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Plantar Fasciopathy

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Other Names

  • Plantar Fasciitis
  • Plantar Fasciopathy
  • Plantar Fasciosis

Background

  • This page refers to fasciopathy of the the Plantar Fascia of the foot, most commonly referred to as 'Plantar Fasciitis' (PF)

History

Epidemiology

  • General
    • Peak age is between 45 and 65 years[1]
    • About 1 in 3 patients will have bilateral symptoms[2]
    • An estimated $284 million is spent each year on plantar fasciitis treatments (need citation)
  • Prevalence
    • Affects 1 in 10 people in their lifetime (need citation)
    • 2 million people receive treatment for this condition annually around the world[1]

Pathophysiology

  • General
    • Defined by pain and structural changes at the proximal insertion of the plantar fascia on the calcaneus
    • It is the most common cause of chronic heel pain in adults (need citation)
    • Generally thought to occur due to degeneration of the plantar fascia as a result of repetitive microtears of the fascia
    • This leads to an inflammatory reaction, and is not a primary inflammatory process (as often thought to be)
    • Approximately 90-95% of cases resolve within 12 months with conservative treatment[3]
  • Terminology
    • Fasciitis: describes inflammation of the plantar fascia
    • Fasciosis: degenerative changes of the plantar fascia
    • Fasciopathy: describes more chronic thickening and degenerative process
    • Fasciopathy is more appropriate as the vast majority of patients have findings consistent with chronic injuries including thickening and degeneration
    • Note that patients often do not seek healthcare until their symptoms can be classified as chronic

Etiology

  • General
    • Overall, this condition is poorly understood
    • Tensile strength of the plantar fascia appears to be a key feature of pathogenesis[4]
    • Known to be associated with several limiting biomechanical risks
    • Often due to either overuse (runners, military personnel) or excessive loading (obesity, sedentary)[5]
  • Tight gastrocnemius
    • Increases Achilles tendon tension and dorsiflexion stiffness of the ankle
    • Thus increasing plantar fascia tension during weight-bearing activities
  • Histopathology[4]
    • The increased fascial load is sensed by the gap junctions between fibrocytes (mechanotransduction)
    • This mediates changes in the extracellular matrix
    • Subsequently, there is myxoid degeneration and fragmentation of the plantar fascia and perifascial structures.

Associated Conditions

Pathoanatomy

  • Plantar Fascia
    • Band of connective tissue originating at the calcaneus and inserting on the tendons of the forefoot and proximal phalanges
    • Function: support the arch of the foot, act as a shock absorber for pressure placed on the foot[6]

Risk Factors

  • Demographic
    • Increasing age[7]
    • Gender: No differences between men and women[7]
    • Obese patients have a 1.4 fold increased risk[8][9]
  • Orthopedic/ Anatomic
    • Calcaneal enthesophytes (heel spurs) do not appear to increase the risk of PF (need citation)
      • One study found neither the shape nor size of the spur has a correlation with function or pain before or after treatment[10]
    • Baxters Neuropathy may co-exist and increase risk[11]
  • Systemic/ Intrinsic
    • Spondyloarthropathy
    • Genetic
  • Sports
  • Occupational
    • Military Service[14]
    • 'Weight Bearing Tasks'
    • Long periods of standing
  • Biomechanical
    • Tight gastrocnemius muscle[15]
    • Planovalgus feet
    • Gastrocnemius contracture
    • Severe hallux valgus[16]
    • Limited ankle dorsiflexion
      • 83% of patients with recalcitrant PF have limited ankle dorsiflexion[17]
    • Pes Cavus
    • Tight intrinsic foot muscles
    • Leg length discrepancy
    • Poor fitting shoes
    • Improper gait[18]

Differential Diagnosis


Clinical Features

  • History
    • The diagnosis is often made clinically
    • The pain is located on the plantarmedial aspect of the heel
    • Post Static Dyskinesia: classically, perhaps pathognomonic, patients report pain upon first waking and standing up in the morning
      • This tends to improve after a walking for a while
      • It improves with activity initially, then worsens as the activity becomes prolonged
    • Pain is described as dull aching or throbbing pain
  • Physical Exam: Physical Exam Foot
    • Tenderness is located at the plantar aspect of the medial calcaneal tuberosity at the fascia insertion
  • Special Tests

