Plantar fasciitis 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
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. Despite the diagnosis containing the segment “itis,” this condition is notably characterized by an absence of inflammatory cells. There are many different sources of pain in the plantar heel besides the plantar fascia and therefore the term “Plantar Heel Pain” serves best to include a broader perspective when discussing this and related pathology.
Comprised of white longitudinally organized fibrous connective tissue which originates on the periosteum of the medial calcaneal tubercle, where it is thinner but it extends into a thicker central portion. The thicker central portion of the plantar fascia then extends into five bands surrounding the flexor tendons as it passes all 5 metatarsal heads.
Pain in the plantar fascia can be insertional and/or non-insertional and may involve the larger central band, but may also include the medial and lateral band of the plantar fascia. Blends with the paratendon of the Achilles tendon, the intrinsic foot musculature, skin, and subcutaneous tissue.
Thick coelastic multilobular fat pad is responsible for absorbing up to 110% of body weight during walking and 250% during running and deforms most during barefoot walking vs. shod walking.
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.
This is often an overuse injury that is primarily due to a repetitive strain causing micro-tears of the plantar fascia but can occur as a result of trauma or other multifactorial causes.
There are many risk factors which contribute to plantar heel pain including:
- Loss of ankle dorsiflexion (talocrural joint, deep or superficial posterior compartment
- Pes cavus OR pes planus deformities
- Excessive foot pronation dynamically
- Impact/weight-bearing activities such as prolonged standing, running, etc.
- Improper shoe fit
- Elevated BMI > kg/m2
- Diabetes Mellitus (and/or other metabolic condition)
- Leg length discrepancy
- Tightness and/or weakness of Gastrocnemius, Soleus, Tendoachilles tendon and intrinsic muscle.
Plantar fasciitis is the most common cause of heel pain presenting in the outpatient setting. The exact incidence and prevalence of plantar fasciitis by age are unknown. This condition accounts for about 10% of runner-related injuries (Some literature shows prevalence rates among a population of runners to be as high as 22%) Thought to occur in about 10% of the general population. 83% of these patients being active working adults between the ages of 25 and 65 years old.11% to 15% of all foot symptoms requiring professional medical care. May present bilaterally in a third of the cases. 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. Females present with the plantar heel slightly more commonly than males. 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 orthopaedic clinics. Plantar heel pain is the most common foot condition treated in physical therapy clinics and accounts for up to 40% of all patients being seen in podiatric clinics.
Plantar fasciitis is a clinical diagnosis. It is based on patient history and physical exam. Patients can have local point tenderness along the antero-medial of the calcaneus, pain on the first steps, or after training.
Plantar facia pain is especially evident upon the dorsiflexion of the patient’s pedal phalanges, which further stretches the plantar fascia. Therefore, any activity that would increase the stretch of the plantar fascia, such as walking barefoot without any arch support, climbing stairs, or toe walking can worsen the pain.
The clinical examination will take into consideration a patient’s medical history, physical activity, foot pain symptoms, and more. The doctor may decide to use Imaging studies like radiographs, diagnostic ultrasound, and MRI.
- Characteristics/Clinical Presentation
- Heel pain with first steps in the morning or after long periods of non-weight bearing
- 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
Take into consideration a patient’s medical history, physical activity, and foot pain symptoms.
Look for the following:
- Pain 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 pain is reproduced.
Secondary findings may include
- Tight Achilles heel cord, pes planus, or pes cavus.
- Biomechanical factors that may predispose client plantar fascia problems) or predisposing factors mentioned previously.
- Work-related weight-bearing
Conservative measures are the first choice:
- Relative rest from offending activity as guided by the level of pain should be prescribed.
- Ice after activity as well as oral or topical NSAIDs can be used to help alleviate pain.
- Deep friction massage of the arch and insertion.
- Shoe inserts or orthotics and night splints may be prescribed in conjunction with the above.
- Educate patients on proper stretching and rehab of the: plantar fascia; Achilles’ tendon; gastrocnemius; and soleus.
If the pain does not respond to conservative measures
More advanced or invasive techniques may be tried e.g. extracorporeal shock-wave therapy, botulinum toxin A, autologous platelet-rich plasma, dex prolotherapy, or steroid injections.
Important that advanced and invasive techniques be combined with conservative therapies.
Surgery should be the last option if this process has become chronic and other less invasive therapies have failed
Physical Therapy Management
The condition can be disabling if not appropriately managed. An important tool is the education of the patient Patients need to be told that the symptoms may take weeks or even months to improve (depending on circumstances of injury).
To follow the advice given e.g. rest from aggravating activities initially, ice, stretch. Be aware of the importance of a home exercise plan
Common treatments include: stretching and strengthening of the gastrocnemius/soleus/plantar fascia; orthotics; ultrasound; iontophoresis; night splints and joint mobilization/manipulation.
Strength Training: 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.
Stretching: consists of the patient crossing the affected leg over the contralateral leg and using the fingers across to the 1base of the toes to apply pressure into toe extension until a stretch can be felt along the plantar fascia. Achilles tendon stretching can be performed in a standing position with the affected leg placed behind the contralateral leg with the toes pointed forward. The front knee was then bent, keeping the back knee straight and heel on the ground. The back knee could then be in a flexed position for more of a soleus stretch
Mobilizations and manipulations – decrease pain and relieve symptoms in some cases. E.g.; Posterior talocrural joint mobilization and subtalar joint distraction manipulation (for hypomobile talocrural joint).Ankle, subtalar and midfoot joint mobilizations
Posterior-night splints maintain ankle dorsiflexion and toe extension, allowing for a constant stretch on the plantar fascia. Some evidence reports night splints to be beneficial but in a review by Cole et al he reported that there was limited evidence to support the use of night splints to treat patients with pain lasting longer than six months, and patients treated with a custom made night splints improved more than prefabricated night splints.
Foot orthoses produce small short-term benefits in function and may also produce small reductions in pain for people with plantar fasciitis, but they do not have long-term beneficial effects compared with a sham device whether they are custom made or prefabricated. When used in conjunction with a stretching program, a prefabricated shoe insert is more likely to produce improvement in symptoms as part of the initial treatment of proximal plantar fasciitis than a custom polypropylene orthotic device
Taping – e.g.; for an entire week tape placed on the gastrocnemius and the plantar fascia.
Usually a self-limited 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 to consider more advanced therapies and evaluation of gait and biomechanical factors that can potentially be corrected through gait retraining.
Corticosteroid injections have been shown to be beneficial in the short-term (less than four weeks) but ineffective in the long term. Evidence of the efficacy of platelet rich plasma, dex prolotherapy, and extra-corporeal shockwave therapy is conflicting.