Plantar fasciitis

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Plantar fasciitis
Classification and external resources
PF-PainAreas.jpg
ICD-10 M72.2
ICD-9 728.71
DiseasesDB 10114
MedlinePlus 007021
eMedicine pmr/107
Patient UK Plantar fasciitis

Plantar fasciitis (also known as plantar fasciopathy or jogger's heel) is a common painful disorder affecting the heel and underside of the foot. It is a disorder of the insertion site of ligament on the bone and is characterized by scarring, inflammation, or structural breakdown of the foot's plantar fascia. It is often caused by overuse injury of the plantar fascia, increases in exercise, weight or age. Though plantar fasciitis was originally thought to be an inflammatory process, newer studies have demonstrated structural changes more consistent with a degenerative process. As a result of this new observation, many in the academic community have stated the condition should be renamed plantar fasciosis.[1]

Plantar fasciitis is the most common injury of the plantar fascia[2] and is the most common cause of heel pain.[3][4] Approximately 10% of people have plantar fasciitis at some point during their lifetime.[5][6] It is commonly associated with long periods of standing and is much more prevalent in individuals with excessive inward rolling of the foot, which is seen with flat feet.[7] Among non-athletic populations, plantar fasciitis is associated with obesity and lack of physical exercise.[7][8]

The heel pain characteristic of plantar fasciitis is usually felt on the bottom of the heel and is most intense with the first steps of the day.[7] Individuals with plantar fasciitis often have difficulty with dorsiflexion of the foot, an action in which the foot is brought toward the shin.[7] This difficulty is usually due to tightness of the calf muscle or Achilles tendon, the latter of which is connected to the back of the plantar fascia.[9] Most cases of plantar fasciitis resolve on their own with time and respond well to conservative methods of treatment.[7][10]

Signs and symptoms[edit]

When plantar fasciitis occurs, the pain is typically sharp[2] and usually unilateral (70% of cases).[10] Heel pain worsens by bearing weight on the heel after long periods of rest.[11] Individuals with plantar fasciitis often report their symptoms are most intense during their first steps after getting out of bed or after prolonged periods of sitting.[7] Improvement of symptoms is usually seen with continued walking.[2][7][12] Rare, but reported symptoms include Numbness, tingling, swelling, or radiating pain.[13]

If the plantar fascia continues to be overused in the setting of plantar fasciitis, the plantar fascia can rupture. Typical signs and symptoms of plantar fascia rupture include a clicking or snapping sound, significant local swelling, and acute pain in the sole of the foot.[2]

Risk factors[edit]

Identified risk factors for plantar fasciitis include excessive running, standing on hard surfaces for prolonged periods of time, high arches of the feet, the presence of a leg length inequality, and flat feet. The tendency of flat feet to excessively roll inward during walking or running makes them more susceptible to plantar fasciitis.[7][11][14] Obesity is seen in 70% of individuals who present with plantar fasciitis and is an independent risk factor.[9] Studies have suggested a strong association exists between an increased body mass index and the development of plantar fasciitis in the non-athletic population; this association between weight and plantar fasciitis has not been observed in the athletic population.[10] Achilles tendon tightness and inappropriate footwear have also been identified as significant risk factors.[15]

Pathophysiology[edit]

The cause of plantar fasciitis is poorly understood and is thought to likely have several contributing factors.[15] The plantar fascia is a thick fibrous band of connective tissue that originates from the medial tubercle and anterior aspect of the heel bone. From there, the fascia extends along the sole of the foot before inserting at the base of the toes, and supports the arch of the foot.[9][11][14]

Originally, plantar fasciitis was believed to be an inflammatory condition of the plantar fascia. However, within the last decade, studies have observed microscopic anatomical changes indicating that plantar fasciitis is actually due to a noninflammatory structural breakdown of the plantar fascia rather than an inflammatory process.[10][15] Due to this shift in thought about the underlying mechanisms in plantar fasciitis, many in the academic community have stated the condition should be renamed plantar fasciosis.[12] The structural breakdown of the plantar fascia is believed to be the result of repetitive microtrauma (small tears).[13][14] Microscopic examination of the plantar fascia often shows myxomatous degeneration, connective tissue calcium deposits, and disorganized collagen fibers.[1]

