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Definition/Description[edit | edit source]
- 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 the diagnosis containing the segment "itis," this condition is notably characterized by an absence of inflammatory cells.
There are many different sources of pain in the plantar heel besides the plantar fascia and therefore the term "Plantar Heel Pain" serves best to include a broader perspective when discussing this and related pathology.
Anatomy[edit | edit source]
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.
- 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[edit | edit source]
This is often an overuse injury that is primarily due to a 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 which contribute to plantar heel pain including but not limited too:
- Loss of ankle dorsiflexion (talocrural joint, deep or superficial posterior compartment)
- 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 > kg/m2
- Diabetes Mellitus (and/or other metabolic condition)
- Leg length discrepancy
- Tightness and/or weakness of Gastrocnemius, Soleus, Tendoachilles tendon and intrinsic muscle.
Epidemiology[edit | edit source]
Plantar fasciitis is the most common cause of heel pain presenting in the outpatient setting.
- The exact incidence and prevalence of plantar fasciitis by age are unknown.
- Accounts for about 10% of runner-related injuries (Some literature shows prevalence rates among a population of runners to be as high as 22%)
- Thought to occur in about 10% of the general population
- 83% of these patients being active working adults between the ages of 25 and 65 years old
- 11% to 15% of all foot symptoms requiring 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 the plantar heel 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 orthopedic 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.
Diagnostic Procedures[edit | edit source]
Plantar fasciitis is a clinical diagnosis. It is based on patient history and physical exam.
- Patients can have local point tenderness along the antero-medial of the calcaneum, pain on the first steps, or after training.
- Plantar facia 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.
- The 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 studies like radiographs, diagnostic ultrasound, and MRI.
Characteristics/Clinical Presentation[edit | edit source]
- 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
Examination[edit | edit source]
Take into consideration a patient's medical history, physical activity, and foot pain symptoms.
Look for the following
- Pain 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 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 client plantar fascia problems) or predisposing factors mentioned previously.
- Work-related weight-bearing
Medical Management[edit | edit source]
Conservative measures are the first choice
- Relative rest from offending activity as guided by the level of pain 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
- More advanced or invasive techniques may be tried eg extracorporeal shock-wave therapy , botulinum toxin A, autologous platelet-rich plasma, dextrose prolotherapy, or steroid injections.
- 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[edit | edit source]
The condition can be disabling if not appropriately managed.
An important tool is the education of the patient
- Patients need to be told that the symptoms may take weeks or even months to improve (depending on circumstances of injury).
- To follow the advice given eg rest from aggravating activities initially, ice, stretch.
- Be aware of the importance of a home exercise plan
Common treatments include: stretching and strengthening of the gastrocnemius/soleus/plantar fascia; orthotics; ultrasound; iontophoresis; night splints and joint mobilization/manipulation. See the details below.
- Strength Training. 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. Level of evidence 1b. Systematic review suggests there is minimal evidence to support the use of foot muscle training in patients with plantar fasciitis.
- Stretching consists of the patient crossing the affected leg over the contralateral leg and using the fingers across to the 1base of the toes to apply pressure into toe extension until a stretch can be felt along the plantar fascia. 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 was then bent, keeping the back knee straight and heel on the ground. The back knee could then be in a flexed position for more of a soleus stretch. Level of evidence 1b. According to the recent systematic review published in Life, stretching interventions seemed to improve in both pain and function over time. A combination of calf and plantar fascia stretches was found to be most effective.
3.Mobilizations and manipulations - decrease pain and relieve symptoms in some cases. eg
- Posterior talocrural joint mobilization and subtalar joint distraction manipulation (for hypomobile talocrural joint)..
- Ankle, subtalar and midfoot joint mobilizations
4. Posterior-night splints maintain ankle dorsiflexion and toe extension, allowing for a constant stretch on the plantar fascia. Some evidence reports night splints to be beneficial but in a review by Cole et al he reported that there was limited evidence to support the use of night splints to treat patients with pain lasting longer than six months, and patients treated with a custom made night splints improved more than prefabricated night splints.
5. Acetic acid iontophoresis combined with taping 
6. Foot orthoses produce small short-term benefits in function and may also produce small reductions in pain for people with plantar fasciitis, but they do not have long-term beneficial effects compared with a sham device whether they are custom made or prefabricated. Level of evidence 1b . When used in conjunction with a stretching program, a prefabricated shoe insert is more likely to produce improvement in symptoms as part of the initial treatment of proximal plantar fasciitis than a custom polypropylene orthotic device . A systematic review suggests the use of insoles may be effective insoles may be a useful treatment however pre-fabricated or custom insoles appear more effective at reducing pain and improving function than sham or some models of off the shelf insoles.
7. Taping - eg For an entire week tape placed on the gastrocnemius and the plantar fascia. ,,. According to a systematic review, Low Dye and calcaneal taping are the most commonly used taping techniques; however, they are likely to only offer around a week of pain reduction. A combination of stretching and tapping is more effective than taping alone.
Outcome Measures[edit | edit source]
Differential Diagnosis[edit | edit source]
- Neurological - abductor digiti quinti nerve entrapment, lumbar spine disorders, problems with 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, tumors (rare), vascular insufficiency, Rheumatoid arthritis
Concluding Comments[edit | edit source]
- Thorough patient education needed.
- Usually a self-limited 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.
References[edit | edit source]
- Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003;93(3):234–7.
- Buchanan BK, Kushner D. Plantar fasciitis.Available from:https://www.ncbi.nlm.nih.gov/books/NBK431073/ (last accessed 22.6.2020)
- Carlson RE, Fleming LL, Hutton WC. The biomechanical relationship between the tendoachilles, plantar fascia and metatarsophalangeal joint dorsiflexion angle. Foot ankle Int / Am Orthop Foot Ankle Soc [and] Swiss Foot Ankle Soc. 2000;21(1):18–25.
