Contents
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.
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:
Diagnosis
Imaging
X-ray:
- Calcifications in the soft tissues
- Heel spurs (inferior aspect of the heel) (50% cases)
Ultrasound (USG):
- Thickening and swelling of the plantar fascia
MRI:
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.
