Plantar fascitis

A review of this commonly seen condition on A4Medicine. It presents the clinician with the risk factors of plantar fasciitis and the typical history of gradual onset of pain which is worse in the morning. Point tenderness on examination and Windlass tests could be elicited during the examination. The GP can also consider other conditions as bruised heal syndrome and sub calcaneal bursitis during the workup. The management options are displayed clearly and include biomechanical treatment, physiotherapy, extracorporal shock wave therapy and hydrocortisone injections. Surgery, although mentioned, is rarely seen in clinical practice. The GP could reassure the patient that the prognosis is generally good.

Pain caused by a degenerative irritation at the insertion of the plantar fascia on the medial process of calcaneal tuberosity Repetitive 
microtrauma of the fascia → chronic degeneration of plantar fascia fibres

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 Sedentary lifestyle Tightening of Achilles tendon and intrinsic foot muscles

History-Slow but gradual onset of pain along the inside of heel Pain worse when taking initial steps in the morning Pain tearing in character Eases after few minutes of walking but may return on weight bearing after periods of inactivity during the day Location → medial side of the foot at bottom of heel

Examination-Point tenderness at origin of plantar fascia on calcaneal tuberosity
 Limited ankle dorsiflexion ( with knee in extension )
 Positive Windlass test- pain reproduced by extension of the first metatarsophalangeal joint
 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 fascitis may be coincidental
○ Patient may focus on spur → may negatively influence outcome
 Plasma viscosity , 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

Differential-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

Weight loss → can be problamatic advice cross training eg swimming or cycling until pain starts to resolve.Take analgesia PRN basis
Paracetamol alone or with codeine
NSAIDs- Ibuprofen

Management-Self limiting condition → usually improves within one year regardless of treatment
 Management involves stretching and strengthening of plantar fascia while attempting to reduce any precipitant.Orthotics-
○ Insoles
○ Night splints ( rarely required )
○ Footwear modifications
○ Taping. Physiotherapy-Stretching exercises Cross-frictional massage →rolling heel over golf ball US , laser treatment.

Extracorporal shockwave therapy –Used to promote neovascularization to aid in healing degenerative tissue Non- invasive and offers the hope of faster recovey time Can be painful

steroid injection-Most common medical treatment used ( cortisone inj )
○ risk of rupture
○ risk atrophy of heel pad
○ US guided injections ↑ accurate but notoriously painful
○ evidence – short term relief ( lacks evidence long term relief )
 other injectible options
○ percutaneous fenestration ( dry needling )
○ hyperosmolar dextrose ( prolotherapy)
○ whole blood , platelet rich plasma
○ botox

Surgery-No evidence from randomised control trials Hard to justify surgery in a case of only few months duration given the likely success with less invasive methods