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Plantar Fasciitis

Original Editor - Brooke Kennedy

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Introduction

Plantar fasciitis (Currently better referred to as Plantar Heel Pain) is the result of collagen degeneration of the plantar fascia at the origin, the calcaneal tuberosity of the heel as well as the surrounding perifascial structures.[1]

Traditionally, the condition was known as 'fasciitis' - containing 'itis' as the condition was believed to have an inflammatory mechanism. However, new findings have characterized the condition by an absence of inflammatory cells, hence it is considered degenerative, and not an inflammatory pathology.[2][1] As such, “fasciosis” or “fasciopathy” are increasingly used to refer to this condition.[3] Plantar heel pain is the most commonly seen foot pain condition treated by health care workers.[4]

  • The plantar fascia plays an important role in the normal biomechanics of the foot.
  • The fascia itself is important in providing support for the arch and providing shock absorption.

The pathology is characterised by insidious-onset sharp pain in the medial heel, from the medial plantar fascia border to insertion at the calcaneal medial tuberosity,[5] which worsens with weight-bearing and after periods of rest or non-weight-bearing.[6] Plantar fasciitis frequently presents as a chronic condition, with symptoms often persisting for more than a year.[7]

There are many different sources of pain in the plantar heel beside the plantar fascia and therefore the term "Plantar Heel Pain" serves best to include a broader perspective when discussing this and related pathology.

Clinically Relevant Anatomy

The plantar fascia is a thick, fibrous aponeurosis that originates from the medial tubercle of the calcaneus. It extends forward, inserting into the deep, short transverse ligaments of the metatarsal heads and dividing into five digital bands at the metatarsophalangeal joints.[6]

Illustration of plantar and medial views[8]
The photo illustrates the thick, fibrous plantar fascia in a human specimen.
  • The thicker central portion of the plantar fascia extends into five bands that surround the flexor tendons as it passes over the five metatarsal heads.
  • Pain in the plantar fascia can be either insertional or non-insertional and may involve the larger central band as well as the medial and lateral bands of the fascia.
  • It blends with the paratenon of the Achilles tendon, the intrinsic foot muscles, skin, and subcutaneous tissue.[9][10]
  • This thick, elastic, multilobular fat pad is responsible for absorbing up to 110% of body weight during walking and up to 250% during running, deforming most significantly during barefoot walking compared to shod walking.[11]

During weight-bearing:

  • Tibia loads the foot “truss” and creates tension through the plantar fascia (windlass mechanism).
  • The tension created in the plantar fascia adds critical stability to a loaded foot with minimal muscle activity.[12][13][14]

Etiology

Often presents as an overuse injury, primarily due to repetitive strain causing micro-tears of the plantar fascia but can occur as a result of trauma or other multifactorial causes.[15]

There are many risk factors for plantar heel pain including but not limited to:

  • Reduced dorsiflexion and first metatarsophalangeal joint extension are weakly associated[16]
  • Increased plantar flexion range[17]
  • Pes cavus or pes planus deformities[18]
    • Pes planus can cause increased strain at the origin of the plantar fascia. Pes cavus can cause excessive strain on the heel because the foot does not effectively evert or absorb shock.[2]
  • Excessive foot pronation or supination dynamically.[19]
  • Impact/weight-bearing activities such as prolonged standing, running, jumping, among other.
  • Improper shoe fit.[20]
  • Elevated Body Mass Index (BMI)
    • In the athletic population, BMI is not associated with increased plantar fasciitis risk, however, evidence suggests BMI is associated with increased risk in the non-athletic population. There is some evidence that weight loss could possibly reduce foot pain.[21]
  • Presence of a sub calcaneal spur.[22]
  • Diabetes Mellitus (and/or other metabolic condition)
  • Leg length discrepancy
  • Tightness and/or weakness of gastrocnemius-soleus complex, Achilles tendon and intrinsic muscles of the foot.[23]
  • Low-quality evidence suggests an association between weight-bearing activities and plantar fasciitis.[24]
  • Active trigger points.[25] A greater number of active trigger points is associated with greater pain intensity and disability in people with plantar heel pain.[26]



