve, is the
only nerve branch that lies deep to the
abductor hallucis and FDB muscles. It
travels superficial to the quadratus
plantae (QP) muscle along the medial
aspect of the calcaneus, providing
motor function to the QP, FDB, and
abductor digiti quinti (ADQ) muscles,
as well as sensation to the lateral
plantar skin, calcaneal periosteum,
and long plantar ligament.
The two
potential points of compression are
the deep margin of the abductor
hallucis muscle and the point at
which the nerve passes anterior to
the medial calcaneal tuberosity
(Figure 2). Pain is felt approximately
aspect of the heel or just distal to the
medial calcaneal tuberosity at the
junction of the glabrous and non-
glabrous skin.
Nerve compression
causes burning pain that may radiate
distally toward the plantar lateral foot.
The diagnosis commonly coexists
with PF. In one study, PF occurred in
52.5% of patients with an MRI finding
of ADQ atrophy, a manifestation of
chronic compression of the first branch
of the lateral plantar nerve.
In con-
trast, ADQ atrophy on MRI is seen in
only 6.3% of the general population.
Although Baxter and Pfeffer
that in some cases a small portion of
the medial plantar fascia was removed
to facilitate exposure, to our knowl-
edge there are no studies that specify
the percentage of patients with Baxter
nerve entrapment who required plan-
tar fascia release.
Presentation and Physical
Physical examination should include
an evaluation of gastrocnemius-soleus
contracture and hindfoot alignment.
Both hindfoot valgus due to posterior
tibial tendon insufficiency and ankle
plantar flexion resulting from equinus
contracture can accentuate symp-
toms. Pressure has been shown to be
highest in the lateral plantar tunnel
during plantar flexion and pro-
Percussion over the nerve
should be performed to assess for
reproduction of symptoms. Dimin-
ished sensation in the plantar lateral
foot may be seen in chronic cases.
Craig R. Lareau, MD, et al
June 2014, Vol 22, No 6 375
the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Similar to other etiologies of chronic
heel pain, entrapment of the first branch
of the lateral plantar nerve is primarily
a clinical diagnosis. Imaging modalities
are of limited usefulness because ADQ
atrophy is seen in 6.3% of all patients
who undergo MRI of the foot.
trodiagnostic studies in conjunction
with clinical evaluation can help
delineate whether compression exists
in the lateral plantar tunnel or more
proximally in the tarsal tunnel.
Initial management may include rest,
ice, NSAIDs, orthoses for hindfoot
malalignment, and physical therapy
with local modalities. There is no evi-
dence to support one nonsurgical
method over another. If nonsurgical
measures have been exhausted and
symptoms persist for .3 months, sur-
gical decompression consisting pri-
marily of release of the superficial and
deep fascia of the abductor hallucis
overlying the nerve is warranted and
usually effective.
Although Baxter
and Pfeffer
also mentioned resection
of small spurs that might be encoun-
tered in some patients, the experience
of the senior author (C.W.D.) indicates
that this is rarely necessary. In our
practice, however, we have on occa-
sion felt the need to provide additional
decompression via release of the FDB
and even the QP depending on their
relative size, proximity, and perceived
direct effect on the course of the lateral
plantar nerve branch as assessed
However, although our
experience in finding and treating this
latter presentation is positive, it is quite
limited and lacks formal study. Baxter
and Pfeffer
described excellent or
good results in 89% of heels managed
with open surgical release.
Calcaneal Stress Fracture
Anatomy and
The calcaneus is the largest tarsal bone
and is subject to considerable weight-
bearing stresses on a routine basis.
Despite these chronic loads, however,
the bone remains predominantly can-
cellous in nature. As a result, stress
fractures of the calcaneus are not
uncommon; typically, they occur
immediately posterior and inferior to
the posterior facet
(Figure 3). The
calcaneus is one of the most common
locations of stress fracture in the foot,
second only to the metatarsals.
Calcaneal stress fractures occur
most frequently in athletes, military
trainees, and elderly patients with
osteopenia. These injuries are caused
by repetitive overload and the
inability of bone formation to match
resorption. A thorough history often
elicits changes in exercise or activity,
typically involving recent adoption of
a more rigorous exercise regimen.
Presentation and Physical
Patients with calcaneal stress fracture
typically report intense, diffuse heel
pain along the medial and lateral
aspects of the posterior tuberosity. Pain
is exacerbated by activity and weight
bearing, and it may progress to become
persistent even at rest.