Disruptions in the plantar fascia's normal mechanical movement during standing and walking (known as the Windlass mechanism) are thought to contribute to the development of plantar fasciitis by placing excess strain on the calcaneal tuberosity.[15] Other studies have also suggested that plantar fasciitis is not actually due to inflamed plantar fascia, but may be a tendon injury involving the flexor digitorum brevis muscle located immediately deep to the plantar fascia.[14]

Diagnosis[edit]

Achilles tendon tightness is a risk factor for plantar fasciitis. It can lead to decreased dorsiflexion of the foot.

Plantar fasciitis is usually diagnosed by a health care provider after consideration of a person's presenting history, risk factors, and clinical examination.[7][16][17] Tenderness to palpation along the inner aspect of the heel bone on the sole of the foot may be elicited during the physical examination.[7][11] The foot may have limited dorsiflexion due to tightness of the calf muscles or the Achilles tendon.[10] Dorsiflexion of the foot may elicit the pain due to stretching of the plantar fascia with this motion.[7][13] Diagnostic imaging studies are not usually needed to diagnose plantar fasciitis.[10] However, in certain cases a physician may decide imaging studies (such as X-rays, diagnostic ultrasound or MRI) are warranted to rule out serious causes of foot pain. Other diagnoses that are typically considered include fractures, tumors, or systemic disease if plantar fasciitis pain fails to respond appropriately to conservative medical treatments.[7][11] Bilateral heel pain or heel pain in the context of a systemic illness may indicate a need for a more in-depth diagnostic investigation. Diagnostic tests such as a CBC or serological markers of inflammation, infection, or autoimmune disease such as C-reactive protein, erythrocyte sedimentation rate, anti-nuclear antibodies, rheumatoid factor, HLA-B27, uric acid, or Lyme disease antibodies may also be obtained.[8] Neurological deficits may prompt an investigation with electromyography to evaluate for damage to the nerves or muscles.[13]

Heel bone with heel spur (red arrow)

Lateral view x-rays of the ankle are the recommended first-line imaging modality to assess for other causes of heel pain such as stress fractures or bone spur development.[10] Plantar fascia aponeurosis thickening at the heel greater than 5 millimeters as demonstrated by ultrasound is consistent with a diagnosis of plantar fasciitis.[12] Authors have noted that medical imaging is not routinely needed as it can be expensive and does not typically change how plantar fasciitis is managed.[15] Findings on imaging such as plantar aponeurosis thickening may be absent in symptomatic individuals or present in asymptomatic individuals thereby limiting the utility of such observations.[14] An incidental finding associated with this condition is a heel spur, a small bony calcification on the calcaneus (heel bone), which can be found in up to 50% of those with plantar fasciitis.[12] In such cases, it is the underlying plantar fasciitis that produces the heel pain, and not the spur itself.[14] The condition is responsible for the creation of the spur though the clinical significance of heel spurs in plantar fasciitis remains unclear.[13]

Differential diagnosis[edit]

The differential diagnosis for heel pain is extensive and includes pathological entities including, but not limited to the following: calcaneal stress fracture, calcaneal bursitis, osteoarthritis, spinal stenosis involving the nerve roots of lumbar spinal nerve 5 (L5) or sacral spinal nerve 1 (S1), calcaneal fat pad syndrome, seronegative spondyloparthopathies such as reactive arthritis, ankylosing spondylitis, or rheumatoid arthritis (more likely if pain is present in both heels),[8] plantar fascia rupture, and compression neuropathies such as tarsal tunnel syndrome or impingement of the medial calcaneal nerve.[8][9][10]

A determination about a diagnosis of plantar fasciitis can usually be made based on a person's medical history and physical examination.[18] In cases in which the physician suspects fracture, infection, or some other serious underlying condition, an x-ray may be used to make a differential diagnosis.[18] However, and especially for people who stand or walk a lot at work, x-rays should not be used to screen for plantar fasciitis unless imaging is otherwise indicated as using it outside of medical guidelines is unnecessary health care.[18]

