Plantar Fasciitis

Original Editor - Brooke Kennedy

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Introduction

Plantar fasciitis (Currently better referred to as Plantar Heel Pain) is the result of collagen degeneration of the plantar fascia at the origin, the calcaneal tuberosity of the heel as well as the surrounding perifascial structures.

• The plantar fascia plays an important role in the normal biomechanics of the foot.
• The fascia itself is important in providing support for the arch and providing shock absorption.
• Despite containing "itis," this condition is characterized by an absence of inflammatory cells, hence it is considered degenerative, and not an inflammatory pathology. As such, “fasciosis” or “fasciopathy” are increasingly used to refer to this condition.

The pathology is characterized by medial heel pain that worsens with weight-bearing, as well as after rest or non-weight bearing. Plantar fasciitis often presents chronically with symptoms lasting over a year in duration.

There are many different sources of pain in the plantar heel beside the plantar fascia and therefore the term "Plantar Heel Pain" serves best to include a broader perspective when discussing this and related pathology.

Clinically Relevant Anatomy

The plantar fascia

• Comprised of white longitudinally organized fibrous connective tissue which originates on the periosteum of the medial calcaneal tubercle, where it is thinner but it extends into a thicker central portion.

• The thicker central portion of the plantar fascia then extends into five bands surrounding the flexor tendons as it passes all 5 metatarsal heads. 
• Pain in the plantar fascia can be insertional and/or non-insertional and may involve the larger central band, but may also include the medial and lateral band of the plantar fascia.
• Blends with the paratenon of the Achilles tendon, the intrinsic foot musculature, skin, and subcutaneous tissue.
• This thick elastic multilobular fat pad is responsible for absorbing up to 110% of body weight during walking and 250% during running and deforms most during barefoot walking vs. shod walking.

During weight-bearing:

• Tibia loads the foot “truss” and creates tension through the plantar fascia (windlass mechanism see R).
• The tension created in the plantar fascia adds critical stability to a loaded foot with minimal muscle activity. 
  

Etiology

Often presents as an overuse injury, primarily due to repetitive strain causing micro-tears of the plantar fascia but can occur as a result of trauma or other multifactorial causes.

There are many risk factors for plantar heel pain including but not limited too: 

• Reduced dorsiflexion and first metatarsophalangeal joint extension are weakly associated
• Increased plantar flexion range
• Pes cavus or pes planus deformities
• Excessive foot pronation dynamically
• Impact/weight-bearing activities such as prolonged standing, running, etc
• Improper shoe fit
• Elevated BMI
  • In the athletic population, BMI is not associated with increased plantar fasciitis risk, however, evidence suggests BMI is associated with increased risk in the non-athletic population. There is some evidence that weight loss could possibly reduce foot pain.
• Presence of a sub calcaneal spur
• Diabetes Mellitus (and/or other metabolic condition)
• Leg length discrepancy
• Tightness and/or weakness of Gastrocnemius, Soleus, Tendoachilles tendon and intrinsic muscle.
• Low-quality evidence suggests an association between weight-bearing activities and plantar fasciitis.

A 2016 systematic review found strong evidence for 3 associations for plantar fasciitis; a thickened plantar fascia, the presence of a sub calcaneal spur, and a high BMI in a non-athletic population.

Epidemiology

Plantar fasciitis is the most common cause of heel pain presenting in the outpatient setting.

• Affects 4% - 7% of the community
• Most prevalent between 40 and 60 years of age and accounts for 15% of foot injuries in the general population.

• Estimated to account for 8% of all running injuries.
• 83% of these patients being active working adults between the ages of 25 and 65 years old
• 11% to 15% of all foot symptoms require professional medical care.
• May present bilaterally in a third of the cases.
• The average plantar heel pain episode lasts longer than 6 months and it affects up to 10-15% of the population.
• Approximately 90% of cases are treated successfully with conservative care..
• Females present with plantar fasciitis slightly more commonly than males.  
• In the US alone, there are estimates that this disorder generates up to 2 million patient visits per year, and account for 1% of all visits to orthopaedic clinics.
• Plantar heel pain is the most common foot condition treated in physical therapy clinics and accounts for up to 40% of all patients being seen in podiatric clinics.