Patients often
experience tenderness along the lateral
wall of the calcaneal tuberosity. A
positive calcaneal squeeze test, or pain
on direct compression of both the
medial and lateral walls of the calca-
neus, is pathognomonic. This maneu-
ver helps to differentiate a calcaneal
stress fracture from other causes of
heel pain.
The amount of ecchymosis
and swelling depends on the acuity of
the injury.
Radiographs, specifically the lateral
foot view, may reveal disruption of
Figure 2
Illustration of a left heel showing the potential sites of compression of the Baxter
nerve: the deep margin of the abductor hallucis muscle (1) and the point at which
the nerve passes anterior to the medial calcaneal tuberosity (2).
Plantar and Medial Heel Pain: Diagnosis and Management
376 Journal of the American Academy of Orthopaedic Surgeons
the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
the trabecular pattern of the calcaneus
although these images are frequently
interpreted as normal during the early
course of this disease process (Figure 3).
The rare finding of a linear sclerotic
line in the tuberosity perpendicular to
the natural trabecular pattern indicates
During the early stages of
fracture, radiographic sensitivity can
be as low as 10%, but follow-up
radiography reveals diagnostic fea-
tures in 50% of patients.
pain persists but radiographs appear
normal, MRI or bone scanning may be
helpful to establish the diagnosis.
Technetium bone scans typically detect
a stress fracture 1 to 2 weeks before
changes become apparent radio-
MRI demonstrates high
signal intensity due to marrow edema
and hemorrhage on T2-weighted im-
ning because it enables concomitant
evaluation of soft-tissue structures.
Treatment consists of activity modi-
fication and protected weight bearing
in a fracture boot or short leg cast for
4 to 8 weeks. The treating clinician
also should consider a metabolic
workup, including vitamin D levels and
bone density testing, especially for the
patient with a previous history of frac-
ture. Normal activities can be resumed
after this period of immobilization,
once tenderness resolves. The prog-
nosis is excellent, and surgery is rarely
required. Significant displacement
and malalignment are uncommon,
and nonunion is rare.
Tarsal Tunnel Syndrome
Anatomy and
Tarsal tunnel syndrome (TTS) is an
entrapment neuropathy of the tibial
nerve as it courses through the tarsal
tunnel. The tarsal tunnel is a fibro-
osseous space located posterior and
distal to the medial malleolus. Its roof
is formed by the flexor retinaculum,
and the medial wall of the calcaneus
serves as its floor. The posterior tibial
neurovascular bundle passes through
this tunnel, along with the tendons of
the tibialis posterior, flexor digitorum
longus, and flexor hallucis longus
muscles. The tibial nerve divides into
the medial and lateral plantar nerves
as well as the medial calcaneal branch.
TTS is a relatively uncommon clinical
entity that may be overdiagnosed.
monly purported causes of TTS because
hindfoot valgus and forefoot abduction
place the nerve under tension.
reported causes include fracture, space-
occupying lesions, tenosynovitis, and
an accessory abductor hallucis mus-
Systemic inflammatory
arthropathy, diabetes, and rheumatoid
arthritis may also play a role in the
development of TTS.
This syndrome
is not typically bilateral, so systemic
and spinal pathology should be
excluded first in patients who present
with neurologic findings in both feet.
Presentation and Physical
Identification of TTS can be chal-
lenging. Patient complaints may be
vague and difficult to localize. Never-
theless, pain and paresthesia are clas-
sically localized to the posteromedial
ankle and heel, often radiating distally
into the plantar foot. Symptoms are
often exacerbated by stance and
exercise. Dysesthesia can disrupt the
may cause weakness; this finding is
among the latest, presenting first
in the toe abductors and subsequently
in the short toe flexors.
sensation along the tibial nerve dis-
tribution associated with a Tinel sign
along the tarsal canal is considered
to be the most pathognomonic find-
Other provocative maneuvers,
such as the dorsiflexion-eversion test,
which stretches the tibial nerve, may
also elicit reproducible discomfort in
this anatomic region.
