> Table of Contents > Plantar Fasciitis
Plantar Fasciitis
Alan J. Williamson, MD, Lr Col, USAF, MC
Amber C. Taylor, MD
image BASICS
DESCRIPTION
  • Degenerative change of plantar fascia at origin on medial tuberosity of calcaneus
  • Pain on plantar surface, usually at calcaneal insertion of plantar fascia upon weight bearing, especially in morning or on initiation of walking after prolonged rest
EPIDEMIOLOGY
Prevalence
  • Lifetime: 10-15% of population
  • Data suggest persistence with BMI >30.
  • Condition is typically self-limiting, resolving within 10 months.
ETIOLOGY AND PATHOPHYSIOLOGY
  • Repetitive microtrauma and collagen degeneration of plantar fascia
  • Chronic degenerative change (-osis/-opathy rather than -itis) of plantar fascia generally at insertion on medial tuberosity of calcaneus
RISK FACTORS
  • Dancers, runners, court sport athletes
  • Obesity (BMI >30)
  • Pes planus (flat feet), pes cavus (high arch), overpronation, leg length discrepancy
  • Occupations with prolonged standing, especially on hard surfaces (nurses, letter carriers, warehouse/factory workers)
  • Female, pregnancy
  • Age (>40 to 60 years)
  • Hamstring, calf tightness
  • Decreased ankle range of motion in dorsiflexion (tight heel cord; <15 degrees of dorsiflexion)
  • Systemic connective tissue disorders
GENERAL PREVENTION
  • Maintain normal body weight.
  • Avoid prolonged standing on bare feet, sandals, or slippers.
  • Avoid training errors (increasing intensity, distance, duration, and frequency of high-impact activities too rapidly).
  • Proper footwear (appropriate cushioning and arch support)
  • Runners should replace footwear after every 250 to 500 miles.
  • Avoid overtraining.
COMMONLY ASSOCIATED CONDITIONS
  • Usually isolated
  • Heel spurs common but not a marker of severity
  • Posterior tibial neuropathy
image DIAGNOSIS
PHYSICAL EXAM
  • Point tenderness on medial tuberosity of calcaneus at insertion of plantar fascia
  • Pain along plantar fascia with dorsiflexion of foot
  • Windlass test: pain with passive dorsiflexion of the toes; high specificity, low sensitivity; sensitivity improves (13.5→31.8%) if performed while standing.
  • Decreased passive range of motion with dorsiflexion
  • Evaluate for pes planus, pes cavus, and overpronation.
  • Loss of heel fat pad suggests heel fat pad syndrome.
  • Point tenderness on posterosuperior aspect of heel suggests Achilles tendinopathy.
DIFFERENTIAL DIAGNOSIS
  • Calcaneal stress fracture
  • Heel fat pad syndrome (painful or atrophic heel pad)
  • Longitudinal arch strain
  • Nerve entrapment (posterior tibial nerve—tarsal tunnel syndrome, medial calcaneal branch of posterior tibial nerve, abductor digiti quinti)
  • Achilles tendinopathy
  • Calcaneal contusion
  • Plantar calcaneal bursitis
  • Tendonitis of posterior tibialis
  • Plantar fascia tear
  • Calcaneal apophysitis (Sever disease)—adolescents
DIAGNOSTIC TESTS & INTERPRETATION
  • None necessary; typically a clinical diagnosis
  • Consider further imaging only if diagnosis is in question.
  • Two radiographic views of foot can rule out fracture, tumor, cyst, periostitis, bony erosions; weightbearing films preferred
  • Ultrasound: hypoechoic at insertion, thickened plantar fascia (≥4 mm)
  • MRI can evaluate for other soft tissue etiologies.
  • CT or technetium-99 bone scan can rule out calcaneal stress fracture and evaluate for infection.
  • Nerve conduction studies can rule out nerve entrapment.
image TREATMENT
Nonoperative management is mainstay of treatment.
GENERAL MEASURES
  • Supportive footwear with stable midfoot; avoid sandals or walking barefoot.
  • Relative rest/activity modification
  • Stretching: plantar fascial stretches more effective than Achilles tendon/gastrocnemius-soleus stretches
  • Weight reduction if BMI >25
  • Orthotics
    • Custom orthotics show no benefit over prefabricated orthotics and are more costly.
    • Improved effectiveness of night splints when used in association with orthotics.
