Plantar Fasciitis

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Plantar Fasciitis

Plantar fasciitis is the most common cause of chronic heel pain, with a lifetime prevalence of up to 10%.

Anatomy

See also: Foot and Ankle Biomechanics

Plantar fascia

The deep plantar fascia, also known as the plantar aponeurosis, is a thick, pearly-white fibrous tissue with longitudinally oriented fibres that are intimately attached to the skin. The thickest area is found centrally where it attaches to the medial process of the tuberosity of the calcaneal. Distally it divides into separate slips for each of the five toes.

Aetiology

Risk factors are obesity, prolonged standing or jumping, flat feet, reduced ankle dorsiflexion. It can occur in isolation or in conjunction with spondyloarthritis.

Pathophysiology

Unknown, but thought to be a degenerative fasciopathy/enthesopathy.

Epidemiology

Peak incidence is between 40-60 years. There is a younger peak in runners. It is bilateral in up to one third of cases.

Decreased ankle dorsiflexion(running on your forefoot technique) and high body mass index are risk factors for development of plantar fasciitis. (See Foot and Ankle Biomechanics)

Clinical Features

Medial heel pain that is worse in the first few steps in the morning.

Dorsiflex the patients toes to pull the plantar fascia taut, then palpate for tenderness.

Investigations

Ultrasound may show thickened plantar fascia >4mm.

Differential Diagnosis

Differential Diagnosis of Heel Pain

• Plantar Fasciitis
• Fat Pad Contusion
• Calcaneal fractures (traumatic and stress)
• Inferior Calcaneal (Baxter) Nerve Entrapment
• Medial Calcaneal Nerve Entrapment
• Lateral Plantar Nerve Entrapment
• Medial Plantar Nerve Entrapment
• Tarsal Tunnel Syndrome
• Lumbar Radicular Pain
• Talar stress fracture
• Retrocalcaneal bursitis
• Spondyloarthritis
• Osteoid osteoma
• CRPS

Treatment

Calcaneal taping.

First line

Common treatments are manual therapy, exercise, stretching, heel pads, taping, orthotics, night splints, education, activity modification, NSAIDs, and weight loss.

Shoe inserts: Felt pads or rubber heel cups seem to be less effective than silicone inserts.

Mulligan calcaneal taping: The patient is seated on the bed with the foot hanging down and the hip is in abduction and external rotation. The ankle is relaxed. Two layers are applied, an under-wrap and a brown rigid over-wrap. Apply the tape diagonally on the lateral surface of the calcaneum. Hold the calcaneum in external rotation and adduction. Pull the tape around the ankle medially and around superior to the Achilles tendon while sustaining the glide.

Second line

Second line treatments include extracorporeal shockwave therapy (ESWT), corticosteroid injection, PRP injection, dextrose prolotherapy, and fasciotomy.

Dextrose prolotherapy: In a systematic review of 8 studies (2 RCTs, 444 patients total), dextrose prolotherapy was found to be more effective than exercise and normal saline injection, however better quality studies are needed. In the 2 RCTs dextrose prolotherapy showed no significant difference to other treatments after 6 months. The concentrations used were 13.5-20% but one study used 1.5%. Generally 2-3 injections were given in intervals of 1-3 weeks.

Resources

Evaluation and Treatment of Chronic Plantar Fasciitis - Latt 2020 - 819 KB (f)

Literature Review

Literature Review

Reviews from the last 7 years: review articles, free review articles, systematic reviews, meta-analyses, NCBI Bookshelf

Articles from all years: PubMed search, Google Scholar search.

TRIP Database: clinical publications about evidence-based medicine.

Other Wikis: Radiopaedia, Wikipedia Search, Wikipedia I Feel Lucky, Orthobullets,