MRI is the modality of choice for eval-
uating the anatomy of the tarsal tunnel
and detecting space-occupying lesions
responsible for tibial nerve compression
(Figure 4). Nerve conduction velocity
(NCV) studies and EMG can be per-
formed to confirm the diagnosis;
however, an overview of four pro-
spective level III studies indicates that
false-negative rates are high with these
Negative NCV findings
do not exclude the diagnosis. Sensi-
tivity of sensory NCV abnormalities
ranged from 90.5% to 96% (false-
negative rate [range], 4% to 9.5%),
and sensitivity of prolonged distal
motor latency ranged from 21.5% to
52.4% (false-negative rate [range],
47.6% to 78.5%).
The usefulness of NCV and EMG in
diagnosis and prediction of outcomes
in TTS remains questionable. These
techniques also vary greatly between
studies, and few high-quality reports
either correlate NCV and EMG with
Figure 3
Lateral foot radiograph
demonstrating a calcaneal stress
fracture (arrow). (Reproduced with
permission from Spitz DJ, Newberg
AH: Imaging of stress fractures in the
athlete. Radiol Clin North Am
Craig R. Lareau, MD, et al
June 2014, Vol 22, No 6 377
the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
outcome or provide supportive evi-
dence for significant diagnostic util-
ity. In an evidence-based review of the
use of NCV and EMG in the diag-
nosis of TTS, sensory NCV was
determined more likely to be abnor-
mal than motor NCV; however, the
actual sensitivity and specificity of
these tests could not be determined.
Nonsurgical options for TTS include
NSAIDs and immobilization. Pa-
tients with pes planus deformity may
benefit from custom orthoses.
Local corticosteroid injection into
the tarsal tunnel has been advocated
by some authors, but its use should
be carefully considered because of
the potential for tendon rupture and
intravascular injection.
Surgery is reserved for patients who
do not respond to nonsurgical treat-
ment and who have no other reason-
able explanation for their symptoms as
well as for those with identifiable space-
occupying lesions. Traditional tarsal
tunnel release involves careful division
of the flexor retinaculum overlying the
posterior tibial nerve as it courses
behind the medial malleolus as well as
release of the fascia over the abductor
hallucis. Complete release minimizes
the chance of persistent or recurrent
symptoms. To this end, anatomic and
clinical studies also suggest release of
the medial septum deep to the abductor
hallucis, under which the lateral and,
sometimes, the medial plantar nerves
In a recent series, all patients demon-
strated improvement in mean sensory
threshold as defined by monofilament
examination 12 months after surgical
Surgical interven-
tion should be carefully considered,
however, because results can be
unpredictable. For example, surgical
decompression successfully relieves
symptoms in only approximately
50% of patients for whom a definite
etiology cannot be identified.
In one study, 56% of patients had
fair or poor results at long-term
In patients with diabe-
tes, decompression has been reported
to significantly improve one-point
pressure threshold as measured by
monofilament examination but not
two-point discrimination 8 to 9 months
Another report sug-
gests that in patients with diabetes,
a positive Tinel sign has a 90% positive
predictive value of symptom relief
following extended decompression.
In patients with TTS resulting from
a space-occupying ganglion in the
tarsal tunnel, excision of the ganglion
results in satisfactory outcomes.
Pain of the plantar and medial heel is
a common complaint. A thorough
history and physical examination is
paramount to establish an accurate
diagnosis. In most patients, the diag-
nosis can be made clinically, taking
care to characterize the quality, loca-
tion, timing, and duration of pain. On
occasion, advanced imaging or neuro-
diagnostic studies may be necessary
Figure 4
Axial proton density-weighted magnetic resonance images without (A) and with (B) fat saturation, and sagittal short tau
inversion recovery (C) sequence image, demonstrating a tarsal tunnel ganglion (*) compressing the medial (red arrow) and
lateral (blue arrow) plantar nerves. (Courtesy of Peter T. Evangelista, MD, Providence, RI.)
Plantar and Medial Heel Pain: Diagnosis and Management
378 Journal of the American Academy of Orthopaedic Surgeons
the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
when radiographs and clinical exami-
nation are inconclusive. Initial man-
agement is typically nonsurgical. For
the small percentage of patients whose
symptoms persist despite an adequate
course of nonsurgical management
surgical intervention can be considered.
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, references 2,
3, 5, 6, 20, 22-25, and 32-41 are
level I studies. References 1, 13, 21,
42, and 66 are level II studies. Ref-
erences 16 and 43 are level III stud-
ies. References 14, 15, 17, 18, 26-30,
44-46, 49-54, 58, 62-65, 67, and 68
are level IV studies. References 4, 7-
12, 19, 31, 47, 48, 55-57, and 59-61
are level V expert opinion.
