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Wheeless' Textbook of Orthopaedics

Plantar Fasciitis

- Discussion:
    - one of several causes of heel pain;
    - the pain is located somewhat more distally than in other causes of heel pain syndrome
    - symptoms include gradual onset of pain at the origin of the plantar aponeurosis and 1 cm distal to this area
    - no definitive evidence that plantar fasciitis is linked with abnormal foot posture (pes planus or pes cavus)
    - pathophysiology:
           - repetitive tensile overload of the soft tissue attachments to the plantar aspect of the heel; causes pathological changes comparable to
                     those of tendinitis (inflammation) and tendinosis (degeneration);
           - in addition, a relative heel cord contracture (which often worsens during the night, since the heel is held in plantar flexion during 
                   sleep), will accentuate these symptoms since the heel cord attaches to the heel pad;
           - these canges can be compared to those seen in lateral epicondylitis of the elbow (tennis elbow), Achilles tendinitis and patellar
                   tendinitis (Jumper's knee) also caused by tensile overload;
    - differential diagnosis of heel pain: 
           - Heel pain triad (HPT): the combination of plantar fasciitis, posterior tibial tendon dysfunction and tarsal tunnel syndrome.


- Symptoms - History - Physical Exam
    - pain:
           - classic symptoms of plantar fasciitis include severe pain which is worse in the morning/after rest and improves after moving around;
           - pain is aggravated by weight bearing all day, and becomes progressively more severe;
           - pain is described as dull aching or sharp;
    - tenderness:
           - be specific about the point of maximal tenderness in relation to the medial calcaneal tuberosity;
           - tenderness is typically produced w/ dorsiflexion of toes (MTPs) tensioning the plantar fascia accentuating tenderness on palpation 
                  of the fascial band;
           - on palpation entire plantar surface is tender and located more into the arch in true plantar fasciitis as compared to heel pain syndrome 
                  in which the maximum tenderness is just anterior to the calcaneal tuberosity or at the plantar medial heel;
    - percuss along the posterior tibial nerve to elicit Tinel's sign for nerve entrapment;
    - assess for heel cord contracture (knee extended, heel in varus)
           - assessment of heel walking is another measure of heel cord contracture;
    - as noted by Powell et al 1998, most patients do not have a pronated foot type (75% were normal);
    - at the midfoot attempt to distinguish FHL tenderness from the underlying plantar fascia; 
    - ref: Association between plantar fasciitis and isolated contracture of the gastrocnemius


- Lab Studies: (ESR, RF, Uric acid)
    - routine blood tests are of little value
    - rheumatologic screening can be important in some instances (young patient, multiple sites of pain) so they are useful to rule out 
           inflammatory arthritides (RA, Reiter's, ...)


- X-rays:
    - lateral view:
          - "saddle sign" is present in 60% of cases of heel pain: radiolucency proximal to plantar calcaneal spur indicating fatigue of tuberosity 
                 at origin of FDB;
          - may demonstrate spurring of the medial calcaneal tuberosity
          - heel spurs are not in the plantar fascia as is commonly thought but are found in the origin of the short flexors;
                 - Tanz (1963) : they are present in 16% of normal population, 50 % of patients with heel pain had spurs;
                 - Lapidus and Guidotti (1965) : 46 % of heel pain patients had no spur, 50 % of patients with bilateral spurs had pain in only one heel;
                 - Callison ( Orthopaedic Foot Club Meeting 1989) : 53 % of heel pain sufferers had no spur;
    - 45 degree medial oblique view
          - Amis (Foot Ankle 1988): 85 % of patients had a change in cortex or trabecular pattern
          - useful to diagnose stress fracture;
    - Axial View:
          - may pick up an occult bone tumour; 
    - References
          - Heel pain
          - Painful heel: report of 323 patients with 364 painful heels

- Bone Scintigraphy:
    - Willliams (1987) : no false positives in painless heels, increased uptake in 60 % of patients with heel pain syndrome;
          - Imaging study of the painful heel syndrome

