AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Plantar heel pain is a common problem in adults. The most common cause of heel pain is inflammation to the dense tissue extending from the calcaneus to the metatarsal region, thus the descriptive term plantar fasciitis. Though not all cases of plantar heel pain are due to plantar fasciitis, an inflamed or damaged fascia may contribute to painful conditions caused by nerve injury or soft-tissue inflammation in local muscle and the fat pad. With the Internet and an increasing public awareness of plantar fasciitis comes greater demand for treatment when time and home remedies do not alleviate pain. The nature of upright human activity is repetitive tensile and compressive stress of the fascia that has a cumulative ability to damage or transform the tissue. Longer lifespans and greater recreational expectations of working adults also are contributing to the volume of patients seeking attention for plantar fasciitis.

Pathophysiology

The functional role of the plantar fascia still is being defined through basic research. One role is the so-called windlass mechanism, which is a vital connection between the hindfoot and forefoot, important in stance and gait. Cadaver studies indicate that cutting the plantar fascia weakens the medial longitudinal support of the arch and increases tensile force in other ligaments and the posterior tibial tendon. The plantar fascia contributes more mechanical support to the arch than does the spring ligament, plantar ligaments, or intrinsic muscles. Changes within the fascia substance may initiate dysfunction, or the histologic changes may be secondary to a damage or disease process. Current evidence indicates that normal cells and extracellular matrix are not associated with pain.

The origin of the plantar fascia on the calcaneus is an area that has fibrocartilage at the site of attachment to bone. This specialized zone of tissue has longitudinal fibers of collagen to resist tension but is metabolically active in the formation of cartilage. Therefore, the healing response may lead to calcified cartilage and eventual bone formation. There is a rich pattern of sensory innervation within the plantar fascia that includes the tissue near the attachment to the calcaneus. This may explain why repair processes beneath the heel are so painful.

Plantar fascia pain may be due to long-term damage with incomplete repair leading to an endless cycle of reparative attempts by the local tissue. The chemical mediators of inflammation most likely are the proximate cause of pain, thus the pain-relieving effects of anti-inflammatory medication reported in clinical experience. The actual repair of torn collagen fibers may be impaired by the mechanical demands of the plantar fascia with repetitive high loading in both tension and compression.

Another process affecting the fascia from within is myxoid degeneration and replacement of normal matrix with abnormal substances that are mechanically inefficient. Spontaneous rupture of all or part of the fascia may occur in extremely high-load situations, and the natural healing of torn fascia often is complicated by painful scar formation.

Frequency

United States

The prevalence of heel pain, particularly plantar fasciitis, has not been reported, and the incidence cannot be determined at present. No epidemiologic surveys have been taken for this condition. The general consensus from the orthopedic, podiatric, and general medicine literature is that plantar fasciitis is a common condition in adults older than 40 years.

Mortality/Morbidity

Morbidity associated with plantar fasciitis primarily is the pain of weightbearing activity. Patients who rupture the fascia acquire a characteristic foot deformity that is similar to pes planus: collapse of the longitudinal arch, valgus of the calcaneus, and abduction of the forefoot. The collapsed foot may require custom insole orthotics and accommodative shoes or corrective surgery to realign and fuse the hindfoot.

The morbidity of surgery includes the same collapse of the foot due to the intentional disruption of the plantar fascia. Surgical morbidity may add considerable impairment if a calcaneal nerve branch is injured. Work activity and many daily living activities may be limited by the degree of plantar heel pain.

Mortality data from this condition are not available, though of itself, plantar fasciitis is not a lethal condition. The notable exception is the rare soft-tissue sarcoma in the foot, as when fibrosarcoma of the plantar fascia is the pathological condition. An estimated 30 such sarcomas of the foot are reported annually in the United States. Due to the delay in diagnosis of most soft-tissue sarcomas of the foot, the 5-year survival rate is less than 10%.

Race

Differences based on race have not been reported, but risk factors have been identified.

