Plantar fasciitis is the most common cause of heel pain. Pain from plantar fasciitis is often most noticeable during the first few steps after getting out of bed in the morning. The plantar fascia is a thick band of tissue in the sole of the foot. 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. Risk factors for plantar fasciitis include: excessive standing, increased body weight, increasing age, a change in activity level, and a stiff calf muscle. Plantar fasciitis can be managed non-operatively in the vast majority of patients. The main components of an effective non-operative treatment program are: calf stretching with the knee straight, plantar fascia stretching, activity modification (to avoid precipitating activities), and comfort shoe wear.
Patients with plantar fasciitis almost universally give a history of pain with the first few steps in the morning. Pain is often also associated with first steps after periods of inactivity, such as sitting for lunch, or after getting out of a car. This pain is located in the heel and can be sharp (Figure 1). It will often improve after some movement or stretching. However, it will tend to recur as the day progresses, particularly if the patient has been doing significant weight-bearing activities, such as walking or standing. Burning pain is not typical of plantar fasciitis, and may suggest nerve irritation as a source of the pain (ex. Baxter’s neurtitis).
Plantar Fasciitis is associated with:
Clinical examination will often localize the pain to the plantar medial heel region. Pain can also occur with direct pressure (palpation). There is often an associated stiffness (equinus contracture) of the calf demonstrated with the knee straight. Symptoms may also be exacerbated by placing the toes in a dorsiflexed position, thereby stretching the plantar fascia (See Figure 3). There is an association between flatfeet and the development of plantar fasciitis. However, any foot type can develop this condition.
Plantar fasciitis is by far the most common cause of heel pain. However, there are other less common causes including:
Plantar fasciitis is typically diagnosed based on the patient’s history and on physical examination. Plain x-rays are not routinely indicated. However, when ordered, a lateral, weight-bearing view of the foot will often demonstrate a calcaneal heel spur. Essentially, the same traction phenomena that causes overloading of the plantar fascia and its origin may cause excessive bone formation, in the form of a calcaneal heel spur. However, the presence of a heel spur does NOT directly correlate with symptoms. Many patients have heel spurs on x-rays and are asymptomatic, whereas, many patients have significant plantar fasciitis and do not demonstrate a heel spur on plain x-ray.
MRI is initially not indicated for patients with heel pain that is believed to be secondary to plantar fasciitis. However, if symptoms fail to resolve after a concerted treatment effort, an MRI may be ordered to rule out other causes of heel pain, such as a calcaneal stress fracture.
There is excellent non-operative treatment available for plantar fasciitis. The vast majority of patients will have their symptoms resolve with non-operative treatment. The main elements of non-operative treatment are as follows:
With resolution of the heel pain symptoms, it is important to continue calf stretching and plantar fascia stretching on a semi-regular basis (3-4 times per week), so as to minimize the risk of recurrence. These treatment modalities treat the symptoms, but do not fully address the underlying biomechanical predisposing factors. Therefore, ongoing management of this condition is essential!
About 90% of patients will respond to appropriate non-operative treatment measures over a period of 3-6 months. Surgery is a treatment option 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. There are a number of reasons why surgery is not immediately entertained, including:
Surgical intervention may include extracorporeal shock wave therapy or endoscopic or open partial plantar fasciectomy.
Extracorporeal Shock Wave Therapy (High Energy): This is often performed under anesthesia. High-intensity shock waves are focused on the plantar fascia insertion. This creates a controlled injury to the plantar fascia. With the new blood supply entering this area as a healing response, the symptoms are often improved. There is a propensity for symptoms to gradually recur, although reasonable results have been reported at 6month and 2-year follow-ups.
Partial Plantar Fasciectomy: This involves removal of the injured area of the plantar fascia, either endoscopically or through the small incision. This is then followed by a 6-week period of relative rest and stretching. Although this procedure has produced good results, it can increase the risk of a rupture of the plantar fascia, with resulting profound flatfoot deformity and an increase in symptoms.
Gastrocnemius recession (a.k.a. Strayer or Volpious procedure): Recently, there have been a few studies which suggest that lengthening the calf muscle (gastrocnemius) can help resolve the symptoms associated with plantar fasciitis. This operation involves making an incision in the lower calf, in order to release the tendon of the gastrocnemius at the point where it inserts just above the Achilles tendon. Following the surgery, patients need a six week period of relative rest. The calf muscle can have noticeable residual weakness that usually resolves in 6-12 months. At this time, there are only limited studies assessing the long-term effectiveness of this procedure.