  • Strengthen calf and interosseous muscles, using the towel drag/pick-up exercise
  • Night splints: can be uncomfortable for the first few nights but generally become less bothersome with time; especially effective with calf and Achilles tightness
  • Ice (frozen water bottle roll)
  • Massage (golf or tennis ball roll)
MEDICATION
First Line
Adjunct to control pain
  • NSAIDs: naproxen 500 mg PO BID or ibuprofen 600 to 800 mg PO TID PRN for pain
  • Acetaminophen 1,000 mg PO TID PRN for pain
Second Line
None
ISSUES FOR REFERRAL
  • Podiatry, surgery: Consider referral if conservative measures fail after 3 to 6 months.
  • Consider physical therapy for patient instruction on proper stretching and strengthening techniques.
ADDITIONAL THERAPIES
  • Corticosteroid injections (1)[A]
    • Short-term pain relief for up to one month, benefit fades with time
    • Recommend ultrasound guidance when possible.
    • Risk for plantar fascial rupture and calcaneal fat pad atrophy with resultant permanent heel pain
    • Can cause injection and postinjection pain for up to 5 to 7 days
  • Extracorporeal shock wave therapy (ESWT) (2,3)[B]
    • Growing body of evidence showing benefit
    • Multiple meta-analyses and systematic reviews show level I evidence of benefit; mixed recommendations on low- versus high-intensity ESWT.
    • Uncomfortable to patients but less risk than injection or surgery
    • Consider prior to surgery and (possibly) prior to steroid injection.
    • Delivery not yet standardized
  • P.807

  • Low-dye and calcaneal taping
    • Limited, short-term evidence
    • Less effective in severe cases
  • Promising therapies with inconsistent supporting evidence
    • Platelet-rich plasma injections (4)[B]: A systematic review demonstrated PRP improved baseline symptoms and was comparable to prolotherapy and better than corticosteroid injections in the short and long term (up to 12 months).
    • Prolotherapy (4)[B]: Comparable in efficacy to PRP for treatment of baseline symptoms, better than corticosteroid injections.
    • Low-level laser therapy
    • Botulinum toxin (BT) A injection (5)[B]
      • RCT comparing steroid injection to BT injection showed similar results in pain reduction and other measures of foot function at 1 month; improvements in these areas persisted at 6 months more so with BT than with steroid injection.
      • Randomized, multicenter, double-blind, placebo-controlled study comparing BT injection to placebo showed no statistical difference in pain and global assessment.
    • Radiofrequency nerve ablation (6)[B]: Prospective, RCT with sham treatment and crossover demonstrated efficacy; also, retrospective case series demonstrated benefit at 1 and 2 years after treatment.
    • Myofascial trigger point manual therapy
    • Intralesional autologous blood injection
    • Plantar iontophoresis
SURGERY/OTHER PROCEDURES
  • Necessary in <10% of patients
  • Recommended if conservative treatment fails after 6 to 12 months and pain is unrelenting.
  • Open/endoscopic plantar fasciotomy (less risk and complications with endoscopic technique but requires specialized equipment and skills; is not widely used)
  • Calcaneal spur resection
  • More likely beneficial in severely obese
  • No RCTs support surgery
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Heel cup with magnet has proven ineffective.
  • Acupuncture shows limited benefit in a few studies.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
  • Ensure patient adherence to proper stretching technique.
  • Following 3 to 6 months of unsuccessful conservative treatment, consider additional therapies or referrals.
PATIENT EDUCATION
  • Weight reduction if BMI >25
  • Proper footwear (adequate cushion and arch support)
  • Stretch plantar fascia: Pull toes into dorsiflexion prior to walking after prolonged sitting or sleep
  • Ice the foot using a frozen water bottle: Roll foot over bottle for 10 minutes in the morning and after work.
  • Massage plantar fascia: Roll foot over a golf ball.
  • Strengthen foot muscles: Grab cloth or carpet by plantar flexing the toes.
  • Decrease repetitive stress.
PROGNOSIS
  • Generally good
  • Self-limited (resolves within 2 years) in up to 85-90% of patients
REFERENCES
1. Li Z, Yu A, Qi B, et al. Corticosteroid versus placebo injection for plantar fasciitis: a meta-analysis of randomized controlled trials. Exp Ther Med. 2015;9(6):2263-2268.
