Orthopaedic Surgery - Heel Pain (Plantar Fasciitis)

Basics

Plantar fasciitis is the most common cause of plantar heel pain in adults.

Although commonly called “fasciitis,” the underlying process is predominantly degenerative rather than inflammatory, and the term plantar fasciopathy may more accurately describe the pathology.

Other Causes of Plantar Heel Pain

Not all plantar heel pain is caused by plantar fasciitis.

Important alternative causes include:

Entrapment of the first branch of the lateral plantar nerve, heel-pad atrophy, inflammatory enthesopathy associated with seronegative spondyloarthropathies, tarsal tunnel syndrome, and calcaneal stress fracture.

The first branch of the lateral plantar nerve is also commonly referred to as Baxter’s nerve.

Geriatric Considerations

In older adults, plantar heel pain may result from atrophy of the calcaneal fat pad, degenerative changes at the plantar fascial origin, or both.

Loss of heel cushioning can produce pain directly beneath the calcaneus during standing and walking.

Pediatric Considerations

Heel pain in children is more commonly caused by calcaneal apophysitis, or Sever disease, rather than plantar fasciitis.

Sever disease is related to repetitive traction and loading at the immature calcaneal apophysis, particularly around the Achilles tendon insertion.

Treatment of Sever Disease

Management typically includes:

Relative rest, activity modification, heel-cord stretching, NSAIDs when appropriate, heel cushioning, and temporary restriction from running or jumping sports.

A walking boot or short period of immobilization may be used for severe symptoms.

The disorder is self-limited and resolves after closure of the calcaneal apophysis with skeletal maturity.

Pregnancy Considerations

Heel pain during pregnancy may result from plantar fasciopathy or enthesopathy related to increased mechanical loading, weight gain, and hormonal changes.

Fluid retention may also contribute to compression neuropathies such as tarsal tunnel syndrome or entrapment of Baxter’s nerve.

Symptoms frequently improve after pregnancy.

Prevention

Plantar fasciitis cannot always be prevented, but risk may be reduced by avoiding:

Excessive weight gain, prolonged standing, poorly supportive footwear, and abrupt increases in running, jumping, or other repetitive impact activities.

Gradual progression of exercise and maintenance of calf flexibility may also be helpful.

Epidemiology

Plantar fasciitis is extremely common in adults.

It occurs most frequently during the third through fifth decades of life, although it can affect patients of virtually any adult age.

Risk Factors

Recognized risk factors include:

Restricted ankle dorsiflexion, tight gastrocnemius or Achilles complex, obesity or body mass index greater than 30, prolonged standing, running, jumping sports, diabetes mellitus, thyroid dysfunction, and inflammatory rheumatologic disease.

Etiology and Pathophysiology

The term “plantar fasciitis” suggests inflammation, but chronic cases usually show degenerative changes without substantial histologic inflammation.

Repeated tensile loading at the plantar fascia origin can result in microscopic injury, collagen degeneration, and chronic pain.

Repetitive Microtrauma

The plantar fascia is repeatedly tensioned during standing, walking, and running.

Overuse may produce microscopic tearing near its calcaneal origin.

Repeated loading before adequate healing can lead to chronic degeneration.

Contracture

A tight plantar fascia or heel cord increases tension across the plantar-medial calcaneal origin and may contribute to symptoms.

Associated Conditions

Frequently associated findings include:

Pes planus, cavus foot, Achilles or gastrocnemius contracture, obesity, and inflammatory arthropathies.

Flatfoot

Pes planus can increase tensile load on the plantar fascia by allowing greater elongation of the medial longitudinal arch.

Cavus Foot

A cavus foot may also predispose to plantar heel pain because the plantar fascia and other plantar soft tissues can become relatively tight.

Diagnosis

Plantar fasciitis is usually diagnosed clinically on the basis of a characteristic history and physical examination.

Imaging is not routinely required in a typical presentation.

History

The classic complaint is pain at the plantar-medial heel that is most severe with the first few steps in the morning.

A similar pattern may occur after prolonged sitting or inactivity.

Start-Up Pain

Pain often improves after several minutes of walking as the plantar fascia and surrounding tissues “loosen.”