References printed in bold type are
those published within the past 5
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Plantar and Medial Heel Pain: Diagnosis and Management
380 Journal of the American Academy of Orthopaedic Surgeons
the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
... The condition presents clinically as paraesthesia along the sole [63]. In other words any compression of the LPN is usually associated with compression of the MPN [26,50]. A tendency to overpronate during walking or running whereby the foot rolls to a considerable extent, is associated with an increased risk of LPN compression [2]. ...
Full-text available
Considerable variations have been reported regarding the branching pattern of tibial nerve (TN) close to its termination in foot. In order to comprehend the clinical anatomy of heel pain awareness of all the possible variations in relation to terminal branching pattern of TN (close to the tarsal tunnel) is essential. The present study was conducted to undertake a comprehensive review of the variations in tibial nerve branches in foot with particular emphasis on the implications for sensory distribution of these branches. Articles were searched in major online indexed databases using relevant key words. The pattern of termination of TN was noted as either trifurcation or bifurcation. Bifurcation pattern was more commonly observed and is associated with the medial calcaneal nerve (MCN) either arising high or low relative to the tarsal tunnel. The most commonly noted type of bifurcation was proximal to malleolar-calcaneal axis but within the tarsal tunnel. Across all five types of bifurcation reported in literature the termination point of TN ranged from 3 cm proximal to 3 cm distal to malleolar-calcaneal axis and therefore the area beyond this region can be considered as safe zone for performing invasive procedures. MCN showed considerable variations in its origin both in trifurcation and bifurcation pattern pertaining to number of branches (one/two/three) at the point of origin. The origin of inferior calcaneal nerve (ICN) was observed to be relatively less variable as it mostly arose as a branch of lateral plantar nerve (LPN) and sometimes as a direct branch from TN before termination. The frequent variation of MCN in the tarsal tunnel should be kept in mind while undertaking decompression measures in medial ankle region.
... The plantar fascia consists of thick fibrous multi-layer connective tissue located on the planter side of the foot. [1][2][3][4] The thickness of the tissue increases in plantar fasciitis. 5 The overloading due to excessive weight-bearing and repetitive micro trauma can cause plantar fasciitis, which is the most common foot problem in obese adult women. ...
Background: Chronic plantar fasciitis has been historically treated with conventional physical therapy. The use of the Garston Technique® (GT) is a new intervention for the management of chronic plantar fascitis, but there is lack of evidence in the literature regarding its efficacy. Study objective: To evaluate the effectiveness of the GT on pain, foot function and general foot health in patients with plantar fasciitis. Methods: This was a randomized clinical trial conducted from November 2020 to March 2021. The non-probability purposive sampling technique was used to select 30 patients. Setting: Madinah Teaching Hospital, Faisalabad, Pakistan. Participants: A total of 30 patients of both genders with a 6-week history of planter fasciitis and the presence of a calcaneus everted ≥2° were included in this study and randomly assigned to one of two groups. Intervention: Both groups received conventional physical therapy (CPT) for 4 weeks and the experimental group in addition received GT. Primary outcome measures: The primary outcome measures were pain, measured at baseline, after the second week and after the end of treatment (ie, the fourth week) on the visual analog scale (VAS); and general foot health and foot function, measured at baseline and after the end of treatment with the Modified Foot Health Status Questionnaire (FHSQ). Results: The mean age of the study patients was 34.1 ± 6.67 years. There was significant improvement in pain in the GT group compared with the CPT group after the second (P = .005; partial η2 = 0.263) and the 4th (P = .000; partial η2 = 0.535) week of intervention. Foot function was also significantly improved (P < .05) in the GT group compared with the CPT group with a large effect size (Cohen's d = 0.080). But in the case of general foot health, no significant difference was observed between the groups at the end of the fourth week. Conclusion: The use of the GT combined with CPT shows significant results compared with CPT alone; ie, GT speeds up the recovery from heel pain and foot function in patients with chronic plantar fasciitis.
... 3,9,11 Noninvasive interventions have usually been the first treatment option (used in 85%-90% of cases) for treating plantar fasciitis, 5 with an effectiveness of up to 90%. 1 A recent meta-analysis reported inconclusive results for clinical practice of both conservative and nonpharmacologic treatments regarding pain relief in patients with plantar heel pain. 12 Thus, injected therapies are frequently used in patients who did not respond to noninvasive treatments. ...
