History

Fact Explanation
Unilateral medial heel pain of a 6 month to 2 year duration. Degenerative changes in the plantar fascia, with or without fibroblastic proliferation and chronic inflammatory changes near the site of origin of the plantar fascia at the medial tuberosity of the calcaneus [1,2,3] Up to 30% of patients may have bilateral heel pain. [4]
Pain is severe on initial few steps and usually lessens with activity. The inflammatory cells and substances accumulate at the site during rest disperse with activity. [5]
Pain gets worse with prolonged standing. Pain occurs due to mechanical stress on degenerative lesions in plantar fascia[4,6].
Numbness, tingling and pain radiating towards the forefoot. Posterior tibial nerve entrapment occurs due to swelling of the surrounding tissue of the fascial insertion due to inflammation. [5]
Risk factors include excessive running or occupations that involve prolonged standing, pes planus and obesity. Thought to predispose to micro tears in the plantar fascia due to excessive or repeated stress. [4]
References
  1. LEACH R.E. et al. Results of surgery in athletes with plantar fasciitis. Foot Ankle,Dec 1986;7(3):156-61.[viewed 5 March 2014].Available from:http://fai.sagepub.com/content/7/3/156.full.pdf
  2. LEMONT H. et al.Plantar fasciitis: a degenerative process (fasciosis) without inflammation.J Am Podiatr Med Assoc. 2003,93,234-7 [viewed 5 March 2014].Available from:http://fai.sagepub.com/content/7/3/156.full.pdf
  3. JARDE O. et al. Degenerative lesions of the plantar fascia: surgical treatment by fasciectomy and excision of the heel spur: a report on 38 cases. Acta Orthop Belg., 2003,69,267-74 [viewed 5 March 2014]. Available from:http://actaorthopaedicabelgica.be/acta/download/2003-3/09-jarde-vernois-.pdf
  4. ROXAS M. Plantar fasciitis: Diagnosis and therapeutic considerations. Alternative Medicine Review,2005,10,83–93. [viewed 5 March 2014].Available from:http://www.altmedrev.com/publications/10/2/83.pdf
  5. BUCHBINDER R. Clinical practice. Plantar fasciitis. N Engl J Med,2004 May,20,350(21),2159- 2166 [viewed 5 March 2014].Available from: http://www.nejm.org/doi/pdf/10.1056/NEJMcp032745
  6. MCPOIL T.G. et al. Heel pain-plantar fasciitis: clinical practice guildelines linked to the international classification of function, disability, and health from the orthopaedic section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008:38(4):A1-A18. ,2008,38,A,1–18.[viewed 5 March 2014].Available from: doi:10.2519/jospt.2008.0302

Examination

Fact Explanation
Sharp, stabbing pain on palpation of the medial plantar calcaneal region and along the plantar fascia[1,2] Commonly affected site is at the insertion of plantar fascia at calcaneum.
Assessment of gait. Patients may walk with the affected foot in equinus. [3] To avoid transmitting pressure on to the painful heel.
Body Mass Index(BMI) [4] Obesity exerts more stress over the heel and it is an important risk factor.
Pain caused by passive flexion of the ankle or the first toe [3] This manoeuvre stretches the plantar fascia which aggravates the pain.
Swelling of the heel [3] Is a rare presentation and occurs due to the inflammatory reaction.
References
  1. THOMAS,J.L, et al.The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010.J Foot Ankle Surg. 2010 May-Jun,49(3 Suppl),S1-19. [viewed 5 March 2014].Available from: doi: 10.1053/j.jfas.2010.01.001.
  2. KARABAY,N. Ultrasonographic evaluation in plantar fasciitis.J Foot Ankle Surg. 2007 Nov-Dec;46(6):442-6. [viewed 5 March 2014].Available from: http://www.jfas.org/article/S1067-2516(07)00291-8/abstract
  3. GOFF,J.D. Diagnosis and treatment of plantar fasciitis.Am Fam Physician. 2011 Sep 15,84(6),676-82. [viewed 5 March 2014].Available from: http://www.aafp.org/afp/2011/0915/p676.html
  4. ROME,K. Anthropometric and biomechanical risk factors in the development of plantar heel pain-a review of the literature.Physical Therapy Reviews, 08/1997; 2(3):123-134. [viewed 5 March 2014].Available from:DOI:10.1179/108331997787247518