- Stecco C, Corradin M, Macchi V, et al. Plantar fascia anatomy and its relationship with Achilles tendon and paratenon. J Anat. 2013;223(August):1–12. doi:10.1111/joa.12111.
- Gefen A, Megido-Ravid M, Itzchak Y. In vivo biomechanical behavior of the human heel pad during the stance phase of gait. J Biomech. 2001;34:1661–1665. doi:10.1016/S0021-9290(01)00143-9
- Tweed JL, Barnes MR, Allen MJ, Campbell J a. Biomechanical consequences of total plantar fasciotomy: a review of the literature. J Am Podiatr Med Assoc. 2009;99(5):422–30.
- Cheung JT-M, An K-N, Zhang M. Consequences of partial and total plantar fascia release: a finite element study. Foot ankle Int / Am Orthop Foot Ankle Soc [and] Swiss Foot Ankle Soc. 2006;27(2):125–32. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16487466.
- Crary JL, Hollis JM, Manoli A. The effect of plantar fascia release on strain in the spring and long plantar ligaments. Foot ankle Int / Am Orthop Foot Ankle Soc [and] Swiss Foot Ankle Soc. 2003;24(3):245–50
- Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. Journal of the American Podiatric Medical Association. 2003 May;93(3):234-7.
- McPoil TG, Martin RL, Cornwall MW, Wukich DK, Irrgang JJ, Godges JJ. Heel pain--plantar fasciitis: clinical practice guildelines linked to the international classification of function, disability, and health from the orthopaedic section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38(4):A1–A18. doi:10.2519/jospt.2008.0302.
- Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for Plantar fasciitis: a matched case-control study. J Bone Joint Surg Am. 2003;85-A(5):872–7
- Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg. 2010;49(3 Suppl):S1–19. doi:10.1053/j.jfas.2010.01.001
- Lopes AD, Hespanhol Júnior LC, Yeung SS, Costa LOP. What are the main running-related musculoskeletal injuries? A Systematic Review. Sports Med. 2012;42(10):891–905. doi:10.2165/11631170-000000000-00000.
- 2002 Podiatric Practice Survey. Statistical results. J Am Podiatr Med Assoc. 2003;93(1):67–86. Available at: http://www.ncbi.nlm.nih.gov/pubmed/12533562.
- Rhim HC, Kwon J, Park J, Borg-Stein J, Tenforde AS. A Systematic Review of Systematic Reviews on the Epidemiology, Evaluation, and Treatment of Plantar Fasciitis. Life. 2021 Dec;11(12):1287.
- Rathleff, M.S., Mølgaard, C.M., Fredberg, U., Kaalund, S., Andersen, K.B., Jensen, T.T., Aaskov, S. and Olesen, J.L., 2015. High‐load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12‐month follow‐up. Scandinavian journal of medicine & science in sports, 25(3). (level of evidence: 1b)
- DioGiovanni BF, Nawoczenski DA, Lintal ME et al. Tissue-specific plantar fascia-stretching exercise enhance outcomes in patients with chronic heel pain. Journal of Bone and Joint Surgery. 2003;85-A:1270-1277. (level of evidence: 1b)
- Young B, Walker MJ, Strunce J et al. A combined treatment approach emphasizing impairment-based manual physical therapy for plantar heal pain: a case series. JOSPT. 2004;34:725-733. (level of evidence: 4)
- Anat Shashua, Shlomo Flechter, Liat Avidan, Dani Ofir, Alex Melayev, Leonid Kalichman. The Effect of Additional Ankle and Midfoot Mobilizations on Plantar Fasciitis: A Randomized Controlled Trial. Journal of Orthopaedic & Sports Physical Therapy. 2015, Vol. 45, 265–272. (level of evidence: 1b)
- Cole C, Seto C, Gazewood J. Plantar fasciitis: evidence-based review of diagnosis and therapy. Am Fam Physician. 2005 Dec 1;72(11):2237-42.(level of evidence: 1a)
- Osborne HR, Allison GT. Treatment of plantar fasciitis by LowDye taping and iontophoresis: short term results of a double blinded, randomised, placebo controlled clinical trial of dexamethasone and acetic acid. Br J Sports Med. 2006 Jun;40(6):545-9; discussion 549. Epub 2006 Feb 17. (level of evidence: 1b)
- Landorf KB, Keenan AM, Herbert RD. Effectiveness of foot orthoses to treat plantar fasciitis: a randomized trial. Arch Intern Med. 2006 Jun 26;166(12):1305-10. (level of evidence: 1b)
- Pfeffer G, Bacchetti P, Deland J et al. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int. 1999 Apr;20(4):214-21. (level of evidence: 2b)
- Chien-Tsung Tsai et al., Effects of Short-Term Treatment with kinesiotaping for Plantar fasciitis, Journal of Musculoskeletal Pain, March 2010, Vol. 18, No. 1, Pages 71-80. (level of evidence: 2b)
- Lori. A. Bolgla – Terry R. Malone, Plantar fasciitis and the Windlass mechanism, Journal of Athletic Training. 2004 (Jan- Mar); 39(1): 77-82 (Level of evidence: 2a)
- Alexander T. M. van de Water, Caroline M. Speksnijder, Efficacy of taping for the treatment of plantar fasciosis: a systematic review, Journal of the American Podiatric Medical Association, 2010; 1: 41-51. (level of evidence: 1a)
- Morrissey D, Cotchett M, J'Bari AS, Prior T, Griffiths IB, Rathleff MS, Gulle H, Vicenzino B, Barton CJ. Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values. British journal of sports medicine. 2021 Oct 1;55(19):1106-18.