Objective: To evaluate the efficacy of botulinum toxin A (BTX-A) for the treatment of plantar fasciitis through a meta-analysis of randomized controlled trials (RCT) focusing on pain and functional outcomes since current literature has supported a potential benefit of BTX-A. Data sources: The MEDLINE, EMBASE, Web of Science, and Scopus databases were searched until December 2020 for RCT reporting the effects of BTX-A injections on plantar fasciitis. The complementary literature search included Cochrane Central Register of Controlled Trials and,, and Study selection: Only RCT assessing the effect of BTX-A injections on either pain, functional improvement, or plantar fascia thickness in patients with plantar fasciitis were included. Multiple researchers carried out the screening process of the 413 records. Data extraction: Data were extracted independently and in duplicate using a standardized data extraction format. Information was contrasted by a third observer. Data synthesis: BTX-A injections resulted in significant pain relief (MD, -2.07 [95% CI: -3.21, -0.93]; p = 0.0004; I2 = 97%) and functional improvement (SMD, 1.15 [95% CI: 0.39, 1.91]; p = 0.003; I2 = 87%). A subanalysis indicated that pain relief was sustained at 12 months while functional improvement remained significant after 0-6 months. The results were not affected by a single study after sensitivity analysis. The site of injection and the use or not of ultrasound-guided injections may account for potential sources of inter-study heterogeneity. Conclusion: This meta-analysis suggests both a statistically significant and a clinically meaningful improvement on plantar fasciitis symptoms after BTX-A treatment.
Plantar fasciitis is one of the most common causes of plantar heel pain. Microtrauma to the plantar fascia can lead to collagen necrosis, angiofibroblastic hyperplasia, and calcification. Symptoms include focal startup pain on initial weight-bearing when getting out of bed in the morning at the plantar heel and sometimes gastrocnemius contracture. Initial conservative treatment for plantar fasciitis includes shock absorbing and orthotic insoles, shoe modification, nonsteroidal anti-inflammatory drugs, steroid injections, and plantar fascia/Achilles stretches. Surgical treatment is indicated for recalcitrant symptoms after 6 to 12 months of nonoperative treatment. Endoscopic plantar fascia release may reduce the surgical complications compared to open procedures and shorten return to the normal activities.KeywordsPlantar fasciitisEndoscopic plantar fascia releaseBaxter’s nerveWindlass mechanismHeel pain
Objective: The aim of this study was to evaluate the thickness and elasticity of the heel fat pad in patients with unilateral plantar fasciitis and to investigate the effects of age, sex, body mass index (BMI), and functional scores on plantas fasciitis. Material and Methods: A total of 70 patients who had been suffering from unilateral plantar fasciitis for longer than 6 months were enrolled in the study. The thickness and elasticity of the fat pad were compared between the painful and healthy feet of the patients with ultrasound. For measurement of elasticity, shear wave elastography (SWE) was used. Functioanl evaluation was performed with the American Orthopaedic Foot and Ankle Society Score (AOFAS). The thickness and elasticity variables were compared between the painful and healthy side groups using the independent samples t-test and Mann–Whitney U test. Results: Mean age of the patients was 44±11.66. The average thickness of the heel fat pad was 17.9±3.1 mm on the affected side and 18.3±3.3 mm on the healthy side. The mean SWE value of the painful side was 23.9 m/s (range 9.3-32) and was 24.7 m/s (range 10.8-34) on the healthy side. The average AOFAS score of the patients was 70 (range 62-78). Heel fat pad thickness was greater in the healthy feet than in the painful feet, but there was no statistical significance (p=0.448). The painful feet were stiffer, but the difference was statistically similar (p=0.347). The elasticity and thickness values between the painful and healthy feet were not affected by sex. BMI had a statistically significant impact on heel fat pad thickness between the painful and healthy feet. Conclusion: The results showed that a decrease in the thickness of the heel fat pad was a supporting finding of plantar fasciitis in patients with normal BMI but not in patients with BMI>25.