Sex

Differences based on sex have not been reported, but risk factors have been identified.

Age

As mentioned, plantar fasciitis is a common condition in adults who are middle aged and older. This may be the result of decreased elasticity and subsequent tearing or a diminished healing response.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Clinically diagnosing plantar fasciitis is easier than determining the various possible causes. Patients complain of pain underneath the heel that is most pronounced on first arising in the morning or after a period of nonweightbearing activity. The pain often is described as a searing or tearing of the tissues under the heel and often improves with further activity, only to recur following continued or prolonged weightbearing activity. Delays in symptoms are common. Therefore, when pain occurs the morning following physically stressful activity, the patient and physician may overlook strenuous or prolonged weightbearing as a source of the symptoms. Another characteristic of plantar fasciitis is the location of the pain, which usually is at the origin of the plantar fascia from the medial portion of the posterior calcaneus.

• The following specific questions should be asked about the patient's pain:
• • Where is the pain?
  • Is it always in the same place?
  • Is it worse with the first few steps in the morning?
  • Does it go away with rest?
• Pain that is in the same location under the heel that is particularly exquisite with the first steps, that is relieved by rest, and that does not radiate into the leg and forefoot is very likely to be caused by plantar fasciitis.

Physical

Diagnosis of plantar fasciitis is confirmed by focal tenderness near the origin of the plantar fascia that often is aggravated by stretching the fascia. On physical examination, heel pain may be reproduced through simultaneous passive dorsiflexion of the toes and ankle. Occasionally, pain radiates along the plantar fascia toward the toes when a tender area is squeezed, and pain may expand to the lateral side of the foot when pressure is applied on the plantar surface of the calcaneus.

Causes

• Clinical risk factors include obesity, repetitive stress activities, and age older than 40 years. Foot biomechanics are implicated, but no proven risk factors exist. Particularly, the cavus foot with the rigid high medial arch and limited heel pronation imparts increased stress within the substance of the plantar fascia. Also at risk is the flexible pes planus with abduction of the forefoot and pronation of the hindfoot causing large tensile strain in the plantar fascia. The Achilles tendon and triceps surae, when contracted, are a source of excessive stress with the plantar fascia.
• Other possible relationships may exist with hard walking surfaces, the presence of a heel spur (osteophyte), height of heel and other shoe properties, and type of employment. To date, plantar fasciitis is not considered a work-related disorder for purposes of compensation.
• Considerable disagreement exists regarding the role of heel spurs and plantar fasciitis. Heel spurs are increasingly prevalent with age. Spurs usually are within the muscles superior to the fascia and are not ossification of the fascia origin. The possibility of spurs causing heel pain indirectly through compression of the nerve to the abductor digiti quinti muscle or through stretching the plantar fascia has implications for surgical treatment of this condition.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Pain beneath the calcaneus may occur from other causes along with plantar fasciitis. Infections, neoplasms, foreign body reactions, inflammatory arthropathies, enthesopathies, and insufficiency fractures of the calcaneus are associated with pain underneath the heel. Bilateral plantar heel pain is reported in less than 30% of cases, and bilateral involvement is associated with systemic disorders of an inflammatory nature. Furthermore, plantar heel pain may be the initial or prodrome of a systemic disorder in as many as 15% of cases, with inflammatory arthritis being the most likely disorder to develop.

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Routine blood or urine evaluation has no proven value in patients with suspected plantar fasciitis.
• Serology for inflammatory conditions such as rheumatoid arthritis or ankylosing spondylitis may be helpful confirmatory studies if those diagnoses are considered. However, human leukocyte antigen (HLA)-B27 is less than 65% sensitive in diagnosing ankylosing spondylitis, and the specificity of the rheumatoid factor is around 50%, thus limiting the value of such tests.
• The possibility of infection may be supported by an elevated white blood cell count, erythrocyte sedimentation rate, and C-reactive protein, but infection cannot be effectively excluded with any group of serologic tests.