Later-Day Symptoms

Although symptoms may improve initially with activity, pain can worsen again after prolonged standing, walking, or exercise later in the day.

Character of Pain

Patients may describe the discomfort as:

Aching, soreness, burning, stabbing, or sharp pain.

Physical Examination

Foot Alignment

The examiner should evaluate the foot for pes planus, cavus alignment, hindfoot deformity, and abnormal loading patterns.

Ankle Dorsiflexion

Ankle dorsiflexion should be measured with the knee both flexed and extended.

This helps distinguish isolated gastrocnemius tightness from a combined gastrocnemius-Achilles contracture.

Plantar Fascia Palpation

The most characteristic finding is focal tenderness at the plantar-medial calcaneal tubercle, where the plantar fascia originates.

Toe Dorsiflexion

Passive dorsiflexion of the toes tensions the plantar fascia through the windlass mechanism.

This maneuver may increase tenderness and reproduce the patient’s pain.

Neurologic Examination

The tarsal tunnel and course of the first branch of the lateral plantar nerve should be examined when neuropathic pain is suspected.

Tinel Sign

Percussion over the tarsal tunnel may reproduce tingling or burning into the plantar foot in patients with tibial nerve compression.

Baxter Nerve Entrapment

Tenderness or neuropathic pain deep to the abductor hallucis region may suggest entrapment of the first branch of the lateral plantar nerve.

Heel-Pad Atrophy

Pain centered directly beneath the calcaneal tuberosity rather than along the plantar-medial origin of the fascia may suggest fat-pad atrophy.

The heel pad may feel thin or poorly cushioned.

Calcaneal Stress Fracture

Medial-lateral compression of the calcaneus may reproduce pain in a calcaneal stress fracture.

This finding should prompt further investigation when symptoms are atypical for plantar fasciitis.

Laboratory Tests

Laboratory studies are not routinely required.

They may be considered in chronic, bilateral, recurrent, or atypical cases when systemic disease is suspected.

Potential Studies

Depending on the clinical setting, testing may include:

Rheumatoid factor, antinuclear antibodies, thyroid function studies, fasting glucose, hemoglobin A1C, inflammatory markers, and HLA-B27 testing.

HLA-B27 testing is most relevant when a seronegative spondyloarthropathy is suspected.

Imaging

Plain Radiographs

Weight-bearing radiographs of the foot may be obtained when pain is persistent, atypical, or associated with deformity.

They can help exclude fracture, arthritis, or other structural abnormalities.

Heel Spur

A plantar calcaneal spur is not diagnostic of plantar fasciitis.

Heel spurs are frequently found in asymptomatic individuals.

Their presence therefore does not establish the cause of heel pain.

Bone Scintigraphy

Bone scintigraphy may demonstrate increased uptake near the plantar fascia origin.

More diffuse calcaneal uptake may suggest a stress fracture.

Today, MRI is generally more useful when further imaging is needed.

MRI

MRI can demonstrate thickening and degenerative change of the proximal plantar fascia, with surrounding soft-tissue or adjacent calcaneal marrow edema.

Calcaneal Stress Fracture

A stress fracture generally produces more extensive bone marrow edema and may reveal a distinct fracture line.

Pathological Findings

Chronic plantar fasciitis demonstrates degenerative collagen changes at the plantar fascial origin.

Substantial chronic inflammatory cell infiltration is typically absent.

Differential Diagnosis

Important alternative diagnoses include:

Calcaneal apophysitis in children, calcaneal stress fracture, heel-pad atrophy, tarsal tunnel syndrome, Baxter nerve entrapment, inflammatory enthesopathy, and spinal radiculopathy.

Treatment

General Principles

Nonoperative treatment is the foundation of management.

Surgery is rarely required because the vast majority of patients improve with conservative measures.

Stretching

Stretching of the gastrocnemius-Achilles complex and plantar fascia should be performed regularly.

Stretching can be performed several times daily and before or after athletic activity.

Activity Modification

Activities that aggravate symptoms should be reduced temporarily.

Running, jumping, prolonged standing, and repetitive impact activity may need to be modified during the symptomatic phase.

Footwear and Heel Cushioning

A soft gel heel cup or cushioned heel insert may improve comfort by reducing impact at the plantar heel.

