Plantar Fasciitis

Summary

  • Microtearing at the origin of the plantar fascia on the heel bone (calcaneus) can occur with repetitive loading. This microtearing leads to an inflammatory response (healing response) which produces the pain.
  • Excessive standing, increased body weight, increasing age, a change in activity level, stiff calf muscle, and flatfeet are risk factors for this condition.
  • Differential diagnoses include overload heel pain syndrome, heel pad atrophy, entrapment of the first branch of the lateral plantar nerve (Baxter’s nerve), tarsal tunnel syndrome, Calcaneal stress fracture, periosteal inflammation, and seronegative arthritis-induced inflammation.

Diagnostic tips

  1. History of pain with the first few steps in the morning (located in the heel and can be sharp).
  2. Pain is often also associated with first steps after periods of inactivity such as sitting (will often improve after some movement or stretching).
  3. Pain can also occur with direct pressure (palpation).
  4. There is often an associated equinus contracture (stiffness) of the calf demonstrated with the knee straight.
  5. Symptoms may also be exacerbated by stretching the plantar fascia by placing the toes in a dorsiflexed position.

Tests and Imaging

  1. Patient’s history and physical examination.
  2. X-ray of weight-bearing (lateral view) foot will often demonstrate a calcaneal heel spur (but some patients do not have).
  3. Ultrasound scan which is helpful in identifying thickening and some tears.
  4. MRI may be ordered to rule out other causes of heel pain such as a calcaneal stress fracture if symptoms fail to resolve after treatment effort.

Immediate Treatment

  1. Activity Modification.
  2. Ice and compression (including massage of the fascia and stretching)
  3. Advise regular daily calf stretching performed over a 6- to 8-week period will alleviate plantar fasciitis.
  4. Prescribe short term use of NSAID’s for acute heel pain only.
  5. Advise weight Loss
  6. Local injection of corticosteroids can be helpful in breaking the cycle of pain.

Possible Referral

  1. Podiatry for biomechanical assessment and appropriate treatment which may include footwear advice, padding, strapping, R.I.C.E.R., orthotics, acupuncture, foot mobilisation and night splints.
  2. Stretching and strengthening exercises are helpful.
  3. PRP (Plasma-Rich Protein) injections can be used to treat recalcitrant plantar fasciitis (very uncomfortable and prone to infections).
  4. Extracorporeal shock wave therapy is building a body of evidence in treating chronic heel pain.
  5. Surgery for patients with persistent symptoms (but is NOT recommended unless a patient has failed a minimum of 6-9 months of appropriate non-operative treatment) to undergo or endoscopic or open partial plantar fasciectomy.

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