Imaging Studies

• Imaging studies are becoming more useful in the diagnosis of plantar fasciitis.
• Plain radiographs should be part of the database for patients with foot problems. The reason for obtaining a radiograph of the foot is to look for causes other than plantar fasciitis that would account for heel pain and for comparison with future radiographs. The lateral radiographic view may reveal an osteophyte, soft-tissue calcification, or stress fracture of the calcaneus, or it may reveal a foreign body or arthrosis of the subtalar joints.
• Ultrasound imaging, magnetic resonance imaging (MRI), and nuclear bone scan all have value in identifying abnormality in the area of concern. If symptoms have been unresponsive to treatment for more than 3 months, MRI of the hindfoot and electrical diagnostic nerve tests are indicated to detect processes such as plantar fascia rupture, muscle inflammation, compression neuropathy, and stress changes in the calcaneus. The application of advanced imaging studies is helpful when the clinical diagnosis is not clearly supportive of plantar fasciitis or when multiple diagnoses are considered.

Histologic Findings

Histologic evidence from surgical specimens indicates that microtearing of the fascia exists along with fibrocyte necrosis, chondroid metaplasia, angiofibroblastic proliferation, and degraded type I collagen fibers. This microscopic evidence is consistent with chronic degenerative change due to repetitive mechanical stress on soft tissue.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

A wide variety of treatments are available for the symptoms of plantar fasciitis. Most cases of heel pain resolve with nonoperative treatments and time. Problems arise when the pain does not significantly diminish within 6 months or when recurrent episodes of worsening pain occur. The medical and orthopedic literature is not very helpful in providing answers to treatment questions. Comparison studies are scarce, and most publications report a single treatment method. Meta-analysis is not feasible because no common methodology is used to study plantar fascia treatment, and statistical analysis within single method studies often are problematic due to the small number of patients monitored throughout the study timeframe.

Though obesity and sedentary lifestyle are reported risk factors, no evidence shows that weight loss improves symptoms. Walking, running, and jumping sports are associated with plantar fasciitis and should not be part of fitness or weight reduction programs in these patients. No known dietary supplement or food is associated with reduced symptoms in patients with heel pain.

Nonoperative treatment is well summarized in a 1997 article by Gill, in which 12 types of treatment are outlined and referenced. His preferred treatment algorithm is based upon the clinician's assessment of pain severity.

• Mild symptoms warrant activity restriction, passive stretching, ice and heat, visco-elastic heel cushions, and oral anti-inflammatory medication. The entire group of nonsteroidal anti-inflammatory medications may be used to relieve pain, while modalities such as stretching exercises and energy-absorbing heel cushions are used to treat the underlying process. Patients should be educated about the natural course of the condition and the importance of decreasing stressful weightbearing activities if symptoms are worsening.
• Patients with moderately painful heels often benefit from the addition of an injection of local anesthetic and soluble corticosteroid in the painful area. Also, a rigid night splint should be worn for several weeks. The night splint may be made of fiberglass and applied with elastic bandages, or prefabricated splints are available commercially. Injections should not be administered directly into the fascia and should not be repeated for a total of more than 3 injections within a period of a few months. If injections and the other modalities are not helpful, Gill recommends a short leg walking cast used for 5-6 weeks. A removable walking brace may substitute for the cast when the patient cannot tolerate a short leg cast.
• Patients whose pain does not respond to nonoperative treatments should be reassessed for the possibility of another diagnosis, especially nerve entrapment. For those in whom a minimum of 6 months of conservative treatment has failed, surgery is the recommendation of the American Orthopaedic Foot and Ankle Society's Position Statement on Endoscopic and Open Heel Surgery. A walking cast is a useful treatment to consider before considering surgery. Further clinical research clearly is needed to improve currently available treatments.