Evaluation

Radiographs

  • Standard Radiographs Foot
    • Often reveal calcaneal enthesophytes (heel spurs)
      • A sign of calcification at the origin of the flexor digitorum brevis muscle, thought to be a response to chronically tight achilles tendon
      • Although here is a higher incidence of heel spurs in patients suffering from PF (75% vs 63% in asymptomatic patients)
      • There is no apparent correlation between spurs and pain[19]

Ultrasound

  • Can be considered to exclude other soft tissue pathology
  • Potential Findings
    • Plantar fascia is softer using sonoelastrography in patients with typical clinical manifestations of plantar fasciitis[20]
    • Thickness tends to be greater than 4 mm on diagnostic ultrasound[21]
    • A plantar fascia thickness >4.5 mm and the presence of hypoechoic areas are specific for PF[22]
    • Subcalcaneal bone spurs (24%), peritendinous edema (5%), subcalcaneal bone erosion (4%), intratendinous calcification (3%), and retrocalcaneal bursitis are associated with PF but are not specific[23][22]

MRI

  • Can be considered to exclude other soft tissue pathology
  • Findings
    • Increased signal intensity and proximal plantar fascia thickening[24]
    • Thickening of the plantar fascia, although there does not appear to be a correlation between thickness and pain[25]

Classification

  • Not applicable

Management

Nonoperative

  • Indications
    • All cases
  • Explanation to patients
    • Explain to patients that pain will likely settle over time and manage expectations
  • Ice Therapy
    • Many clinicians recommend 'rolling' the arch with a frozen water bottle
  • Physical Therapy
    • First line choice and primary treatment modality
    • Calf-stretching exercises with eccentric loading may be the most important treatment[26]
    • Benefits from strengthening extrinsic and intrinsic foot muscles, strengthening abductor and lateral rotator hip muscles, and stretching[27]
  • Foot Orthotic
    • Goals: decrease pronation, off-load the proximal insertion of the fascia
    • RCT comparing over-the-counter shoe inserts with customized shoe inserts found no difference in pain relief 12-month follow-up[28]
    • Can also consider Heel Cup
    • More effective when combined with night splint[29]
  • Nocturnal Splint
    • Goal: stretch the fascia to prevent morning stiffness and pain[30]
    • Multiple studies show benefit, but patients do not tolerate well and compliance can be problematic[31][32][33]
  • Corticosteroid Injection
    • Cochrane review shows low quality evidence of benefits for 1 month, but none after[34]
    • Risks: heel pad atrophy, plantar fascia rupture
    • Consider alternative treatment options
    • Strongly consider use of ultrasound to avoid risks
  • Autologous Blood Injection
    • One small prospective study of 35 patients showed some benefit[35]
  • Botulinum Toxin A Injection
    • A small RCT showed statistically significant changes in the treatment group[36]
  • Platelet Rich Plasma
    • A systematic review and meta-analysis found benefit at 3 months compared to placebo[37]
  • Extracorporeal Shock Wave Therapy (ECSWT)
    • Meta-analysis suggests focused shock wave (FSW) can relieve pain but no firm conclusions of general ECSWT and radial shock wave (RSW)[38]
  • Radiation Therapy
    • Thought to have anti-inflammatory effects that reduce inflammatory mediators and pain
    • Small risk of carcinogenesis
    • Superior to corticosteroid injections for pain relief at 3 and 6 months[39]

Operative

  • Indications
    • Failure of at least 12 months of conservative therapy
  • Technique
    • Medial open release of approximately the medial third of the fascia (fasciotomy)
    • Release of the first branch of the lateral plantar nerve (nerve decompression
    • Isolated proximal medial gastrocnemius release

Rehab and Return to Play

Rehabilitation

  • Typical postoperative course
    • 3 weeks of immobilization
    • Followed by 3 weeks of partial weight bearing

Return to Play

  • General
    • Typically gradual with emphasis on avoiding training through pain
    • Often cross training with non-impact activities

