|Classification and external resources|
Plantar fasciitis (also known as Plantar fasciopathy or Jogger's heel) is a common painful enthesopathy of the heel and plantar surface of the foot characterized by inflammation, fibrosis, or structural deterioration of the plantar fascia of the foot. The plantar fascia is a thick fibrous band of connective tissue that originates from the medial tubercle and anterior aspect of the heel bone, extends along the sole of the foot before inserting at the base of the toes, and supports the arch of the foot. Plantar fasciitis is often caused by overuse of the plantar fascia, increases in physical activity, weight or age. Chronic cases often demonstrate structural changes more consistent with a degenerative process than an inflammatory one and such cases are termed plantar fasciosis.
Plantar fasciitis is the most common injury of the plantar fascia and is the most common cause of heel pain. Approximately 10% of people have plantar fasciitis at some point during their lifetime. It is commonly associated with long periods of weight bearing and is much more prevalent in individuals with hyperpronation (flat feet). Among non-athletic populations, plantar fasciitis is associated with obesity. The heel pain characteristic of plantar fasciitis is usually felt on the underside of the heel and is most intense with the first steps of the day. Individuals with plantar fasciitis often have difficulty bringing their toes toward the shin (decreased dorsiflexion of the ankle). This difficulty is usually due to tightness of the gastrocnemius muscle or Achilles tendon, the latter of which is posteriorly connected to the plantar fascia. Most cases of plantar fasciitis are self-limited and respond well to conservative methods of treatment.
Signs and symptoms
The classical presentation of plantar fasciitis pain is sharp and usually unilateral (30% of cases are bilateral) heel pain worsened by bearing weight on the heel after long periods of rest. Individuals with plantar fasciitis often report their symptoms are most intense during their first steps after getting out of bed or after sitting for a prolonged period and subsequently improves with continued walking. Numbness, tingling, swelling, or radiating pain are rarely reported symptoms.
Plantar fasciitis occurs more often in runners, people who stand on hard surfaces for prolonged periods of time, people with high arches of the foot, or in those susceptible to hyperpronation of the foot. Obesity is an independent risk factor for plantar fasciitis and has been observed in 70% of individuals who present with plantar fasciitis. Studies have suggested that there is a strong association 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.
Originally, plantar fasciitis was believed to be an inflammatory condition of the plantar fascia; however, histological changes observed in recent studies have indicated that plantar fasciitis is actually due to a noninflammatory structural degeneration of the plantar fascia rather than an inflammatory process. Due to this shift in thought about the underlying mechanisms in plantar fasciitis, many in the academic community have stated that the condition should be renamed plantar fasciosis. The structural breakdown of the plantar fascia is believed to be the result of repetitive microtrauma.
The diagnosis of plantar fasciitis is usually made by a physician after consideration of a patient's presenting history, risk factors, and clinical examination. Tenderness to palpation along the medial plantar aspect of the calcaneus may be elicited during the physical examination. Decreased dorsiflexion of the foot may be present due to tightness of the gastrocnemius muscle or the Achilles tendon and when dorsiflexed may elicit the pain due to stretching of the plantar fascia with this motion. Diagnostic imaging studies are not usually needed to diagnosis plantar fasciitis, but in some 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 such as fractures, tumors, or systemic disease if plantar fasciitis pain fails to respond appropriately to conservative medical treatments. Bilateral heel pain or heel pain in the context of a systemic illness may indicate a need for a more in-depth diagnostic investigation and may include 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. Neurological deficits may prompt an investigation with electromyography to evaluate for damage to the nerves or muscles.