Surgical Care

Endoscopic plantar fascia release currently is a popular procedure with some advantages over conventional surgery, but there are concerns over the safety and efficacy of limited exposure procedures. Open surgical procedures have few safety caveats, but again, the efficacy of these operations has not been convincingly demonstrated over many years of follow-up. The goal of plantar fascia surgery is to relieve pain and to minimize unwanted sequelae, such as painful scar formation and painful pes planus. Open procedures offer more than a means of releasing the fascia; these operations may decompress the local nerve, excise diseased fascia, remove the heel spur, and decompress the underlying calcaneus by drilling cortical holes.

Activity

Walking, running, and jumping sports are associated with plantar fasciitis; restriction of these activities may be necessary.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Drug Category: Nonsteroidal anti-inflammatory drugs

Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known but may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Complications

• Complications following plantar fascia surgery include nerve injury with worsening pain and development of causalgia.
• • The medial and lateral plantar nerves usually are not injured during surgery that exposes the plantar fascia, but the small medial calcaneal nerve branches may be unavoidably injured in the regular course of an operation in this region of the heel. A minor consequence of transecting a calcaneal nerve branch is numbness in a small area of the heel.
  • Wound infection and osteomyelitis are rare complications of plantar fascia surgery.
  • Dividing or removing the entire plantar fascia predisposes the patient to an acquired flatfoot deformity over time, and patients should be instructed to use supportive footwear or an arch support should be prescribed.
  • Postoperative pain may develop along the lateral side of the foot following successful relief of the plantar heel discomfort.

Prognosis

• Conservative treatments are effective in more than 90% of patients with first-time plantar fasciitis, but there is no consensus regarding efficacy of the many treatment choices.

Patient Education

• Patients should be informed that improvement often takes many weeks or months and requires considerable effort to maintain a heel-cord stretching program or to wear a nighttime splint.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Pitfalls in the diagnosis and treatment of painful plantar heel pain pertain to misdiagnosis. Not all plantar heel pain is due to damage of the plantar fascia. A plain radiograph to exclude obvious fracture, calcaneus infection, or foreign body is routinely part of an initial evaluation. Tumor of the bone or soft tissue do occur, and screening blood tests and an MRI plus repeat radiographs are indicated in patients with a change in the shape or appearance of the foot or symptoms that are increasing despite treatment.
• Another concern in the working population pertains to cause and effect. At present, plantar fasciitis is considered a degenerative medical condition and not the result of work-related standing, walking, climbing, or lifting. A blunt or penetrating trauma at work may be the proximate cause of painful plantar fasciitis.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Berkowitz JF, Kier R, Rudicel S. Plantar fasciitis: MR imaging. Radiology. Jun 1991;179(3):665-7. [Medline].
• Daly PJ, Kitaoka HB, Chao EY. Plantar fasciotomy for intractable plantar fasciitis: clinical results and biomechanical evaluation. Foot Ankle. May 1992;13(4):188-95. [Medline].
• Gill LH, Kiebzak GM. Outcome of nonsurgical treatment for plantar fasciitis. Foot Ankle Int. Sep 1996;17(9):527-32. [Medline].
• Gill LH. Plantar Fasciitis: Diagnosis and Conservative Management. J Am Acad Orthop Surg. Mar 1997;5(2):109-117. [Medline].
• Miller RA, Torres J, McGuire M. Efficacy of first-time steroid injection for painful heel syndrome. Foot Ankle Int. Oct 1995;16(10):610-2. [Medline].
• Pfeffer GB. Plantar heel pain. Instr Course Lect. 2001;50:521-31. [Medline].
• Schon LC, Glennon TP, Baxter DE. Heel pain syndrome: electrodiagnostic support for nerve entrapment. Foot Ankle. Mar-Apr 1993;14(3):129-35. [Medline].
• Tisdel CL, Harper MC. Chronic plantar heel pain: treatment with a short leg walking cast. Foot Ankle Int. Jan 1996;17(1):41-2. [Medline].
• Wall JR, Harkness MA, Crawford A. Ultrasound diagnosis of plantar fasciitis. Foot Ankle. Oct 1993;14(8):465-70. [Medline].

Article Last Updated: Oct 1, 2004