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Musculoskeletal System ORGAN SYSTEMS

Plantar fasciitis/fasciosis

Introduction

Overuse injury causing degenerative irritation of the plantar fascia origin at the medial calcaneal tuberosity of the heel as well as the surrounding perifascial structures.

  • M/C type of plantar fascia injury
  • M/C cause of heel pain (80% cases)

Aetiology

Intrinsic risk factors:
Anatomic Obesity
Pes planus (flat feet)
Pes cavus (high-arched feet)
Shortened Achilles tendon
Biomechanic Overpronation (inward roll)
Limited ankle dorsiflexion
Weak intrinsic muscles of the foot
Weak plantar flexor muscles
Extrinsic risk factors:
Environmental Poor biomechanics or alignment
Deconditioning
Hard surface
Walking barefoot
Prolonged weight bearing
Inadequate stretching
Poor footwear

Pathophysiology

Plantar fascia is a thick fibrous aponeurosis that originates at the medial calcaneal tubercle and helps support the arch of the foot.

471px-pf-plantardesigncrop
Planter fascia anatomy | Kosi Gramatikoff – https://en.wikipedia.org/wiki/File:PF-PlantarDesign.jpg, CC0, https://commons.wikimedia.org/w/index.php?curid=40497835

It is thought that repetitive tensile overload from standing for long periods of time or running causes changes in the aponeurosis that can be either acute or chronic.

  • More recently, the term plantar fasciosis has been introduced to de-emphasize the idea that inflammation is the cause of pain.

Histopathology

  • Granulation tissue, micro-tears, collagen disarray, and notably a lack of traditional inflammation

Clinical features

  • Progressive pain (inferior and medial heel):
    • Severe pain in the morning or after a rest period
    • Improves with movement
    • Aggravated by long periods of weight bearing
    • Radiate proximally (severe cases)
  • Signs:
    • Tenderness to palpation over the medical calcaneal tubercle
    • Discomfort with passive dorsiflexion of the first toe

 


Diagnosis

Imaging

X-ray:

  • Calcifications in the soft tissues
  • Heel spurs (inferior aspect of the heel) (50% cases)
623px-projectional_radiography_of_calcaneal_spur
Calcaneal spur (heel spur) is a bony outgrowth from the calcaneal tuberosity (heel bone) | Lucien Monfils – CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=4408603

Ultrasound (USG):

  • Thickening and swelling of the plantar fascia
640px-plantarfascia
Plantarfasciosis (thickened plantar fascia) in ultrasound | Mme Mim – CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=38305075

MRI:

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Sagittal T2-weighted magnetic resonance imaging showing thickening of the plantar fascia (short arrows) and increased signal intensity (long arrow). | Goff, J. D., & Crawford, R. (2011). Diagnosis and treatment of plantar fasciitis. American Family Physician, 84(6), 676–682.

Differential diagnosis

  • Plantar fascia rupture
    • Sudden, acute, knife-like pain, ecchymosis (more proximal) and with palpable gap
    • MRI/USG (confirmatory)
  • Fat pad syndrome (atrophy of heel pad)
    • Pain usually centrally located and no morning pains
    • Common in elderly and diabetics
  • Calcaneal stress fracture
    • Pain with weight-bearing, diffuse heel tenderness
  • Tumour
    • Achy pain, constant, nocturnal, even with no weight bearing and at rest
    • Constitutional symptoms (late onset)
  • Calcaneal bursitis “Policeman’s heel”
    • Burning, aching or throbbing pain, swelling, erythema (posterior heel)
  • Boxter’s nerve entrapment
    • Pain more proxima and dorsal
    • No sensory disturbance
  • Medial calcaneal nerve compression
    • Occurs in tarsal tunnel
    • Postitve Tinnl’s sign
    • Altered sensation of medial side of heel
  • Seronegative arthropathies
    • Bilateral with h/o back pain, urethritis, uveitis, elevated inflammatory markers, etc
  • Spinal stenosis & L5-S1 nerve root irritation

Management

Usually improves within 12 months (80-90% symptoms) regardless of treatment.

Rest and analgesia:

  • Rest, activity modification, ice massage, and acetaminophen or nonsteroidal anti-inflammatory drugs.

Stretching and physical therapy:

Progressive plantar fascia and intrinsic foot muscle stretching techniques have been shown to reduce plantar fasciitis pain.

 

Over-the-counter orthotics (arch supports, heel cups, night splints):

Recommended for persons with plantar fasciitis to aid in preventing overpronation of the foot and to unload tensile forces on the plantar fascia.

 

 

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