- Non Operative Treatment:
    - of note, one of the major negative factors in determining the effectiveness of non operative treatment is standing more than 8 hrs per day;
    - heel cord and plantar fascia stretching:
           - in patients w/ even mild heel cord contracture, the mainstay of plantar fasciitis should be heel cord stretching;
                  - several retrospective studies show that this is the most effective form of treatment;
           - this will unload stress over the midfoot and will aleviate plantar fascial pain in the majority of patients:
           - in the acute phase stretching can be done by applying POP
           - dorsiflex and add stretching effect to the fascia itself - can be initially very painful);
           - references:
                  - The effects of duration and frequency of Achilles tendon stretching on dorsiflexion and outcome in painful heel syndrome: a randomized, blinded, control study.
                  - Tissue-Specific Plantar Fascia-Stretching Exercise Enhances Outcomes in Patients with Chronic Heel Pain. A Prospective, Randomized Study. 
                  - Plantar Fascia-Specific Stretching Versus Radial Shock-Wave Therapy as Initial Treatment of Plantar Fasciopathy
                  - Association between plantar fasciitis and isolated contracture of the gastrocnemius.

    - casting:  
           - forces the ankle to remain in a neutral position (placing the heel cord in a stretched position);
           - does not allow the patient to cheat (ie the cast cannot be taken off);
           - Callison (Orthopaedic Foot Club Meeting 1989): 61% of patients had recurrent pain within four weeks of cast removal
    - night splints:
           - night splints (w/ or w/o a wedge underneath great toe) are often effective;
           - in the study by Powell M (1998), 88% of patients improved w/ night splinting;
                  - presence of a heel spur had no effect on outcome;
           - ref: Effective treatment of chronic plantar fascitis with dorsiflexion night splints: a crossover prospective randomized outcome study
    - nsaids:
    - oral steroids will often be dramatically effective;
    - steroid injection:
           - injection of 0.1 to 0.2 ml of corticosteroid from the medial side of heel; into the tender area may be helpful  in order to avoid 
                 steroid-induced atrophy of the fat pad, inject deep into the plantar fascia;
           - improvement is often temporary;
           - in rare cases, there are patients who swear by repeated steroid injections (noting that it cures their symptoms);
           - note the occurance of plantar fascia rupture from steroid injection;
                  - often the plantar fascia pain will be relieved but often the pain is replaced with longitudinal arch strain, lateral plantar nerve 
                          pain, stress frx, and hammertoe deformity;
                  - in the study by Acevedo and Beskin (1998), the authors followed 52 patients w/ plantar fascia rupture;
                          - 44 out of 52 patients has steroid injections into the plantar fascia;
                          - out of 122 patients w/ plantar fasciitis who had had steroid injections, 12 had plantar fascia ruptures (10%);
           - ref: Complications of plantar fascia rupture associated with corticosteroid injection
    - foot orthotics:
           - for most patients foot orthotics will provide only fair success;
           - in the prospective randomized study by Pfeffer G, et al (1999), it was found that when used in conjunction with a stretching
                 program, a prefabricated shoe insert is more likely to produce improvement in symptoms than a customized polypropylene device;
           - Thomas Heel:
                 - medial heel wedge tilts the heel into varus and may be helpful in treatment of symptomatic pes planus and plantar fasciitis
                 - this heel should not be used if calcaneus is in varus position;
                 - this heel should extend from mid portion of navicular on medial side to line that intersects longitudinal axis of fibula on the lateral side
                 - also consider UC-BL insert, a heel cup, or a medial heel wedge (these place the heel in a varus position and thus relaxes the tension in the plantar fascia); 
           - references:
                   - Effectiveness of Foot Orthoses to Treat Plantar Fasciitis. A Randomized Trial  
                   - Effective treatment of chronic PF with dorsiflexion night splints: a crossover prospective randomized outcome study.  
                   - Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis

    - platlet consentrate:
            - Platelets rich plasma for treatment of chronic plantar fasciitis


- Surgical Treatment:
    - necessary in less than 5 % of patients in most series
    - has been controversial, but most common procedure is plantar fascia release
    - excision of the plantar spur (which is located at the origin of the FDB & not plantar fascia;
           - no evidence that this improves results over fascia release and it may actually exacerbate heel pain by altering mechanics of the heel pad;
    - plantar fascia release



The relationship of pes planus and calcaneal spur to plantar heel pain.

Rupture of the plantar fascia in athletes.

Plantar fasciitis. The painful heel syndrome

The effects of duration and frequency of Achilles tendon stretching on dorsiflexion and outcome in painful heel syndrome: a randomized, blinded, control study.

Treatment of Plantar Fasciitis

Electrohydraulic High-Energy Shock-Wave Treatment for Chronic Plantar Fasciitis  


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Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, May 29, 2012 11:10 am