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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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