Plantar fasciitis is one of the most common causes of foot pain. It results from sustained stress of weight bearing - hopping, jumping, running -which results in micro trauma to plantar fascia which further leads to plantar fasciitis. It constitutes 11% to 15% of all foot symptoms. Its prevalence is 8% to 10% in general population. It commonly affects at the age of 40 to 60 years. Recently platelet rich plasma was used in treating in degeneration, muscle and tendon injuries. Hence, the present study aimed to assess the treatment outcome of autologous platelet rich plasma injection in treatment of plantar fasciitis. In this prospective study, we enrolled 35 patients with plantar fasciitis coming to OPD or casualty. Patients satisfying inclusion criteria were selected based on consecutive sampling. 11 patients responded well to conservative management and 3 patients had loss of follow up. The different scoring systems were adopted such as VAS and AOFAS for pain assessment. The thickness of plantar fascia was determined by ultrasound technique. Autologous platelet rich plasma was prepared and the same was injected. The outcome analysis was done at 2 weeks, 3 months, and 6 months; and compared with pre injection values. From pre-injection to up to post-6 months period, the VAS reduction was statistically significant (P<0.0001). All the time interval, the AOFAS was increased which was statistically significant (P<0.001). The injection was effective in reducing the thickness of plantar fascia, which was found to be statistically significant at all the time intervals (P<0.001). Autologous PRP injection for chronic plantar fasciitis was found to be an effective treatment modality for chronic plantar fasciitis.
Plantar fasciitis (FP) is one of the most frequent pathologies in foot and ankle. Management is non-surgical in 95% of patients. An adequate history and physical examination allow the diagnosis to be made without performing imaging tests. The initial treatment is a protocol of exercises to stretch the plantar fascia and gastrosoleus complex for at least 2 months. The use of orthotics or insoles is also indicated. In case of diagnostic doubt or duration of symptoms of more than 1 to 2 months, we recommend a study with a standing X-ray plus an ultrasound. If after 4 to 6 months the symptoms persist (or in patients with atypical symptoms such as progressive claudication or neuropathic symptoms), it is recommended to request an MRI to rule out tumors or stress fractures. Shock waves are indicated after 4 to 6 months of treatment failure. Surgical treatment is indicated no earlier than 9–12 months of conservative treatment. If there are neurological symptoms that suggest compression of the lateral plantar branch, we recommend performing tarsal tunnel release plus open partial plantar fasciotomy. In cases of insertional plantar fascia pain (recalcitrant FP), we recommend releasing the proximal medial gastrocnemius. It has shown similar results to plantar fasciotomy, but with less comorbidity and a simpler postoperative period for the patient.
Background: Local ultrasound (US)-guided injections of anesthetics with corticosteroids are commonly performed for the conservative treatment of tarsal tunnel syndrome (TTS). Objective: This retrospective study aimed to investigate the outcomes of TTS after US-guided injections. Methods: The study included patients who were diagnosed with TTS and received US-guided injections as part of their initial treatment. The pain levels were noted on a scale between zero and ten before and after each injection. The patients were divided into non-surgical and surgical groups. The nonsurgical group included patients who had received US-guided injections and did not proceed to surgical treatment, and the surgical group included those who received US-guided injections and ultimately underwent tarsal tunnel release (TTR). The two groups were compared in terms of age, post-injection follow-up time, and the amount of pain reduction immediately after injection (ΔPN). In the surgical group, outcomes of surgical treatment were also assessed. Results: A total of 218 patients were diagnosed with TTS and received US-guided injections. After the injections, 169 patients (77.5%) did not go on to TTR (nonsurgical group) and 49 patients (22.5%) underwent TTR (surgical group). The average ages for the nonsurgical and surgical groups were 53.8 and 48.9 years (P = 0.03). The average time between the injection and final follow-up for the nonsurgical group was 339 days. The average time between the injection and TTR for the surgical group was 145 days. There were no differences in pain relief after the injections between the nonsurgical and surgical groups (mean ΔPN: 3.6 and 3.8, respectively). The average post-surgical follow-up time was 117 days. At final follow-up, 41 patients (84%) in the surgical group had complete resolution of pain and neurological symptoms. Conclusion: US-guided injection can be an effective conservative treatment option for patients with TTS. Younger patients may be more likely to proceed to TTR. Level of evidence: Level III.