Treatment[edit]

Non-surgical[edit]

About 90% of plantar fasciitis cases are self-limiting and will improve within six months with conservative treatment,[5] and within a year regardless of treatment.[7][10] Many treatments have been proposed for the treatment of plantar fasciitis. The effectiveness of most of these treatments has not been adequately investigated and consequently there is little evidence to support recommendations for such treatments.[7] First-line conservative approaches include rest, heat, ice, calf-strengthening exercises, techniques to stretch the calf muscles, achilles tendon, and plantar fascia, weight reduction in the overweight or obese, and nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen.[11][12][19] NSAIDs are commonly used to treat plantar fasciitis, but fail to resolve the pain in 20% of people.[11]

Extracorporeal shockwave therapy (ESWT) is an effective treatment modality for plantar fasciitis pain unresponsive to conservative nonsurgical measures for at least three months. Evidence from meta-analyses suggests significant pain relief lasts up to one year after the procedure.[4][5] However, debate about the therapy's efficacy has persisted.[1] ESWT can be performed with or without anesthesia though studies have suggested that the therapy is less effective when anesthesia is given.[20] Complications from ESWT are rare and typically mild when present.[20] Known complications of ESWT include the development of a mild hematoma or an ecchymosis, redness around the site of the procedure, or migraine.[20]

Corticosteroid injections are sometimes used for cases of plantar fasciitis refractory to more conservative measures. The injections may be an effective modality for short-term pain relief up to one month, but studies failed to show effective pain relief after three months.[1] Notable risks of corticosteroid injections for plantar fasciitis include plantar fascia rupture,[9] skin infection, nerve or muscle injury, or atrophy of the plantar fat pad.[7][11] Custom orthotic devices have been demonstrated as an effective method to reduce plantar fasciitis pain for up to 12 weeks.[21] The long-term effectiveness of custom orthotics for plantar fasciitis pain reduction requires additional study.[3] Orthotic devices and certain taping techniques are proposed to reduce pronation of the foot and therefore reduce load on the plantar fascia resulting in pain improvement.[14]

Another treatment technique known as plantar iontophoresis involves applying anti-inflammatory substances such as dexamethasone or acetic acid topically to the foot and transmitting these substances through the skin with an electrical current.[11] Moderate evidence exists to support the use of night splints for 1–3 months to relieve plantar fasciitis pain that has persisted for six months.[10] The night splints are designed to position and maintain the ankle in a neutral position thereby passively stretching the calf and plantar fascia overnight during sleep.[10] Other treatment approaches may include supportive footwear, arch taping, and physical therapy.[12]

Surgery[edit]

Plantar fasciotomy is often considered after conservative treatment has failed to resolve the issue after six months and is viewed as a last resort.[7][12] Minimally invasive and endoscopic approaches to plantar fasciotomy exist but require a specialist who is familiar with certain equipment. The availability of these surgical techniques is currently limited.[8] A 2012 study found 76% of patients who underwent endoscopic plantar fasciotomy had complete relief of their symptoms and had few complications (level IV evidence).[1] Heel spur removal during plantar fasciotomy has not been found to improve the surgical outcome.[22] Plantar heel pain may occur for multiple reasons and release of the lateral plantar nerve branch may be performed alongside the plantar fasciotomy in select cases.[8][22] Possible complications of plantar fasciotomy include nerve injury, instability of the medial longitudinal arch of the foot,[23] fracture of the calcaneus, prolonged recovery time, infection, rupture of the plantar fascia, and failure to improve the pain.[7] Coblation surgery has recently been proposed as alternative surgical approaches for the treatment of recalcitrant plantar fasciitis.[22]

Novel treatments[edit]

Dry needling is a treatment being researched for treatment of plantar fasciitis

Botulinum Toxin A injections as well as similar techniques such as platelet-rich plasma injections and prolotherapy have recently garnered attention as potentially effective methods to treat plantar fasciitis heel pain.[10][11] However, recent studies failed to demonstrate botulinum toxin A's superiority to placebo and did not find platelet-rich plasma injections to be a more effective treatment than corticosteroid injections for plantar fasciitis.[1]