Physical Examination

Plantar fasciitis is a clinical diagnosis. It is based on patient history and physical examination.

• Patients can have local point tenderness along the anteromedial of the calcaneum, pain on the first steps, or after training.
• Plantar fasciitis pain is especially evident upon the dorsiflexion of the patient's pedal phalanges, which further stretches the plantar fascia. Therefore, any activity that would increase the stretch of the plantar fascia, such as walking barefoot without any arch support, climbing stairs, or toe walking can worsen the pain.
• Clinical examination will take into consideration a patient's medical history, physical activity, foot pain symptoms, and more.
• The doctor may decide to use imaging modalities like radiographs, diagnostic ultrasounds, and MRIs.

Look for the following:

• reproduced by palpating the plantar medial calcaneal tubercle at the site of the plantar fascial insertion on the heel bone.
• Pain reproduced with passive dorsiflexion of the foot and toes.
• Windlass Test - Passive dorsiflexion of the first metatarsophalangeal joint (test to provoke symptoms at the plantar fascia by creating maximal stretch), positive test if the pain is reproduced. (shown in 40-second video below)

Secondary findings may include

• Tight Achilles heel cord, pes planus (see R), or pes cavus.
• Altered gait (look for biomechanical factors that may predispose the client to plantar fascia problems) or predisposing factors mentioned previously.
• Obesity
• Work-related weight-bearing

Clinical Presentation

• Heel pain with first steps in the morning or after long periods of non-weight bearing
• Tenderness to the anterior medial heel
• Limited dorsiflexion and tight achilles tendon
• A limp may be present or may have a preference to toe walking
• Pain is usually worse when barefoot on hard surfaces and with stair climbing
• Many patients may have had a sudden increase in their activity level prior to the onset of symptoms

Physical Examination

Take into consideration a patient's medical history, physical activity, and foot pain symptoms.

Diagnostic Procedure

Ultrasonography is the most used imaging modality for this condition, and plantar fascia thickness is most often assessed - meta-analysis showed patients with plantar fasciitis have a plantar fascia 2.16 mm thicker when compared to a control group, and typically had plantar fascia thickness of 4.0 mm and above.

Some evidence suggests that patients with plantar fasciitis have a “softer” plantar fascia, and sonoelastography could detect this - identifying plantar fasciitis in symptomatic patients with normal ultrasound findings.

Medical Management

Conservative measures are the first choice:

• Relative rest from offending activity as guided by pain level should be prescribed.
• Ice after activity as well as oral or topical NSAIDs can be used to help alleviate pain.
• Deep friction massage of the arch and insertion.
• Shoe inserts or orthotics and night splints may be prescribed in conjunction with the above.
• Educate patients on proper stretching and rehab of the: plantar fascia; achilles' tendon; gastrocnemius; and soleus.

If the pain does not respond to conservative measures:

• Corticosteroid injections
  • found to be more effective versus placebo or no treatment, in pain relief at one month, but these effects were not sustained over longer periods. Overall, according to a recent systematic review, they have no significant effect neither on pain or the thickness of plantar fascia.
• Platelet-Rich Plasma (PRP)
• Extracorporeal Shockwave Therapy
  • In three meta-analyses, ESWT showed greater VAS score reduction and over a 60% success rate of reducing heel pain over placebo.
  • A systematic review by Sun et al. found ESWT had higher Roles and Maudsley scores, greater VAS score reduction, decreased return to work time, and fewer complications to other interventions - placebo, ultrasound, and endoscopic plantar fasciotomy
• Needling Therapies
• Low-Level Laser Therapy (LLLT)
• Prolotherapy
• Iontophoresis
• Endoscopic Plantar Fasciotomy
• Important that advanced and invasive techniques be combined with conservative therapies.
• Surgery should be the last option if this process has become chronic and other less invasive therapies have failed

Physical Therapy Management

An important tool is patient education:

• Patients need to be told that symptoms may take weeks or even months to improve (depending on the circumstances of the injury).
• To follow the advice given eg rest from aggravating activities initially, ice, and stretch.
• Be aware of the importance of a home exercise plan

The Clinical Practice Guidelines provide recommended physical therapy interventions based on available evidence. Interventions most recommended include manual therapy, stretching, taping, foot orthoses, and night splints.