Full-text available
To investigate the effectiveness of ultrasound guided corticosteroid injection in the treatment of plantar fasciitis. Randomised, investigator and participant blinded, placebo controlled trial. University clinic in Melbourne, Australia. 82 people with a clinical and ultrasound diagnosis of plantar fasciitis unrelated to systemic inflammatory disease. Participants were randomly allocated to ultrasound guided injection of the plantar fascia with either 1 mL of 4 mg/mL dexamethasone sodium phosphate (experimental group) or 1 mL normal saline (placebo). Before injection the participants were given an ultrasound guided posterior tibial nerve block with 2% lidocaine (lignocaine). Primary outcomes were pain, as measured by the foot health status questionnaire (0-100 point scale), and plantar fascia thickness, measured by ultrasound at 4, 8, and 12 weeks. Reduction in pain at four weeks favoured the dexamethasone group by 10.9 points (95% confidence interval 1.4 to 20.4, P=0.03). Between group differences for pain scores at eight and 12 weeks were not statistically significant. Plantar fascia thickness measured at four weeks favoured the dexamethasone group by -0.35 mm (95% confidence interval -0.67 to -0.03, P=0.03). At eight and 12 weeks, between group differences for plantar fascia thickness also favoured dexamethasone, at -0.39 mm (-0.73 to -0.05, P=0.02) and -0.43 mm (-0.85 to -0.01, P=0.04), respectively. The number needed to treat with dexamethasone for one successful outcome for pain at four weeks was 2.93 (95% confidence interval 2.76 to 3.12). There were no reported adverse events associated with the intervention. A single ultrasound guided dexamethasone injection is a safe and effective short term treatment for plantar fasciitis. It provides greater pain relief than placebo at four weeks and reduces abnormal swelling of the plantar fascia for up to three months. However, clinicians offering this treatment should also note that significant pain relief did not continue beyond four weeks. Australian New Zealand Clinical Trials Registry ACTRN12610000239066.
Tarsal tunnel syndrome is an uncommon clinical entity, This article will review the published reports on tarsal tunnel syndrome with respect to ifs anatomy, cause, pathophysiology, clinical presentation, diagnosis, treatment, and results of treatment in an attempt to improve understanding of this problem.
Evaluation of the effectiveness of three different types of prefabricated foot orthotics in the treatment of plantar fasciitis. Prospective, randomized head-to-head trial in 30 adults (21 women, 9 men) with plantar fasciitis without any anatomic alterations. Three different prefabricated orthotics were tested (thin, non supportive orthotic (NO); soft supportive foam orthotic (FO); foam covered rigid self-supporting plastic orthotic (PO)). The follow up was 3 weeks. Main outcome measures were maximum and average pain (VAS), duration of pain per day, walking distance and subjective comfort. There was no significant effect of NO on maximal pain and average pain. FO and PO had a significant effect on pain levels (p<0.05) whereas PO was superior concerning pain reduction and the time until the onset of effect (p<0.05). PO are superior regarding pain reduction and pain free time when compared to FO. NO did not demonstrate a significant effect in the test setup used.
Limited quantitative information is available about the improvement of protective sensation after tarsal tunnel release in patients with diabetic peripheral neuropathy. Prospective, non-blinded, non-randomized case series of 10 feet in 8 diabetic patients and 24 feet in 22 non-diabetic patients who had tarsal tunnel release. Preoperative and postoperative (average, 8-9 months) anatomic, quantitative sensory testing was done with touch pressure 1-point threshold (Semmes-Weinstein monofilaments) and 2-point discrimination. There was marked, significant postoperative improvement of mean touch pressure 1-point threshold, compared with preoperative values, for medial calcaneal, medial plantar, and lateral plantar nerves in both non-diabetic and diabetic patients. There was minimal improvement in 2-point discrimination only for the medial calcaneal nerve in non-diabetic, but not in diabetic, patients. Nerve entrapment at the tarsal tunnel is an important component of diabetic peripheral neuropathy. Tarsal tunnel decompression may improve sensory impairment and restore protective sensation.