A 2016 systematic review found strong evidence for 3 associations for plantar fasciitis; a thickened plantar fascia, the presence of a sub calcaneal spur, and a high BMI in a non-athletic population.[22]

Approximately 50% of patients with this condition also have heel spurs, although the spurs are not the cause of the condition. Plantar fasciitis is commonly associated with runners and older adults, but other risk factors include obesity, heel pad atrophy, ageing, and occupations requiring prolonged standing and weight-bearing. While plantar fasciitis is sometimes linked to various seronegative spondyloarthropathies, no known systemic factors are identified in approximately 85% of cases.[2]

Epidemiology

Plantar fasciitis is the most common cause of heel pain presenting in the outpatient setting.[2]

  • Affects 4% - 7% of the community. [27] [28]
  • Most prevalent and peak incidence is among 40 to 60 years of age and it accounts for 15% of foot injuries in the general population.[29][30]
  • Estimated to account for 8% of all running injuries. [28]
  • 83% of these patients being active working adults between the ages of 25 and 65 years old
  • 11% to 15% of all foot symptoms require professional medical care.
  • May present bilaterally in a third of the cases.[2]
  • The average plantar heel pain episode lasts longer than 6 months and it affects up to 10-15% of the population.
  • Approximately 90% of cases are treated successfully with conservative care.[31][32][33]
  • Females present with plantar fasciitis slightly more commonly than males in those aged 45 to 64 versus those aged 18 to 44, and in those with a body mass index >25 kg/m2.[34][35]
  • In the US alone, there are estimates that this disorder generates up to 2 million patient visits per year, and account for 1% of all visits to orthopedic clinics.
  • Plantar heel pain is the most common foot condition treated in physical therapy (PT) clinics and accounts for up to 40% of all patients being seen in podiatric clinics.[36]

Physical Examination

Plantar fasciitis is a clinical diagnosis by a physician.

  • Patients may experience localised point tenderness along the anteromedial aspect of the calcaneum, pain with the first steps in the morning, or discomfort following exercise.
  • Pain from plantar fasciitis is particularly evident during dorsiflexion of the toes, which further stretches the plantar fascia. Consequently, any activity that increases the stretch of the plantar fascia—such as walking barefoot without arch support, climbing stairs, or toe walking—can exacerbate the pain.
  • Clinical examination will take into consideration a patient's medical history, physical activity, foot pain symptoms, and more.
  • Diagnostic imaging is rarely needed for the initial diagnosis of plantar fasciitis. Use of ultrasonography and magnetic resonance imaging is reserved for recalcitrant cases or to rule out other heel pathology; findings of increased plantar fascia thickness and abnormal tissue signal the diagnosis of plantar fasciitis.[37]
  • The attending physician may decide to use imaging modalities like plain radiographs, diagnostic ultrasounds, and Magnetic Resonance Imaging (MRI).


Look for the following:

  • Reproduced by palpating the plantar medial calcaneal tubercle at the site of the plantar fascial insertion on the heel bone.
  • Pain reproduced with passive dorsiflexion of the foot and toes.
  • Windlass Test - Passive dorsiflexion of the first metatarsophalangeal joint (test to provoke symptoms at the plantar fascia by creating maximal stretch), positive test if the pain is reproduced.[2] (shown in 40-second video below)

[38]

Secondary findings may include:

  • Tight Achilles heel cord, pes planus, or pes cavus.
  • Altered gait (look for biomechanical factors that may predispose the client to plantar fascia problems) or predisposing factors mentioned previously.
  • Obesity
  • Work-related prolonged weight-bearing

Clinical Presentation

  • Heel pain with first steps in the morning upon waking-up or after long periods of non-weight bearing or at the start of a workout.[39]
  • Tenderness to the anterior medial heel.
  • Limited dorsiflexion and tight Achilles tendon .
  • A limp may be present or may have a preference to toe walking.
  • Pain is usually worse when barefoot on hard surfaces and with stair climbing.
  • Many patients may have had a sudden increase in their activity level prior to the onset of symptoms.