2. Yin MC, Ye J, Yao M, et al. Is extracorporeal shock wave therapy clinical efficacy for relief of chronic, recalcitrant plantar fasciitis? A systematic review and meta-analysis of randomized placebo or active-treatment controlled trials. Arch Phys Med Rehabil. 2014;95(8):1585-1593.
3. Speed C. A systematic review of shockwave therapies in soft tissue conditions: focusing on the evidence. Br J Sports Med. 2014;48(21):1538-1542. doi:10.1136/bjsports-2012-091961.
4. Franceschi F, Papalia R, Franceschetti E, et al. Platelet-rich plasma injections for chronic plantar fasciopathy: a systematic review. Br Med Bull. 2014;112(1):83-95.
5. Jabbari B, Machado D. Treatment of refractory pain with botulinum toxins—an evidence-based review. Pain Med. 2011;12(11):1594-1606.
6. Landsman AS, Catanese DJ, Wiener SN, et al. A prospective, randomized, double-blinded study with crossover to determine the efficacy of radiofrequency nerve ablation for the treatment of heel pain. J Am Podiatr Med Assoc. 2013;103(1):8-15.
Additional Reading
&NA;
  • Akşahin E, Doğruyol D, Yüksel HY, et al. The comparison of the effect of corticosteroids and platelet-rich plasma (PRP) for the treatment of plantar fasciitis. Arch Orthop Trauma Surg. 2012;132(6):781-785.
  • Aqil A, Siddiqui MR, Solan M, et al. Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: a meta-analysis of RCTs. Clin Orthop Relat Res. 2013;471(11):3645-3652.
  • Chang KV, Chen SY, Chen WS, et al. Comparative effectiveness of focused shock wave therapy of different intensity levels and radial shock wave therapy for treating plantar fasciitis: a systematic review and network meta-analysis. Arch Phys Med Rehabil. 2012;93(7):1259-1268.
  • Crawford F, Thomson CE. WITHDRAWN. Interventions for treating plantar heel pain. Cochrane Database Syst Rev. 2010;(1):CD000416.
  • Erken HY, Ayanoglu S, Akmaz I, et al. Prospective study of percutaneous radiofrequency nerve ablation for chronic plantar fasciitis. Foot Ankle Int. 2014;35(2):95-103.
  • Goff JD, Crawford R. Diagnosis and treatment of plantar fasciitis. Am Fam Physician. 2011;84(6):676-682.
  • Hawke F, Burns J, Radford JA, et al. Custom-made foot orthoses for the treatment of foot pain. Cochrane Database Syst Rev. 2008;(3):CD006801.
  • Healey K, Chen K. Plantar fasciitis: current diagnostic modalities and treatments. Clin Podiatr Med Surg. 2010;27(3):369-380.
  • Huang YC, Wei SH, Wang HK, et al. Ultrasonographic guided botulinum toxin type A treatment for plantar fasciitis: an outcome-based investigation for treating pain and gait changes. J Rehabil Med. 2010;42(2):136-140.
  • Jastifer JR, Catena F, Doty JF, et al. Low-level laser therapy for the treatment of chronic plantar fasciitis: a prospective study. Foot Ankle Int. 2014;35(6):566-571.
  • Monto RR. Platelet-rich plasma efficacy versus corticosteroid injection treatment for chronic severe plantar fasciitis. Foot Ankle Int. 2014;35(4): 313-318.
  • Peterlein CD, Funk JF, Hölscher A, et al. Is botulinum toxin A effective for the treatment of plantar fasciitis? Clin J Pain. 2012;28(6):527-533.
  • Ragab EM, Othman AM. Platelets rich plasma for treatment of chronic plantar fasciitis. Arch Orthop Trauma Surg. 2012;132(8):1065-1070.
  • Uden H, Boesch E, Kumar S. Plantar fasciitis—to jab or to support? A systematic review of the current best evidence. J Multidiscip Healthc. 2011;4: 155-164.
See Also
&NA;
Algorithm: Heel Pain
Codes
&NA;
ICD10
M72.2 Plantar fascial fibromatosis
Clinical Pearls
&NA;
  • Plantar fasciitis is due to degeneration of plantar fascia at origin (medial calcaneal tuberosity) with characteristic pattern of pain.
  • Pain with weight bearing (especially first few steps in the morning or after prolonged rest) is hallmark presentation.
  • Conservative treatment is preferred. Wear supportive footwear to avoid excess pronation and provide adequate cushion. Modify activity, stretch plantar fascia, ice (water bottle roll), massage (golf ball roll), and provide arch support.