Windlass effect occurs during the pre-swing phase of gait cycle in which the peak tensile strain and force of the plantar aponeurosis (PA) is reached. The increased dorsiflexion angle of the 1st metatarsophalangeal (MTP) joint is the main causing factor. The aim of this study was to investigate thoroughly in finding the appropriate shoe and insole combination that can effectively decrease the windlass effect. Foot kinematic analyses of 10 normal volunteers (aged 25.2±2.1years, height of 167.4±9.1cm, and weight of 66.2±18.1kg) were performed during gait under the conditions of barefoot, standard shoe (SS) with flat insole (FI) or carbon fiber insole (CFI), and rocker sole shoe (RSS) with FI or CFI. The shoe cover consisting of transparent polymer was used for accurate measurement of kinematic data as specific areas on the cover can be cut away for direct placement of reflective markers onto the skin. Under barefoot condition, the mean of maximum dorsiflexion angle of the 1st MTP joint was measured to be 48.0±7.3°, and decreased significantly to 28.2±5.7° when wearing SS with FI, and 24.1±5.7° when wearing SS with CFI. This angle was further decreased to around 13° when wearing RSS with FI or CFI. Subjects wearing footwear alone can increase the minimum medial longitudinal angle and decrease the maximum plantarflexion angle of metatarsus related to the calcaneus as compared with barefoot condition, resulting in flatter medial foot arch. Results suggested that RSS is the effective footwear in reducing the windlass effect regardless the type of insole inserted. The findings in this study provided us with the evidences in finding the appropriate footwear for treating foot disorders such as plantar fasciitis by effectively reducing the windlass effect.
Background: Tarsal tunnel syndrome (TTS) is an entrapment neuropathy of the posterior tibial nerve or its branches within its fibro-osseous tunnel beneath the flexor retinaculum on the medial side of the ankle. It is a rare but important condition which is regularly under diagnosed leading to a range of symptoms affecting the plantar aspect of the foot. Management of this entrapment neuropathy remains a challenge and we have therefore reviewed the published literature in an attempt to clarify aspects of initial presentation, investigation and definitive treatment including surgical decompression. We also assessed the continuing controversial role of electrodiagnostic techniques in its diagnosis. Conclusion: Recommendations from literature: Excellent results with decompression in selected patients. To prevent nerve fibrosis, decompression should be performed early. Remain aware of false negative NCS (under-diagnosing of those with symptoms but ‘normal’ NCS. Role of NCS remains controversial with inability to predict which cases respond to decompression. Poor outcome may be due to nerve fibrosis.
The results of surgical treatment for tarsal tunnel syndrome have been suboptimal, especially in the absence of space-occupying lesions. We attribute this to a poor understanding of the detailed anatomy of the `tarsal tunnel' and potential sites of nerve compression. This study involved the dissection of 19 cadaveric feet. All findings and measurements were documented with digital photography and digital calipers. This study demonstrated three well-defined, tough fascial septae in the sole of the foot. In addition to the flexor retinaculum and the abductor hallucis, two of these septae represented potential sites of compression of the posterior tibial nerve and its branches. The medial plantar nerve may be entrapped under the medial septum. However, in 16 of 19 feet, the medial plantar nerve did not traverse beneath the septum. The lateral plantar nerve traversed beneath the medial septum in all specimens. The nerve to abductor digiti minimi may be trapped under the medial and intermediate septum. We detailed the anatomical relationship of the nerve branches relative to the fibrous septae and found that the medial plantar nerve did not traverse a septae in all specimens. We believe better understanding of the anatomical relationships of the tarsal tunnel and a clear communication system among anatomists, neuroradiologists and foot and ankle surgeons will facilitate accurate preoperative localization of the site of nerve compression possibly leading to better outcomes.
Botulinum toxin A (BoNT-A) is used as an alternative treatment for chronic orthopedic conditions. This study was conducted to investigate the efficacy and safety of BoNT-A on pain and functional outcome in patients with chronic plantar fasciitis. In this short-term, randomized, multicenter, double-blind, placebo-controlled study, patients (N=40) were randomized to receive 200 units of BoNT-A (Dysport) or saline placebo. The injection was administered in a fan-shaped manner directly at the calcaneal origin of the plantar fascia. The primary outcome measure was the proportion of responders at week 6 [≥50% decrease from baseline in pain score (visual analog scale) while moving during the previous 48 h). Global assessments were performed by the patient and physician at each visit up to week 18. More patients in the BoNT-A group achieved a response at week 6 (25% vs. 5% for placebo; P=0.18). Differences between treatments were in favor of BoNT-A on secondary measures of pain, but did not reach statistical significance. In the BoNT-A group, 52.7% (vs. 40% for placebo) assessed their condition as slightly/significantly improved at week 6. At study endpoint (week 18), 63.1% of the BoNT-A group perceived an improvement versus 55% of the placebo group. There was no difference in global assessment between physician and patient. No adverse events related to treatment were noted. There is a need for larger, prospective, long-term, placebo-controlled studies to fully establish the role of BoNT-A for the treatment of plantar fasciitis.