Dry needling is also being researched for treatment of plantar fasciitis.[24] A systematic review of available research found limited evidence of efficacy, due to the poor quality of the available studies.[25]

Epidemiology[edit]

Plantar fasciitis is the most common type of plantar fascia injury[2] and is the most common reason for heel pain, responsible for 80% of cases. The condition tends to occur more often in women, military recruits, older athletes, the obese, and young male athletes.[10][13][14] Plantar fasciitis is estimated to affect 1 in 10 people at some point during their lifetime and most commonly affects people between 40-60 years of age.[1][9] In the United States alone, more than two million people receive treatment for plantar fasciitis.[9] The cost of treating plantar fasciitis in the United States is estimated to be $284 million each year.[9]

References[edit]

  1. ^ a b c d e f g Lareau CR, Sawyer GA, Wang JH, DiGiovanni CW (June 2014). "Plantar and Medial Heel Pain: Diagnosis and Management". The Journal of the American Academy of Orthopaedic Surgeons 22 (6): 372–80. doi:10.5435/JAAOS-22-06-372. PMID 24860133. 
  2. ^ a b c d e Jeswani T, Morlese J, McNally EG (September 2009). "Getting to the heel of the problem: plantar fascia lesions". Clin Radiol 64 (9): 931–9. doi:10.1016/j.crad.2009.02.020. PMID 19664484. 
  3. ^ a b Anderson J, Stanek J (May 2013). "Effect of foot orthoses as treatment for plantar fasciitis or heel pain". J Sport Rehabil 22 (2): 130–6. PMID 23037146. 
  4. ^ a b Aqil A, Siddiqui MR, Solan M, Redfern DJ, Gulati V, Cobb JP (November 2013). "Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: a meta-analysis of RCTs". Clin Orthop Relat Resl 471 (11): 3645–52. doi:10.1007/s11999-013-3132-2. PMID 23813184. 
  5. ^ a b c Zhiyun L, Tao J, Zengwu S (July 2013). "Meta-analysis of high-energy extracorporeal shock wave therapy in recalcitrant plantar fasciitis". Swiss Med Wkly 143: w13825. doi:10.4414/smw.2013.13825. PMID 23832373. 
  6. ^ Mohseni-Bandpei MA, Nakhaee M, Mousavi ME, Shakourirad A, Safari MR, Vahab Kashani R (May 2014). "Application of Ultrasound in the Assessment of Plantar Fascia in Patients With Plantar Fasciitis: A Systematic Review". Ultrasound Med Biol. S0301-5629 (14): 00148–3. doi:10.1016/j.ultrasmedbio.2014.03.001. PMID 24798393. 
  7. ^ a b c d e f g h i j k l m n o p q Goff JD, Crawford R (September 2011). "Diagnosis and treatment of plantar fasciitis". Am Fam Physician 84 (6): 676–82. PMID 21916393. 
  8. ^ a b c d e f Cutts S, Obi N, Pasapula C, Chan W (November 2012). "Plantar fasciitis". Ann R Coll Surg Engl 94 (8): 539–42. doi:10.1308/003588412X13171221592456. PMC 3954277. PMID 23131221. 
  9. ^ a b c d e f g h Rosenbaum AJ, DiPreta JA, Misener D (March 2014). "Plantar Heel Pain". Med Clin North Am 98 (2): 339–52. doi:10.1016/j.mcna.2013.10.009. PMID 24559879. 
  10. ^ a b c d e f g h i j k l m Tahririan MA, Motififard M, Tahmasebi MN, Siavashi B (August 2012). "Plantar fasciitis". J Res Med Sci. 17 (8): 799–804. PMC 3687890. PMID 23798950. 
  11. ^ a b c d e f g h i j Molloy LA (November 2012). "Managing chronic plantar fasciitis: when conservative strategies fail". JAAPA 25 (11): 48, 50, 52–53. doi:10.1097/01720610-201211000-00009. PMID 23620924. 
  12. ^ a b c d e f g Tu P, Bytomski JR (October 2011). "Diagnosis of heel pain". Am Fam Physician 84 (8): 909–16. PMID 22010770. 