Diagnostic Procedure

Ultrasonography is the most commonly used imaging modality for this condition, with plantar fascia thickness frequently assessed. Meta-analyses have shown that patients with plantar fasciitis have a plantar fascia that is, on average, 2.16 mm thicker compared to a control group, typically measuring 4.0 mm or more.[40]

Some evidence suggests that patients with plantar fasciitis may have a “softer” plantar fascia, which can be detected by sonoelastography. This technique could help identify plantar fasciitis in symptomatic patients who have normal findings on standard ultrasound.[41]

Ultrasound should be considered the first-choice modality for assessing plantar fascia (PF) disorders due to its affordability, speed, dynamic imaging capabilities, high-resolution visualisation of the PF, and ability to provide comparison with the contralateral side. Conventional radiographs can reveal several indirect indicators of PF disorders and should be reviewed even when patients are being assessed for other reasons. While MRI is reliable in detailing both soft tissue and bone anatomy of the sole and allows accurate diagnosis of PF disorders, it is costly and should be considered a second-line imaging option.[42]

Treatment for Plantar Fasciitis

Medical Management

Conservative measures are the first choice to manage symptoms:

  • Relative rest from rigorous activities as guided by pain level should be prescribed.
  • Pharmacologic approach: oral or topical NSAIDs can be used to help alleviate pain.
  • Ice after activities will also help alleviate pain.
  • Deep friction massage of the plantar arch and insertion.
  • Shoe inserts or orthotics and night splints may be prescribed in conjunction with the above.
  • Educate patients on proper stretching of the Plantar Fascia, Achilles Tendon, Gastrocnemius, and Soleus muscles.


If the pain does not respond to conservative measures:

  • Corticosteroid injections
    • found to be more effective versus placebo or no treatment, in pain relief at one month, but these effects were not sustained over longer periods.[43][44] Overall, according to a recent systematic review, they have no significant effect neither on pain or the thickness of plantar fascia. [45]
  • Platelet-Rich Plasma (PRP)[46]
  • Surgery should be the last option if this process has become chronic and other less invasive therapies have failed. Important that advanced and invasive techniques be combined with conservative therapies.[2]
  • Endoscopic Plantar Fasciotomy

Physical Therapy Management

An important tool is patient education:

  • Patients should be advised that symptoms may take weeks or even months to improve, depending on the nature of the injury.
  • They should follow the instructions provided by the physiotherapist, such as initially resting from aggravating activities, applying ice to the painful area, and performing stretches for the calf and plantar muscles.
  • Emphasize of the importance of a home exercise plan.[2]

The Clinical Practice Guidelines provide recommended PT interventions based on available evidence. PT Interventions most recommended include manual therapy, stretching, taping, foot orthoses, and night splints.[47]

  1. Manual Therapy should include soft tissue and joint mobilization.[47]
  2. Stretching should include the plantar fascia and gastrocnemius-soleus complex.[47]
    • Stretching the plantar fascia consists of the patient crossing the affected leg over the contralateral leg and using the fingers across the base of the toes to apply pressure into the toe extension until a stretch can be felt along the plantar fascia.[50]
    • Achilles tendon stretching can be performed in a standing position with the affected leg placed behind the opposite leg, toes pointing forward. The front knee is bent while keeping the back knee straight and the heel on the ground. To target the soleus muscle, the back knee can then be slightly flexed.
    • A systematic review found moderate quality evidence favoring plantar fascia-specific stretching (PFSS) over the Achilles tendon or calf stretching (CS) for short-term (< 3 months) pain relief.[51]
  3. Taping should prevent pronation.[47] Low dye is the most commonly used taping technique and can improve pain in the short term, yet there is lacking evidence for its long-term effects.[52] A combined approach of taping with stretching may yield better results than stretching alone.[52]
  4. Foot orthoses can be prefabricated or custom-made by orthotists. They should support the medial longitudinal arch and provide cushioning for the heel. If the patient experiences pain with initial steps in the morning, a night splint may be beneficial..[47]
    • Posterior-night splints maintain ankle dorsiflexion and toe extension, allowing for a constant stretch on the plantar fascia.
  5. Trigger point dry needling on the gastrocnemius muscles can be used as a good alternative option before proceeding to more invasive therapies of plantar fasciitis.[53]