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. Thickening of the plantar fascia aponeurosis at the heel greater than 5 millimeters as demonstrated by ultrasonography is consistent with a diagnosis of plantar fasciitis. However, authors have noted that medical imaging does not typically change how plantar fasciitis is managed and findings such as thickening of the plantar aponeurosis may be absent in symptomatic individuals or present in asymptomatic individuals thereby limiting the utility of such observations. 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 plantar fasciitis patients, in which case it is the underlying plantar fasciitis that produces the pain, and not the spur itself. The condition is responsible for the creation of the spur though the clinical significance of heel spurs in plantar fasciitis remains unclear. Other studies have suggested that plantar fasciitis is not actually due to inflamed plantar fascia, but may be a tendinopathy involving the flexor digitorum brevis muscle located immediately deep to the plantar fascia.
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), plantar fascia rupture, and compression neuropathies such as tarsal tunnel syndrome or impingement of the medial calcaneal nerve.
Most cases (90%) of plantar fasciitis are self-limited and will improve within the span of six months with conservative treatment or within the span of a year regardless of treatment. Many treatments have been proposed for the treatment of plantar fasciitis, but the effectiveness of most of these treatments has not been adequately investigated and consequently there is little evidence to support recommendations for such treatments. First-line conservative approaches such as rest, heat, ice, calf-strengthening exercises, plantar fascia stretching techniques, achilles tendon stretching techniques, weight reduction in overweight or obese patients, and nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen are considered first-line treatments for plantar fasciitis. NSAIDs are commonly used to treat plantar fasciitis, but fail to resolve the pain in 20% of patients.
Extracorporeal shockwave therapy (ESWT) is an effective treatment modality for plantar fasciitis pain unresponsive to conservative nonsurgical measures for at least three months; evidence suggests significant pain relief lasts up to one year after the procedure. ESWT can be performed with or without anesthesia though studies have suggested that the therapy is less effective when anesthesia is administered. Complications from ESWT are rare and typically mild when present. Known complications of ESWT include the development of a mild hematoma or an ecchymosis, redness around the site of the procedure, or migraine.
Corticosteroid injections are sometimes used for cases of plantar fasciitis refractory to more conservative measures and may be an effective modality for pain relief, but have notable risks such as plantar fascia rupture, skin infection, nerve or muscle injury, or atrophy of the plantar fat pad. Custom orthotic devices have been demonstrated as an effective method to reduce plantar fasciitis pain for up to 12 weeks; the long-term effectiveness of custom orthotics for plantar fasciitis pain reduction requires additional study. Orthotic devices and low-dye taping are proposed to reduce pronation of the foot and therefore reduce load on the plantar fascia resulting in pain improvement.
Another form of treatment is plantar iontophoresis, a technique which 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. 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. 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. Other treatment approaches may include supportive footwear, arch taping, and physical therapy.
Plantar fasciotomy is often considered after treatment failure by conservative measures for at least six months and is viewed as a last resort. Minimally invasive and endoscopic approaches to plantar fasciotomy exist, but require a high degree of technical skill and familiarity with certain equipment thereby limiting the availability of these surgical techniques. Removal of heel spurs during plantar fasciotomy has not been found to improve the surgical outcome. 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. Possible complications of plantar fasciotomy include nerve injury, instability of the medial longitudinal arch of the foot, fracture of the calcaneus, prolonged recovery time, infection, rupture of the plantar fascia, and failure to improve the pain. Coblation surgery has recently been proposed as alternative surgical approaches for the treatment of recalcitrant plantar fasciitis.
Continued overuse of the plantar fascia in the setting of plantar fasciitis may result in rupture of the plantar fascia; typical signs and symptoms of plantar fascia rupture include a clicking or snapping sound, significant local swelling, and acute pain in the plantar fascia region.
Plantar fasciitis is the most common type of plantar fascia injury and is the most common reason for heel pain (responsible for 80% of cases); approximately 1 in 10 people develop plantar fasciitis at some point in their life. The condition tends to occur more often in women, the middle-aged, military recruits, older athletes, the obese, and young male athletes. Plantar fasciitis is estimated to affect 1 in 10 people at some point during their lifetime and its annual economic burden is estimated to be between 192 to 376 million dollars. Each year, pain from plantar fasciitis is responsible for 1–2 million physician office visits.
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.
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