Differential Diagnoses

Fact Explanation
Fat pad atrophy Deep seated bruise-like heel pain. Occurs in the elderly and manifests as pain or tenderness in the central heel that is classically absent on arising in the morning which contrasts with plantar fasciitis. Atrophy of the heel pad is also usually bilateral.[1,2]
Plantar fascia rupture Sudden onset of tearing heel pain and inability to bear weight after physical activity.Pain may be accompanied by bruising and/or swelling and a marked decrease in arch height as compared with the other foot.[3]
Pes planus (Flat feet) Heel pain caused by prolonged standing occurs due to abnormal weight distribution. [4,5]
Pes cavus (High arch) Heel pain due to metatarsal compression. Pain maybe due metatarsalgia, plantar fasciitis, painful callosities, ankle arthritis or Achilles tendonitis.[6]
Nerve-entrapment or compression syndromes (Posterior tibial nerve/ tarsal tunnel syndrome) Burning heel pain (and tenderness) that follows the path of the posterior tibial nerve inferior to the medial malleolus, radiating into the plantar aspect of the foot and toward the toes.May also radiate proximally up the leg.The pain is aggravated by prolonged weight bearing and walking on hard surfaces.[3]
Neuropathy Heel pain is accompanied by diffuse nocturnal foot pain. [3]
Calcaneal stress fracture Heel pain may occur after excessive or repetitive weight-bearing exercise; pain may be made worse by weight bearing, and relieved by rest. On examination tenderness on medio-lateral compression of the calcaneus. [3]
Bursitis Heel pain presents with retro-calcaneal swelling and erythema of the posterior heel. [3,7,8]
References
  1. TAE,I.Y. et al. Clinical Characteristics of the Causes of Plantar Heel Pain.2011,35,507-513. [viewed 5 March 2014].Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3309235/
  2. DALAL,S.The plantar fat pad and the diabetic foot - a review.International Wound Journal. Available from: http://onlinelibrary.wiley.com/doi/10.1111/iwj.12173/abstract
  3. BUCHBINDER,R. Clinical practice. Plantar fasciitis. N Engl J Med,2004 May,20,350(21),2159- 2166 [viewed 5 March 2014].Available from: http://www.nejm.org/doi/pdf/10.1056/NEJMcp032745
  4. PANDEY,S. et al. Flatfoot in Indian population.J Orthop Surg (Hong Kong),2013 Apr,21(1),32-6. [viewed 5 March 2014].Available from: http://davidpotach.com/wp-content/uploads/2013/07/Flatfoot-in-Indian-population.pdf
  5. FRANCO,A.H. Pes cavus and pes planus. Analyses and treatment.Phys Ther,1987 May,67(5),688-94.[viewed 5 March 2014].Available from:http://ptjournal.apta.org/content/67/5/688.long
  6. BURNS,J. et al. Interventions for the prevention and treatment of pes cavus. Cochrane Database of Systematic Reviews, 2007, Issue 4. Art. No.: CD006154. DOI: 10. [viewed 5 March 2014].Available from:DOI: 10.1002/14651858.CD006154.pub2
  7. LOHRER,H. et al. Retrocalcaneal bursitis but not Achilles tendinopathy is characterized by increased pressure in the retrocalcaneal bursa. Available from: http://www.clinbiomech.com/article/S0268-0033(13)00305-7/abstract
  8. KONDREDDI,V. Outcome of endoscopic decompression of retrocalcaneal bursitis.Indian Journal of Orthopaedics,2012 Nov,46(6),659-63.[viewed 5 March 2014].Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3543883/

