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Plantar Fasciitis

Plantar fasciitis – Pain caused by a degenerative irritation at the insertion of the plantar fascia
 on the medial process of calcaneal tuberosity

How common ? One of the most common causes of heel pain Exact prevalence is not known Twice as common in women One of the most common foot and ankle injury condition observed in 
professional athletes Approximately 50 % if patients with this condition also have heel spurs but the spurs themselves are not the cause


What Happens –Exact cause not known Considered to be an overuse injury Repetitive microtrauma of the fascia → chronic degeneration of plantar fascia fibers Previously thought to be an inflammatory process but characteristic features of inflammation have not been found ( Lemont et al ) It has been suggested that the condition should be called as plantar ” FASCIOSIS ” Other terms for the condition
○ plantar fasciopathy
○ policeman’s heel
○ joggers heel

Risk Factors –Excessive foot pronation ( pes planus ) Excessive running High arch ( pes cavus ) Leg length discrepancy Overweight people 40-60 yrs of age Prolonged standing / walking occupations Runners Sedentary lifestyle Tightening of Achilles tendon and intrinsic foot muscles

Why important –Associated with high morbidity in athletes Morbidity due to 
○ pain
○ difficulty with ambulation
○ limitation in exercise
○ inability to weight bear Inability to perform work related activities – loss of income Weight gain can be a significant issue Recurrence

History Presentation –Main complain is pain in the arch of the foot when bearing weight- worse during the first few steps in the morning and improves with rest Pain is made worse by prolonged standing or walking Pain can be reproduced by palpating the plantar medial calcaneal tubercle at the site of the plantar fascial insertion on the heel bone Limited ankle dorsiflexion ( with knee in extension ) Positive Windlass ( or Jack’s test )- pain reproduced by passive dorsiflexion of the first metatarsophalangeal joint 
( see external link ) Abnormal walking ( walk in equine position to avoid placing pressure ) / limping due to pain may be observed

Investigations –None usually required
 XRay – unhelpful – presence of spur is not diagnostic
○ Heel spur- ossification on plantar aspect of calcaneum
○ Association with plantar fasciitis may be coincidental
○ Patient may focus on spur → may negatively influence outcome
 Plasma viscosity , rheumatoid factor , CRP and HLA-B27 may be useful if b/l and other enthesopathy or arthropathy present
 Nerve conduction study- if compressive neuropathy suspected
 ( including suspicion of tarsal tunnel syndrome)
 MRI ( valuable tool ) , US ( r/o soft tissue pathology of heel ) , Bone scan- via secondary care

What else can it be ? Bruised heel syndrome
○ obese elderly or younger athletes training on hard surfaces
○ pain is felt more posteriorly → under fat pad of calcaneum
○ biomechanical problem → Rx similar as in PF
 Subcalcaneal bursitis
○ elderly with new shoes ○ tender swelling under the calcaneum
○ not ↑↑ by dorsiflexion of toes
 Tarsal tunnel syndrome
○ compression of tibial N or associated branches as the N passes underneath the flexor retinaculum
○ pain , numbness and burning felt in medial side of foot , ankle or even calf
 ( usually poorly localised )
○ ↑↑ at night – can be associated with other systemic illnesses
 Stress fracture calcaneum Servers dis ( children and adolescents ) Rare cause- consider referral if no better in 3-6 months
○ fibrosarcoma , metastases, foreign body , Paget’s , osteomyelitis , TB , Gout
 



Reassurance –More than 90 % cases will resolve with non-surgical measures within 12 months

Conservative 
treatment involving several measures in combination

Self-care-Rest – effective in up to 25 % cases Icing ( see under links ) Low dye taping ( see under links ) Shoes with adequate support Activity modification Insoles/ heel pad consider orthotics advice Stretching of tendo-achilles and plantar fascia- 3 times/ day with Night splints ( look under resources ) NSAIDs

Physiotherapy-massage myofascial release specific soft tissue mobilisations myofascial trigger point therapy

Other treatments –Injection therapy
○ corticosteroids- used for acute pain for short term benefits ( can be v painful -serious side effects are rare )
○ platelet rich plasma ( PRP )
○ autologous bone injection
○ botulinum toxin ( Botox , Dysport ) inj Iontophoresis and phonophoresis Cast immobilisation Cryotherapy