1. Manual Therapy should include soft tissue and joint mobilization.
   1. Myofascial release can be helpful in reducing pain.
2. Stretching should include the plantar fascia and gastrocnemius/Soleus complex.
   1. Stretching the plantar fascia consists of the patient crossing the affected leg over the contralateral leg and using the fingers across the base of the toes to apply pressure into the toe extension until a stretch can be felt along the plantar fascia.
   2. Achilles’ tendon stretching can be performed in a standing position with the affected leg placed behind the contralateral leg with the toes pointed forward. The front knee is then bent, keeping the back knee straight and the heel on the ground. The back knee could then be in a flexed position for more of a soleus stretch.
   3. A systematic review found moderate quality evidence favouring plantar fascia-specific stretching (PFSS) over the Achilles tendon or calf stretching (CS) for short-term (< 3 months) pain relief.
3. Taping should prevent pronation.Low dye is the most commonly used taping technique and can improve pain in the short term, yet there is lacking evidence for its long-term effects. A combined approach of taping with stretching may yield better results than stretching alone.
4. Foot orthoses can be prefabricated or custom. They must support the medial longitudinal arch and provide cushioning to the heel.
5. If the patient has pain with initial steps in the morning, a night splint would be beneficial.
   1. Posterior-night splints maintain ankle dorsiflexion and toe extension, allowing for a constant stretch on the plantar fascia

According to the Clinical Practice Guidelines, ultrasound, electrotherapy, and dry needling cannot be recommended. There is some support for low-level laser, phonophoresis with ketoprofen gel, change in footwear, weight loss, therapeutic exercise, and neuromuscular re-education. Meanwhile, shockwave diathermy is considered outside of physiotherapy practice according to the American Physical Therapy Association Clinical Practice Guidelines 2023 review.

1. Footwear should include a rocker-bottom shoe.
2. If weight is a concern, the patient should be referred to a more appropriate healthcare provider for nutritional advice.
3. Therapeutic exercise and neuromuscular re-education should focus on reducing pronation and improving weight distribution in weight bearing.
   1. Similar to tendinopathy management, high-load strength training appears to be effective in the treatment of plantar fasciitis. High-load strength training may aid in a quicker reduction in pain and improvements in function.. The systematic review suggests there is minimal evidence to support the use of foot muscle training in patients with plantar fasciitis.

Plantar fascia stretching video provided by Clinically Relevant

Outcome Measures

• Foot and Ankle Ability Measure
• VAS
• Patient Specific Functional Scale

Differential Diagnosis

• Neurological - abductor digiti quinti nerve entrapment, lumbar spine disorders, problems with the medial calcaneal branch of the posterior tibial nerve, tarsal tunnel syndrome
• Soft tissue - Achilles Tendinopathy, fat pad atrophy, heel contusion, plantar fascia rupture, posterior tibial tendonitis, retrocalcaneal bursitis
• Skeletal - Severs' disease, calcaneal stress fracture, infections, inflammatory arthropathies, subtalar arthritis
• Miscellaneous - metabolic disorders, osteomalacia, Paget's disease, sickle cell disease, tumours (rare), vascular insufficiency, Rheumatoid arthritis

Concluding Comments

• Thorough patient education is needed.

• Usually a self-limiting condition, and with conservative therapy, symptoms are usually resolved within 12 months of initial presentation and often sooner.
• Sometimes more chronic cases of this condition will need additional follow-up to consider more advanced therapies and evaluation of gait and biomechanical factors that can potentially be corrected through gait retraining.
• Corticosteroid injections have been shown to be beneficial in the short term (less than four weeks) but ineffective in the long term.
• Evidence of the efficacy of platelet-rich plasma, dex prolotherapy, and extra-corporeal shockwave therapy is conflicting.

Resources

Clinical practice Guideline (Heel Pain – Plantar Fasciitis: Revision 2023)