Complications & Prognosis

Prognosis

  • Nonoperative management
    • Approximately 95% of patients will be pain free at 12 months without surgery[40]
  • Comparing surgical technique
    • Monteagudo et al found more patients improved with complete gastrocnemius release (95%) than those who had partial plantar fasciotomy (60%)[41]

Complications

  • Surgical
    • Infection
    • Nerve injury
    • Plantar fascia rupture

See Also


References

  1. 1.0 1.1 Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int 2004;25:303–310.
  2. Neufeld, SK, Cerrato, R. Plantar fasciitis: evaluation and treatment. J Am Acad Orthop Surg 2008;16(6):338–346.
  3. Crawford F, Thompson CE. Interventions for treating plantar heel pain. Cochrane Database Syst Rev 2003;3:CD000416.
  4. 4.0 4.1 Zhang, J, Nie, D, Rocha, JL, Hogan, MV, Wang, JH-C. Characterization of the structure, cells, and cellular mechanobiological response of human plantar fascia. J Tissue Eng. 2018;9:2041731418801103.
  5. Riddle, DL, Pulisic, M, Pidcoe, P, Johnson, RE. Risk factors for plantar fasciitis: a matched case-control study. J Bone Joint Surg Am. 2003;85(5):872–877.
  6. Tong KB, Furia J. Economic burden of plantar fasciitis treatment in the United States. Am J Orthop (Belle Mead NJ). 2010;39(5):227–231.
  7. 7.0 7.1 Beeson P. Plantar fasciopathy: revisiting the risk factors. Foot Ankle Surg 2014;20:160–165
  8. Frey C, Zamora J. The effects of obesity on orthopaedic foot and ankle pathology. Foot Ankle Int 2007;28:996–999.
  9. Van Leeuwen KD, Rogers J, Winzenberg T, van Middelkoop M. Higher body mass index is associated with plantar fasciopathy/‘plantar fasciitis’: systematic review and meta-analysis of various clinical and imaging risk factors. Br J Sports Med 2016;50:972–981.
  10. Ahmad J, Karim A, Daniel JN. Relationship and classification of plantar heel spurs in patients with plantar fasciitis. Foot Ankle Int 2016;37:994–1000.
  11. Ferkel E, Davis WH, Ellington JK. Entrapment neurophaties of the foot and ankle. Clin Sports Med 2015;34:791–801.
  12. Sobhani S, Dekker R, Postema K, Dijkstra PU. Epidemiology of ankle and foot overuse injuries in sports: a systematic review. Scand J Med Sci Sports 2013;23:669–686
  13. Noon M, Hoch AZ, McNamara L, Schimke J. Injury patterns in female Irish dancers. PM R 2010;2:1030–1034.
  14. Scher DL, Belmont PJ, Jr, Bear R, et al. The incidence of plantar fasciitis in the United States military. J Bone Joint Surg Am 2009;91:2867–2872
  15. Amis J. The gastrocnemius: a new paradigm for the human foot and ankle. Foot Ankle Clin N Am 2014;19:637–647.
  16. Kitaoka HB, Luo ZP, An KN. Mechanical ulticent of the foot and ankle after plantar fascia release in the unstable foot. Foot Ankle Int 1997;18:1–15.
  17. Patel A, DiGiovanni B. Association between plantar fasciitis and isolated contracture of the gastrocnemius. Foot Ankle Int 2011;32:5–8.
  18. Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg. 2010;49(3 suppl):S1–S19.
  19. Solan MC, Carne A, Davies MS. Gastrocnemius shortening and heel pain. Foot Ankle Clin 2014;19:719–738.
  20. Wu CH, Chen WS, Wang TG. Plantar fascia softening in plantar fasciitis with normal B-mode sonography. Skeletal Radiol. 2015 Nov;44(11):1603-7. doi: 10.1007/s00256-015-2215-4. Epub 2015 Jul 16. PMID: 26173419.
  21. Draghi F, Gitto S, Bortolotto C, et al. Imaging of plantar fascia disorders: findings on plain radiography, ultrasound and magnetic resonance imaging. Insights Imaging. 2017;8(1):69–78.