Investigations - for Diagnosis

Fact Explanation
Lateral X-Ray of the ankle Imaging plays a limited role in routine clinical practice; although, it may be useful in selected cases to rule out other causes such as calcaneal stress fractures or to establish the diagnosis of plantar fasciitis when it is in doubt.[1] The appearance of a sub-calcaneal spur on lateral foot radiographyis not diagnostic of plantar fasciitis,as this may even be seen in those without plantar fasciitis.[2]
Ultrasonography of the plantar heel region Ultrasonography may be diagnostically useful although it is not routinely used. The plantar fascia can be easily distinguished from the hyperechoic superficial heel pad of fat and the underlying calcaneus. In plantar fasciitis there is marked increase in the thickness of the fascia to 7mm from the usual 2mm. In addition local or diffuse hypoechogenicity at the calcaneal insertion of the plantar fascia and peri-insertional edema can be seen.[1,3,4]
Magnetic resonance imaging (MRI) Marked increase in the thickness of the plantar fascia. [5,6]
Bone Scans In the event of a normal radiograph, bone scans are useful in distinguishing plantar fasciitis from a calcaneal stress fracture. Findings are of Increased blood flow and pooling, focal increase in activity at the plantar fascial insertion.[1]
References
  1. BUCHBINDER,R. Clinical practice. Plantar fasciitis. N Engl J Med,2004 May,20,350(21),2159- 2166 [viewed 5 March 2014].Available from: http://www.nejm.org/doi/pdf/10.1056/NEJMcp032745
  2. GOFF,J.D, R.C.CRAWFORD.Diagnosis and treatment of plantar fasciitis.American Family Physician,2011 Sep,15,84(6),676-82.[viewed 5 March 2014].Available from: http://pubs.rsna.org/doi/abs/10.1148/radiology.179.3.2027971?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed&
  3. GROSHAR,D. et al. Plantar fasciitis: detection with ultrasonography versus bone scintigraphy.The International Journal of clinical foot science,2000,10,164-8.[viewed 5 March 2014].Available from: http://dx.doi.org/10.1054/foot.2000.0621
  4. GIBBON,WW, G.LONG.Ultrasound of the plantar aponeurosis (fascia). Skeletal Radiology,1999,28,21-6.[viewed 5 March 2014].Available from:DOI 10.1007/s002560050467
  5. BERKOWITZ,J.F, R.KIER, S.RUDICEL.Plantar fasciitis: MR imaging. Radiology,1991,179,665-7.[viewed 5 March 2014].Available from:http://pubs.rsna.org/doi/abs/10.1148/radiology.179.3.2027971?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed&
  6. MCGONAGLE,D. et al. The role of biomechanical factors and HLA-B27 in magnetic resonance imaging-determined bone changes in plantar fascia enthesopathy. Arthritis Rheum,2002,46,489-93. [viewed 5 March 2014].Available from: DOI:10.1002/art.10125

Investigations - Fitness for Management

Fact Explanation
Lateral X-ray of the ankle Often a plain radiograph is performed before injecting steroids to exclude other differential diagnosis. [1]
References
  1. KALACI,A. Treatment of plantar fasciitis using four different local injection modalities: a randomized prospective clinical trial. Journal of the American Pediatric Medical Association,2009,99(2),108-11 [viewed 5 March 2014].Available from: http://www.japmaonline.org/content/99/2/108.long

Management - General Measures

Fact Explanation
Rest, modification of activity, correction of training errors.[1,2] Avoidance of activities such as prolonged standing. Correction of training errors and avoidance of additional strain over the affected area.
Application of ice for 20 mins upto 3 to 4 times a day. [1} Local vasoconstriction and analgesia.
Education on choosing the right shoe size. Tight fitting shoes are a precipitating factor.[2]
Weight reduction Reduces the amount of strain on the plantar fascia when standing.[3]
Orthotic devices Devices such as viscoelastic heel cups, prefabricated longitudinal arch supports and custom-made full-length shoe insoles can be used. Aids in the prevention of over pronation of the foot and unloads tensile forces from the plantar fascia.[3]
Night splints Prevents flexion of the plantar fascia during sleeping by keeping the foot and ankle in a neutral 90-degree position. [3,4]
Stretching exercises and physical therapy . Progressive plantar fascia and intrinsic foot muscle stretching techniques have been shown to reduce pain in plantar fasciitis.[5]
References
  1. BUCHBINDER,R. Clinical practice. Plantar fasciitis. N Engl J Med,2004 May,20,350(21),2159- 2166 [viewed 5 March 2014].Available from: http://www.nejm.org/doi/pdf/10.1056/NEJMcp032745
  2. CLINTON,J.D, A.P. MORRELB.Chiropractic management of pediatric plantar fasciitis.J Chiropr Med. Mar 2012,11(1), 58–63. [viewed 5 March 2014].Available from: doi: 10.1016/j.jcm.2011.06.009
  3. GOFF,J.D. Diagnosis and treatment of plantar fasciitis.Am Fam Physician. 2011 Sep 15,84(6),676-82. [viewed 5 March 2014].Available from: http://www.aafp.org/afp/2011/0915/p676.html
  4. CHIA,K.K. et al. Comparative trial of the foot pressure patterns between corrective orthotics, formthotics, bone spur pads and flat insoles in patients with chronic plantar fasciitis.Ann Acad Med Singapore,2009,38(10),869-875.[viewed 5 March 2014].Available from: http://www.annals.edu.sg/pdf/38VolNo10Oct2009/V38N10p869.pdf
  5. HYLAND,M.R. et al. Randomized controlled trial of calcaneal taping, sham taping, and plantar fascia stretching for the short-term management of plantar heel pain. J Orthop Sports Phys Ther. ,2006,36(6),364-371.[viewed 5 March 2014].Available from: doi:10.2519/jospt.2006.2078