Specialist treatment –Extracorporeal shock wave therapy ( ESWT )
○ recommended 2nd line 
○ no sign adverse effects
○ evidence base of efficacy is gradually evolving
 Surgery
○ effective
○ 3rd line
○ endoscopic plantar fascia release / fasciotomy

LINKS AND RESOURCES

A comprehensive patient information leaflet from Oxford University Hospital NHS Trust
( 12 pages printable ) https://www.ouh.nhs.uk/patient-guide/leaflets/files/49007Pfasciitis.pdf

Two page exercise leaflet from ARC UK https://www.cnwl.nhs.uk/wp-content/uploads/Plantar-Fasciitis-Information-Sheet.pdf

American Academy of Orthopaedic Surgeons Orthoinfo PIL https://orthoinfo.aaos.org/globalassets/pdfs/planter-fasciitis.pdf

Windlass or Jack’s test from the Student Physical Therapist (TSPT) https://www.thestudentphysicaltherapist.com/windlass-test.html

Low Dye Tapingprintable information from Sheffield Primary Care Trusthttps://www.sth.nhs.uk/clientfiles/File/8.pdf

NHS Borders – useful and concise PIL https://www.nhsborders.scot.nhs.uk/media/450853/Plantar-Fasciopathy-Patient-Information-leaflet-December-2016.pdf

Questionnaire –Foot and ankle ability measure ( FAAM ) Online tool https://www.orthotoolkit.com/faam/

Foot Health Status Questionnaire ( printable ) https://static1.squarespace.com/static/59e80b898dd041540eecce86/t/5a377782f9619a424b81d3b9/1513584518613/fhsq_full_V1.04.pdf

NSCP Plantar fasciitis self help guide https://www.careuk.com/sites/hc/files/legacy_files/Patient_Leaflet_Plantar_Fasciitis.pdf

Guidelines

American College of Foot and Ankle Surgeons Clinical Consensus Statement: Diagnosis and Treatment of Adult Acquired Infracalcaneal Heel Pain https://www.ncbi.nlm.nih.gov/pubmed/29284574?dopt=Abstract

Full guidance https://www.acfas.org/Research-and-Publications/Clinical-Consensus-Documents/Heel-Pain/

NICE guideline Extracoropeal Shockwave therapy for Achilles tendinopathy https://www.nice.org.uk/Guidance/IPG571

American Physical Therapy Association ( APTA ) Clinical Practice Guideline Revision 2014 https://www.jospt.org/doi/full/10.2519/jospt.2014.0303

Review articles

Plantar fasciitis : A review in Indian Journal of pain ( 2018 ) http://www.indianjpain.org/article.asp?issn=0970-5333;year=2018;volume=32;issue=1;spage=24;epage=29;aulast=Menon

Plantar fasciitis in athletes: diagnosis and treatment strategies. A systemic review https://pdfs.semanticscholar.org/e225/d740c192f569d07a1bbf1be520bc6ba3627c.pdf

 

Referral-Review to assess progress F/U at 1 and 6 weeks is suggested by BMJ Best Practice Consider using questionnaires as
○ foot health status questionnaire ( FHS find under links )
○ foot an ankle ability measure ( FAAM ) Refer if situation worsens or an an alternative diagnosis is suspected Refer if pain persist following treatment by physiotherapist / podiatrist

References Sports Medicine-Edited by David Drez et al DeLee & Drez’s Orthopaedic Sports Medicine-4th Edition Plantar heel pain BMJ 2016;353:i2175 Plantar Fascitis : Background , Anatomy , Pathophysiology -Emedicine Craig C Young et al Nov 2016 Reports on the Rheumatic Diseases Series 5 Plantar Fascitis and Heel Pain Ross Duff MBChB , DipPCR Diagnosis and Treatment of Plantar Fascitis Am Family Physician. 2011 Sep 15;84(6):676-682 Plantar fascitis BMJ John Orchard 2012;345:e6603 Diagnosis and management of plantar fascitis in primary care James Thing et al Br J Gen Practice 2012 Aug;62(601):443-444 Hands On Report : Plantar fascitis and heel pain Arthritis Research UK Feb 2004 Plantar fasciitis CKS NHS June 2015 BMJ Best Practice Plantar Fasciitis StatPearls Plantar Fasciitis Benjamin K Buchanan , Donald Kushner Feb 2019

 

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