Therapeutic Modalities to manage pain caused by Plantar Fasciitis:

  1. Cryotherapy
  2. Low-Level Laser Therapy (LLLT)
  3. Tecar Therapy and High-Intensity Laser Therapy (HILT)[54]
  4. Prolotherapy - Tendinopathy Treatment Adjuncts
  5. Iontophoresis
  6. Extracorporeal Shockwave Therapy [55]
    • In three meta-analyses, ESWT showed greater VAS score reduction and over a 60% success rate of reducing heel pain over placebo.[56][57][58]
    • A systematic review by Sun et al. found that ESWT had higher Roles and Maudsley scores, greater VAS score reduction, decreased return to work time, and fewer complications to other interventions - placebo, ultrasound, and endoscopic plantar fasciotomy.[59]

According to the Clinical Practice Guidelines, ultrasound, electrotherapy, and dry needling are not recommended. There is some support for low-level laser therapy, phonophoresis with ketoprofen gel, changes in footwear, weight loss, therapeutic exercise, and neuromuscular re-education. Meanwhile, shockwave diathermy is regarded as outside the scope of physiotherapy practice according to the 2023 review by the American Physical Therapy Association Clinical Practice Guidelines.[47][60]

  1. Footwear should include a rocker-bottom shoe.[47]
  2. If weight is a concern, the patient should be referred to a more appropriate healthcare provider for nutritional advice.
  3. Therapeutic exercise and neuromuscular re-education should focus on reducing pronation and improving weight distribution in weight bearing. [47]
    • Similar to tendinopathy management, high-load strength training appears to be effective in the treatment of plantar fasciitis. High-load strength training may aid in a quicker reduction in pain and improvements in function.[61]. The systematic review suggests there is minimal evidence to support the use of foot muscle training in patients with plantar fasciitis.[62]

Plantar fascia stretching video provided by Clinically Relevant


[63]
[64]

Outcome Measures

Differential Diagnosis

Concluding Comments
  • Thorough patient education and adherence to PT rehabilitation is needed.
  • Plantar Heel Pain is usually a self-limiting condition, and with conservative therapy, symptoms are usually resolved within 12 months of initial presentation and often sooner.
  • Sometimes more chronic cases of this condition will need additional follow-up with a Physician and a Physiotherapist to consider more advanced management and evaluation such as activities of daily living specifically gait factors, biomechanical components, and quality of life that can potentially be corrected through PT interventions like gait training among other remedies.
  • Corticosteroid injections have been shown to be beneficial in the short term (less than four weeks) but ineffective in the long term circumstances.
  • Evidence of the efficacy of platelet-rich plasma, dextrose prolotherapy, and extra-corporeal shockwave therapy is conflicting.[2]

Resources

Clinical Practice Guideline (Heel Pain – Plantar Fasciitis: Revision 2023)