Management - Specific Treatments

Fact Explanation
NSAIDs Has an analgesic and anti-inflammatory effect.[1]
Corticosteroid injections Used for their anti inflammatory effect. Steroid injections are of benefit if administrated early in the illness. Usually reserved for patients who do not improve with conservative methods. Steroids can be injected via plantar or medial approaches. Has a 70% success rate.[2] Fat pad atrophy and fascial rupture are potential side effects.[3]
Extracorporeal shock wave therapy. Treatment options for chronic plantar fasciitis. Mechanism of action is thought to be by neo-vascularization and modulation of endogenous Nitrous Oxide( NO). [4]
Plantar fasciotomy Performed in patients in whom conservative measures have failed. The fascia is incised to relieve tension.[5]
Prolotherapy with platelet-rich plasma The platelet rich plasma contains growth factors that stimulate healing in degenerating tissue. Currently, there is evidence for the use of platelet-rich plasma in non-healing tendinopathies. [6,7]
References
  1. GOFF,J.D. Diagnosis and treatment of plantar fasciitis.Am Fam Physician. 2011 Sep 15,84(6),676-82. [viewed 5 March 2014].Available from: http://www.aafp.org/afp/2011/0915/p676.html
  2. KALACI,A. Treatment of plantar fasciitis using four different local injection modalities: a randomized prospective clinical trial.J Am Podiatr Med Assoc.,2009,99(2),108-11 [viewed 5 March 2014].Available from: http://www.japmaonline.org/content/99/2/108.long
  3. ACEVEDO,J.I, J.L.BESKIL. Complications of plantar fascia rupture associated with corticosteroid injection.Foot Ankle Int,1998 Feb,19(2),91-7.[viewed 5 March 2014].Available from: http://fai.sagepub.com/content/19/2/91.short
  4. ROMPE,J.D. et al. Shock wave therapy for chronic plantar fasciopathy. Br Med Bull,2007,81-82,183-208.[viewed 5 March 2014].Available from: doi: 10.1093/bmb/ldm005
  5. OTHMAN,A.M, E.M.RAGAB. Endoscopic plantar fasciotomy versus extracorporeal shock wave therapy for treatment of chronic plantar fasciitis. Arch Orthop Trauma Surg,2010,130(11),1343-1347.[viewed 5 March 2014].Available from: doi: 10.1007/s00402-009-1034-2.
  6. RYAN,M.B. et al. Sonographically guided intratendinous injections of hyperosmolar dextrose/lidocaine: a pilot study for the treatment of chronic plantar fasciitis. Br J Sports Med.,2009,43(4),303-306.[viewed 5 March 2014].Available from: doi: 10.1136/bjsm.2008.050021
  7. SAMPSON S. et al. Platelet rich plasma injection grafts for musculoskeletal injuries: a review. Curr Rev Musculoskelet Med,2008,1(3-4),165-174.[viewed 5 March 2014].Available from:doi: 10.1007/s12178-008-9032-5