  22. 22.0 22.1 Mahowald, S, Legge, BS, Grady, JF. The correlation between plantar fascia thickness and symptoms of plantar fasciitis. J Am Podiatr Med Assoc. 2011;101(5):385–389.
  23. Kane, D, Greaney, T, Shanahan, M, et al. The role of ultrasonography in the diagnosis and management of idiopathic plantar fasciitis. Rheumatology (Oxford). 2001;40(9):1002–1008.
  24. amba, C, Sala-Pujals, A, Perez-Prieto, D, et al. Relationship of plantar fascia thickness and preoperative pain, function, and quality of life in recalcitrant plantar fasciitis. Foot Ankle Int. 2018;39(8):930–934.
  25. Toomey EP. Plantar heel pain. Foot Ankle Clin 2009;14:229–245.
  26. . DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain: a prospective, randomized study. J Bone Joint Surg Am 2003;85:1270–1277.
  27. Cheung RT, Sze LK, Mok MW, Ng GY. Intrinsic foot muscle volume in experienced runners with and without chronic plantar fasciitis. J Sci Med Sport 2016;19:713–715.
  28. Landorf KB, Keenan AM, Herbert RD. Effectiveness of foot orthoses to treat plantar fasciitis: a randomized trial. Arch Intern Med 2006;166:1305–1310.
  29. Lee WC, Wong WY, Kung E, Leung AK. Effectiveness of adjustable dorsiflexion night splint in combination with accommodative foot orthosis on plantar fasciitis. J Rehabil Res Dev. 2012;49(10):1557–1564.
  30. Roos E, Engstrom M, Soderberg B. Foot orthoses for the treatment of plantar fasciitis. Foot Ankle Int 2006;27:606–611.
  31. Batt ME, Tanji SL, Skattum N. Plantar fasciitis: a prospective randomized clinical trial of the tension night splint. Clin J Sport Med 1996;6:158–162.
  32. Powell M, Post WR, Keener J, et al. Effective treatment of chronic plantar fasciitis with dorsiflexion night splints: a crossover prospective randomized outcome study. Foot Ankle Int 1998;19:10–18.
  33. Probe RA, Baca M, Adams R, Preece C. Night splint treatment for plantar fasciitis: a prospective randomized study. Clin Orthop Relat Res 1999;368:190–195.
  34. David JA, Sankarapandian V, Christopher PR, Chatterjee A, Macaden AS. Injected corticosteroids for treating plantar heel pain in adults. Cochrane Database Syst Rev 2017;11:CD009348
  35. Wheeler, Patrick. "Autologous blood injections for chronic plantar fasciitis–a pilot case-series study shows promising results." International Musculoskeletal Medicine 35.1 (2013): 3-7.
  36. Babcock MS, Foster L, Pasquina P, Jabbari B. Treatment of pain attributed to plantar fasciitis with botulinum toxin A: a short-term, randomized, placebo-controlled, double-blind study. Am J Phys Med Rehabil 2005;84:649–654
  37. Singh, Prashant, et al. "A systematic review and meta-analysis of platelet-rich plasma versus corticosteroid injections for plantar fasciopathy." International orthopaedics 41.6 (2017): 1169-1181.
  38. Sun, Jiale, et al. "Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: A meta-analysis of RCTs." Medicine 96.15 (2017).
  39. Canyilmaz E, Canyilmaz F, Aynaci O, et al. Prospective randomized comparison of the effectiveness of radiation therapy and local steroid injection for the treatment of plantar fasciitis. Int J Radiat Oncol Biol Phys. 2015;92(3):659–666.
  40. Davies MS, Weiss GA, Saxby TS. Plantar fasciitis: how successful is surgical intervention? Foot Ankle Int 1999;20:803–807
  41. Monteagudo M, Maceira E, Garcia-Virto V, Canosa R. Chronic plantar fasciitis: plantar fasciotomy versus gastrocnemius recession. Int Orthop. 2013;37(9):1845–1850.
Created by:
John Kiel on 7 July 2019 08:17:07
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Last edited:
4 October 2022 12:39:59
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