References

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  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Buchanan BK, Kushner D. Plantar fasciitis. Available from:https://www.ncbi.nlm.nih.gov/books/NBK431073/ (last accessed 22.6.2020)
  3. ↑ Rhim HC, Kwon J, Park J, Borg-Stein J, Tenforde AS. A Systematic Review of Systematic Reviews on the Epidemiology, Evaluation, and Treatment of Plantar Fasciitis. Life. 2021 Dec;11(12):1287.
  4. ↑ Menz HB, Jordan KP, Roddy E, Croft PR. Characteristics of primary care consultations for musculoskeletal foot and ankle problems in the UK. Rheumatology. 2010 Jul 1;49(7):1391-8.
  5. ↑ Canoso JJ. Heel pain: diagnosis and treatment, step by step. Clev Clin J Med. 2006 May;73(5):465-9.
  6. ↑ 6.0 6.1 Williams PL, Warwick R. Myology. Gray's Anatomy. Philadelphia: WB Saunders; 1980. 36:612:613
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  9. ↑ Carlson RE, Fleming LL, Hutton WC. The biomechanical relationship between the tendoachilles, plantar fascia and metatarsophalangeal joint dorsiflexion angle. Foot & Ankle International. 2000 Jan;21(1):18-25.
  10. ↑ Stecco C, Corradin M, Macchi V, Morra A, Porzionato A, Biz C, De Caro R. Plantar fascia anatomy and its relationship with Achilles tendon and paratenon. Journal of anatomy. 2013 Dec;223(6):665-76.
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  18. ↑ Mørk M, Soberg HL, Hoksrud AF, Heide M, Groven KS. The struggle to stay physically active-A qualitative study exploring experiences of individuals with persistent plantar fasciopathy. J Foot Ankle Res. 2023 Apr 15;16(1):20.
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  23. ↑ Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. Journal of the American Podiatric Medical Association. 2003 May 1;93(3):234-7.
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  25. ↑ Travell JG, Simons DG. Myofascial pain and dysfunction: the trigger point manual. Lippincott Williams & Wilkins; 1992.
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  39. ↑ Buchbinder R. Plantar fasciitis. New England Journal of Medicine. 2004 May 20;350(21):2159-66.
  40. ↑ Rhim HC, Kwon J, Park J, Borg-Stein J, Tenforde AS. A Systematic Review of Systematic Reviews on the Epidemiology, Evaluation, and Treatment of Plantar Fasciitis. Life. 2021 Dec;11(12):1287.
  41. ↑ Fusini F, Langella F, Busilacchi A, Tudisco C, Gigante A, Massé A, Bisicchia S. Real-time sonoelastography: principles and clinical applications in tendon disorders. A systematic review. Muscles, ligaments and tendons journal. 2017 Jul;7(3):467.
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  43. ↑ David JA, Sankarapandian V, Christopher PR, Chatterjee A, Macaden AS. Injected corticosteroids for treating plantar heel pain in adults. Cochrane Database of Systematic Reviews. 2017(6).
  44. ↑ Li Z, Yu A, Qi B, Zhao Y, Wang W, Li P, Ding J. Corticosteroid versus placebo injection for plantar fasciitis: A meta-analysis of randomized controlled trials. Experimental and Therapeutic Medicine. 2015 Jun 1;9(6):2263-8.
  45. ↑ Peña-Martínez VM, Acosta-Olivo C, Simental-Mendía LE, Sánchez-García A, Jamialahmadi T, Sahebkar A, Vilchez-Cavazos F, Simental-Mendía M. Effect of corticosteroids over plantar fascia thickness in plantar fasciitis: a systematic review and meta-analysis. The Physician and Sportsmedicine. 2023 Jun 11(just-accepted).
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  47. ↑ 47.0 47.1 47.2 47.3 47.4 47.5 47.6 47.7 Enseki K, Harris-Hayes M, White DM, Cibulka MT, Woehrle J, Fagerson TL, Clohisy JC. Nonarthritic hip joint pain: clinical practice guidelines linked to the International Classifiation of Functioning, Disability and Health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2014 Jun;44(6):A1-32.
