Plantar Fasciitis: Time Wounds All Heels…

Case

You are seeing a 27yo patient who presents with left foot pain. He reports 5 days of pain, specifically pointing to the posterior plantar aspect of the left foot, and also at his left heel at and above the calcaneus. No known trauma. He says that the pain is especially bad when he takes his first steps after awakening each morning.  

He has a history of T2NIDDM, obesity, tobacco use disorder, alcohol use disorder, and depression. He works as a landscaper and is on his feet all day. 

On exam, there is tenderness at the proximal plantar fascial insertion at the anteromedial calcaneus. 

Diagnosis: plantar fasciitis


Quick facts!

Plantar fasciitis is the most common cause of heel pain in adults!

  • 1 million patient visits/year
  • 10% lifetime risk
  • Increased incidence in women 40-60 yo
  • Common in many sports but running is the most common associated activity (affects 5-10% of recreational and elite runners)

Anatomy: 

  • The deep plantar fascia (plantar aponeurosis) is a thick, pearly-white tissue with longitudinal fibers intimately attached to the skin. It extends from the posteromedial calcaneal tuberosity and inserts into each metatarsal head.

Misnomer?

  • Plantar fasciitis is an overuse condition rather than an inflammatory condition (i.e., a better name might be “plantar fasciopathy”)
  • Myxoid degeneration with fragmentation and degeneration of the plantar fascia and bone marrow vascular ectasia (dilation)

Risk factors:

  • Limited ankle dorsiflexion
  • BMI >27
  • Standing for prolonged periods of time
  • Excessive running
  • Pes cavus (high arch)
  • Pes planus (excessive foot pronation)
  • Sedentary lifestyle

Diagnosis

Plantar fasciitis is a clinical diagnosis. 

Key history:

  • Sharp pain in the anteromedial aspect of the heel
  • Pain begins with ambulation after period of inactivity and improves as activity continues
  • Pain can be especially bad with the first steps after awakening
  • Pain returns at the end of the day
  • Often starts after an increase in weight-bearing activity

Exam: 

  • Tenderness at the proximal plantar fascial insertion at the anteromedial calcaneus

Clinical pearl: The Windlass test has 100% specificity for plantar fasciitis.

  • Place head of metatarsal at edge of stool with weight on leg while stabilising the foot, then passively dorsiflex the great toe. A positive result is heel pain reproduced by forced dorsiflexion of the toes at the metatarsophalangeal joints with the ankle stabilized.

Imaging

Typically not necessary, but should be considered in the presence of atypical symptoms/exam or symptoms that persist >3 months despite usual therapy. 

  • US shows plantar fascia thickness >4 mm and reduced echogenicity of the plantar fascia.
  • MRI can rule out plantar fascia tears or calcaneal stress fracture. MRI also can show increased plantar fascia thickness and signal intensity.
Source: UpToDate

Clinical pearl: Patients with chronic heel pain often have calcaneal bone spurs on XR imaging. The presence of spurs does not affect treatment approach, and spurs will persist even after symptoms resolve. 


Treatment

The American College of Foot and Ankle Surgeons recommends tailoring treatment to the patient’s symptoms, lifestyle, and activity level rather than following a treatment ladder because most treatment modalities are not supported by sufficient evidence, but most are clinically successful when used.

Mainstays of treatment: 

  • Stretching
  • Icing
  • Massage
  • NSAIDs

Stretching:

  • Plantar fascia-specific stretching may be better than Achilles tendon stretching, although both are effective. 

Other therapies:

  • Night splints (not shown to be better than placebo)
    • Holds the ankle in neutral or dorsiflexed position during sleep to prevent contracture of the gastrocnemius-soleus complex
  • Orthotics (may help with short-term use over 7-12 weeks but not longer)
    • All studies showed that customized orthotics had no benefit over prefabricated orthotics
  • Taping
    • Low-dye taping for people with excessive pronation reduces pain at 1 week but less helpful after that
  • Dry needling / acupuncture
    • A thin needle is inserted into a myofascial trigger point, which alters the biochemical environment and local blood flow, decreasing pain
  • Injections
    • Steroid injections may provide relief, but risks include fascia rupture (2.4% of patients after multiple injections) and fat pad atrophy
    • Injections of platelet-rich plasma or whole blood may potentially stimulate tissue regeneration, but little evidence 
    • Botox injections may be more effective than steroid injections
  • Extracorporeal shock wave therapy
    • Shock waves may stimulate healing by vibration, which stimulates circulation
    • Thought to stimulate neovascularization, increase growth factors, and destroy unmyelinated nerve fibers (substance P fibers)
  • Surgery
    • Effective, but multiple risks including arch destabilization, midfoot pain, heel pain, and loss of arch height

DDx

Neurological: 

  • Nerve entrapment or compression
  • Neuropathic pain
  • S1 radiculopathy

Soft tissue: 

  • Achilles tendinopathy
  • Tendinitis of posterior tibialis / flexum digitorum longus
  • Fat pad atrophy
  • Painful heel pad syndrome
  • Plantar fascia rupture
  • Piezogenic papule (herniations of fat with painful papule at the medial-inferior border of the heel)

Skeletal

  • Calcaneal stress fracture
  • Bony contusion
  • Osteomyelitis
  • Neoplasm
  • Haglund’s syndrome (enlarged bony calcanea tubercle compressing soft tissue)

Inflammatory

  • Reactive arthritis and other spondyloarthritides
  • Sarcoidosis

Take-home points!

  • Plantar fasciitis is common in many sports, especially in runners. 
  • Consider US/MRI imaging if symptoms persist after 3 months of conservative treatment or in presence of an atypical exam. 
  • Tailor treatment to the patient’s symptoms, lifestyle, and activity level. 

Further reading!

  • Trojian T, Tucker A. Plantar Fasciitis. Am Fam Physician 2019 Jun 15;99(12):744-750.
  • Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003;93(3):234–237.
  • Sanzo P, Bauer T. The Effects of Low Dye Taping on Vertical Foot Pressure in Subjects with Plantar Fasciitis, Int J of Prevention and Treatment, Vol. 4 No. 1, 2015, pp. 1-7. doi: 10.5923/j.ijpt.20150401.01.
  • Vahdatpour B, Kianimehr L, Ahrar MH. Autologous platelet-rich plasma compared with whole blood for the treatment of chronic plantar fasciitis; a comparative clinical trial. Adv Biomed Res. 2016;5:84.
  • De Garceau D, Dean D, Requejo SM, Thordarson DB. The association between diagnosis of plantar fasciitis and windlass test results. Foot Ankle Int. 2003;24(3):251–255.
  • Schneider HP, et al. American College of Foot and Ankle Surgeons clinical consensus statement: diagnosis and treatment of adult acquired infracalcaneal heel pain. J Foot Ankle Surg. 2018;57(2):370–381.

Blog post based on Med-Peds Forum talk by Nick Grumbach, MP Core Faculty