  13. ^ a b c d e f Monto RR (December 2013). "Platelet-rich plasma and plantar fasciitis". Sports Med Arthrosc 21 (4): 220–4. doi:10.1097/JSA.0b013e318297fa8d. PMID 24212370. 
  14. ^ a b c d e f g h Orchard J (October 2012). "Plantar fasciitis". BMJ 10 (345): e6603. doi:10.1136/bmj.e6603. PMID 23054045. 
  15. ^ a b c d e Yin MC, Ye J, Yao M, Cui XJ, Xia Y, Shen QX, Tong ZY, Wu XQ, Ma JM, Mo W (March 2014). "Is Extracorporeal Shock Wave Therapy Clinical Efficacy for Relief of Chronic, Recalcitrant Plantar Fasciitis? A Systematic Review and Meta-Analysis of Randomized Placebo or Active-Treatment Controlled Trials". Arch Phys Med Rehabil. S0003-9993 (14): 00207–X. doi:10.1016/j.apmr.2014.01.033. PMID 24662810. 
  16. ^ Buchbinder R (May 2004). "Plantar Fasciitis". New England Journal of Medicine 350 (21): 2159–66. doi:10.1056/NEJMcp032745. PMID 15152061. 
  17. ^ Cole C, Seto C, Gazewood J (December 2005). "Plantar fasciitis: Evidence-based review of diagnosis and therapy". American Family Physician 72 (11): 2237–42. PMID 16342847. 
  18. ^ a b c American College of Occupational and Environmental Medicine (February 2014), Five Things Physicians and Patients Should Question, Choosing Wisely: an initiative of the ABIM Foundation (American College of Occupational and Environmental Medicine), retrieved 24 February 2014 , which cites
    • Haas, N; Beecher, P; Easly, M; et al. (2011). "Ankle and foot disorders". In Kurt T. Hegmann. Occupational medicine practice guidelines : evaluation and management of common health problems and functional recovery in workers (3rd ed.). Elk Grove Village, IL: American College of Occupational and Environmental Medicine. p. 1182. ISBN 978-0615452272. 
  19. ^ "Plantar Fasciitis and Bone Spurs". American Academy of Orthopaedic Surgeons. 2010. Retrieved 24 June 2014. 
  20. ^ a b c Wang CJ (March 2012). "Extracorporeal shockwave therapy in musculoskeletal disorders". J Orthop Surg Res 7 (1): 11–8. doi:10.1186/1749-799X-7-11. PMC 3342893. PMID 22433113. 
  21. ^ Lee SY, McKeon P, Hertel J (February 2009). "Does the use of orthoses improve self-reported pain and function measures in patients with plantar fasciitis? A meta-analysis". Phys There Sport 10 (1): 12–8. doi:10.1016/j.ptsp.2008.09.002. PMID 19218074. 
  22. ^ a b c Thomas JL, Christensen JC, Kravitz SR, Mendicino RW, Schuberth JM, Vanore JV, Weil LS, Zlotoff HJ, Bouché R, Baker J (May–June 2010). "The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010". J Foot Ankle Surg 49 (3 Suppl): S1–19. doi:10.1053/j.jfas.2010.01.001. PMID 20439021. 
  23. ^ Tweed JL, Barnes MR, Allen MJ, Campbell JA (September–October 2009). "Biomechanical consequences of total plantar fasciotomy: a review of the literature". J Am Podiatr Med Assoc 99 (5): 422–30. PMID 19767549. 
  24. ^ Cotchett MP, Landorf KB, Munteanu SE, Raspovic A (January 2011). "Effectiveness of trigger point dry needling for plantar heel pain: study protocol for a randomised controlled trial". Journal of Foot and Ankle Research 4 (1): 5. doi:10.1186/1757-1146-4-5. PMC 3035595. PMID 21255460. 
  25. ^ Cotchett MP, Landorf KB, Munteanu SE (September 2010). "Effectiveness of dry needling and injections of myofascial trigger points associated with plantar heel pain: a systematic review". Journal of Foot and Ankle Research 3 (1): 18. doi:10.1186/1757-1146-3-18. PMC 2942821. PMID 20807448. 

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