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  49. ↑ Pawlukiewicz M, Kochan M, Niewiadomy P, Szuścik-Niewiadomy K, Taradaj J, Król P, Kuszewski MT. Fascial Manipulation Method Is Effective in the Treatment of Myofascial Pain, but the Treatment Protocol Matters: A Randomised Control Trial-Preliminary Report. J Clin Med. 2022 Aug 4;11(15):4546. doi: 10.3390/jcm11154546. PMID: 35956161; PMCID: PMC9369771.
  50. ↑ DiGiovanni BF, Nawoczenski DA, Lintal ME, Moore EA, Murray JC, Wilding GE, Baumhauer JF. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain: a prospective, randomized study. JBJS. 2003 Jul 1;85(7):1270-7.
  51. ↑ Siriphorn A, Eksakulkla S. Calf stretching and plantar fascia-specific stretching for plantar fasciitis: A systematic review and meta-analysis. Journal of bodywork and movement therapies. 2020 Oct 1;24(4):222-32.
  52. ↑ 52.0 52.1 Podolsky R, Kalichman L. Taping for plantar fasciitis. Journal of back and musculoskeletal rehabilitation. 2015 Jan 1;28(1):1-6.
  53. ↑ Eftekharsadat B, Babaei-Ghazani A, Zeinolabedinzadeh V. Dry needling in patients with chronic heel pain due to plantar fasciitis: A single-blinded randomized clinical trial. Med J Islam Repub Iran. 2016 Jul 23;30:401. PMID: 27683642; PMCID: PMC5038993.
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  55. ↑ Al-Abbad H, Allen S, Morris S, Reznik J, Biros E, Paulik B, Wright A. The effects of shockwave therapy on musculoskeletal conditions based on changes in imaging: a systematic review and meta-analysis with meta-regression. BMC Musculoskeletal Disorders. 2020 Dec;21(1):1-26.
  56. ↑ Sun J, Gao F, Wang Y, Sun W, Jiang B, Li Z. Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: A meta-analysis of RCTs. Medicine. 2017 Apr;96(15).
  57. ↑ Aqil A, Siddiqui MR, Solan M, Redfern DJ, Gulati V, Cobb JP. Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: a meta-analysis of RCTs. Clinical Orthopaedics and Related Research®. 2013 Nov;471:3645-52.
  58. ↑ Lou J, Wang S, Liu S, Xing G. Effectiveness of extracorporeal shock wave therapy without local anesthesia in patients with recalcitrant plantar fasciitis: a meta-analysis of randomized controlled trials. American journal of physical medicine & rehabilitation. 2017 Aug 1;96(8):529-34.
  59. ↑ Sun K, Zhou H, Jiang W. Extracorporeal shock wave therapy versus other therapeutic methods for chronic plantar fasciitis. Foot and Ankle Surgery. 2020 Jan 1;26(1):33-8.
  60. ↑ Martin RL, Davenport TE, Reischl SF, McPoil TG, Matheson JW, Wukich DK, McDonough CM, Altman RD, Beattie P, Cornwall M, Davis I. Heel pain—plantar fasciitis: revision 2014. Journal of Orthopaedic & Sports Physical Therapy. 2014 Nov;44(11):A1-33.
  61. ↑ Rathleff MS, Mølgaard CM, Fredberg U, Kaalund S, Andersen KB, Jensen TT, Aaskov S, Olesen JL. High‐load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12‐month follow‐up. Scandinavian journal of medicine & science in sports. 2015 Jun;25(3):e292-300.
  62. ↑ Rhim HC, Kwon J, Park J, Borg-Stein J, Tenforde AS. A Systematic Review of Systematic Reviews on the Epidemiology, Evaluation, and Treatment of Plantar Fasciitis. Life. 2021 Dec;11(12):1287.
  63. ↑ gerrybphysio. Plantar Fasciitis taping that works. Available from: https://www.youtube.com/watch?v=Pe6UEck_hIY [last accessed 11/3/2023]
  64. ↑ TheProactiveAthlete. Plantar Fascia Exercises. Available from: https://www.youtube.com/watch?v=kStuJAu0a20 [last accessed 6/6/2009]
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