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Plantar Fasciitis

Plantar fasciitis, also known as plantar fasciosis, plantar fasciopathy, jogger's heel, or heel spur syndrome, is a connective tissue disorder affecting the plantar fascia. This condition is characterised by pain in the heel and bottom of the foot, typically more severe with the first steps of the day or after periods of rest. Pain may also be induced by bending the foot and toes towards the shin. The onset of pain is generally gradual, and about one-third of cases affect both feet.

Signs and Symptoms

The hallmark symptom of plantar fasciitis is sharp heel pain, often unilateral. Bearing weight on the heel after extended periods of rest worsens the pain. Patients frequently report that symptoms are most intense during their first steps after getting out of bed or after prolonged sitting, with improvement noted with continued walking. Rare symptoms may include numbness, tingling, swelling, or radiating pain. There are typically no systemic symptoms such as fever or night sweats.

Overuse of the plantar fascia can lead to its rupture, presenting with a clicking or snapping sound, significant swelling, and acute pain at the bottom of the foot.

Most common areas of pain in plantar fasciitis
Most common areas of pain in plantar fasciitis.

Risk Factors

Risk factors for plantar fasciitis include excessive running, prolonged standing on hard surfaces, high foot arches, leg length inequality, and flat feet. Flat feet tend to excessively roll inward, making them more susceptible. Obesity is seen in 70% of affected individuals and is an independent risk factor. Achilles tendon tightness and inappropriate footwear have also been identified as significant risk factors.

Pathophysiology

The plantar fascia is a thick fibrous band originating from the heel bone and extending along the sole to insert at the base of the toes. Plantar fasciitis is characterised by a non-inflammatory structural breakdown of the plantar fascia, including micro tears, collagen breakdown, and scarring. Newer findings suggest renaming the condition to plantar fasciosis. Disruptions in the normal mechanical movement of the fascia, known as the Windlass mechanism, place excess strain on the heel bone, contributing to the condition.

Drawing of the plantar fascia
Drawing of the plantar fascia.

Diagnosis

Diagnosis typically relies on the patient's history and physical examination. Palpation of the heel and limited dorsiflexion due to calf or Achilles tendon tightness can elicit pain. Imaging studies like X-rays, ultrasound, or MRI are not routinely needed but may be used to rule out other conditions. Heel spurs, often found in patients with plantar fasciitis, are incidental findings and not the cause of pain.

Achilles tendon tightness is a risk factor
Achilles tendon tightness is a risk factor for plantar fasciitis.
Heel bone with heel spur
Heel bone with heel spur (red arrow).
Thickened plantar fascia in ultrasound
Thickened plantar fascia in ultrasound.

Treatment

Non-surgical

Most cases improve within six months with conservative treatment. Recommended initial treatments include daily stretching, foot taping, and education on appropriate footwear. Strengthening foot muscles through barefoot exercises can reduce pain and stress on the plantar fascia. If conservative measures fail after three months, extracorporeal shockwave therapy (ESWT) may be considered, though its efficacy is debated. Customised foot orthoses may offer short-term pain relief.

Customised foot orthoses can offer short-term pain relief
Customised foot orthoses can offer short-term pain relief.

Further conservative approaches include rest, massage, heat, ice, calf-strengthening exercises, weight reduction, and NSAIDs. Corticosteroid injections provide short-term relief but are not effective long-term. Night splints may relieve persistent pain by passively stretching the calf and plantar fascia during sleep.

Surgical

Surgery, specifically plantar fasciotomy, is a last resort after six months of failed conservative treatment. Minimally invasive approaches exist but are limited to specialists. Potential complications include nerve injury, infection, and prolonged recovery time. Heel spur removal during surgery does not improve outcomes.

Unproven Treatments

Botulinum toxin A injections, platelet-rich plasma injections, and prolotherapy remain controversial. Dry needling shows limited evidence of effectiveness. Combining stretching with botulinum toxin may improve outcomes.

Epidemiology

Plantar fasciitis is the most common cause of heel pain, affecting about 1 in 10 people during their lifetime. It is more prevalent in women, military recruits, older athletes, dancers, individuals with obesity, and young male athletes. In the United States, more than two million people are treated annually for plantar fasciitis, with an estimated cost of $284 million each year.

Prognosis

Studies show that 20% to 75% of individuals with plantar fasciitis no longer have symptoms within a year. The presence of a heel spur does not worsen the prognosis.


Self-assessment MCQs (single best answer)

What is the primary symptom of plantar fasciitis?



Which of the following is NOT a common risk factor for plantar fasciitis?



The structural breakdown of the plantar fascia in plantar fasciitis includes all of the following EXCEPT:



Which imaging study is most commonly used to examine the thickened plantar fascia?



What conservative treatment is NOT typically recommended for plantar fasciitis?



What is the term used to describe the mechanical movement disruption of the plantar fascia contributing to plantar fasciitis?



What is the last resort treatment option for plantar fasciitis after six months of failed conservative treatment?



Which of these is a debated and potentially ineffective treatment for plantar fasciitis?



What percentage of individuals with plantar fasciitis report no symptoms within a year?



Which of the following is NOT typically a symptom of plantar fasciitis?



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