Supportive footwear is preferable to poorly cushioned or worn-out shoes.

Orthotic Arch Support

An arch support may be useful, particularly in patients with pes planus or excessive pronation.

Prefabricated devices are often sufficient initially.

Night Splints

A dorsiflexion night splint may help chronic symptoms by maintaining the ankle and plantar fascia in a gently stretched position overnight.

This may reduce severe first-step morning pain.

Ice and Massage

Ice application and deep-tissue or plantar fascial massage may provide symptomatic relief.

Rolling the plantar foot over a chilled bottle or similar device combines stretching, massage, and cooling.

Immobilization

A walking boot or short period of cast immobilization can be used for severe or recalcitrant symptoms to reduce repetitive loading of the plantar fascia.

Corticosteroid Injection

Local corticosteroid injection may be considered for persistent symptoms that have not responded to other nonoperative measures.

However, injections should be used cautiously because they carry risks including plantar fascial rupture and fat-pad atrophy.

Repeated injections are generally avoided.

Post-Injection Protection

Temporary restriction of high-impact activity after injection is appropriate.

A short period of protected weight bearing or boot use may be considered in selected patients.

Return to Activity

Once symptoms improve, activity should be resumed gradually.

Running and jumping should not be restarted abruptly at full intensity because sudden increases in repetitive stress can provoke recurrence.

Extracorporeal Shock-Wave Therapy

Extracorporeal shock-wave therapy can be considered for chronic plantar fasciitis that persists despite prolonged conservative treatment.

It may offer an alternative before operative intervention in appropriately selected patients.

Calcaneal Stress Fracture

Calcaneal stress fractures are generally treated with:

Activity restriction, protected weight bearing, NSAIDs or other analgesia when appropriate, and temporary immobilization when symptoms are severe.

Sever Disease

Treatment of calcaneal apophysitis similarly emphasizes:

Relative rest, heel-cord stretching, activity modification, heel cushioning, and short-term immobilization for severe cases.

Surgery is not indicated.

Heel-Pad Atrophy

Heel-pad atrophy is managed primarily with well-cushioned footwear, shock-absorbing heel cups, and reduction of repetitive impact loading.

Physical Therapy

Physical therapy can help teach proper calf and plantar fascia stretching, gait mechanics, strengthening, and graded return to activity.

It is particularly useful when tightness or biomechanical abnormalities contribute to symptoms.

Medication

NSAIDs may be used for short-term relief when pain is substantial.

Because the condition is largely degenerative rather than inflammatory, medication primarily provides symptomatic benefit rather than correcting the underlying pathology.

Surgery

Surgery is rarely indicated and is generally reserved for patients with persistent disabling symptoms despite at least 6–9 months of well-performed nonoperative treatment.

Partial Plantar Fascia Release

The usual procedure consists of partial release of the plantar fascia origin.

A complete release should be avoided because it may destabilize the longitudinal arch.

Heel-Spur Removal

Routine removal of a calcaneal spur is generally unnecessary because the spur itself is often not the source of pain.

Nerve Decompression

When persistent tarsal tunnel syndrome or entrapment of Baxter’s nerve contributes to symptoms, decompression may be performed in selected cases, sometimes in combination with partial plantar fascia release.

Contraindication in Sever Disease

Plantar fascia surgery is not appropriate for calcaneal apophysitis.

Sever disease is a self-limited developmental condition.

Follow-Up

Prognosis

The prognosis is excellent.

More than 90% of patients improve with nonoperative treatment and are able to return to normal activities.

Resolution may nevertheless require several months.

Complications

Plantar Fascia Rupture

Plantar fascial rupture may occur after corticosteroid injection or excessive surgical release.

Arch Collapse

Excessive release of the plantar fascia can weaken support of the medial longitudinal arch and contribute to arch collapse.

Lateral Column Overload

Loss of plantar fascial tension may shift mechanical stress toward the lateral midfoot, producing painful lateral column overload.

Fat-Pad Atrophy

Corticosteroid injection may contribute to degeneration or thinning of the heel fat pad, producing persistent plantar heel pain.

Patient Monitoring

Follow-up should assess pain intensity, morning first-step symptoms, tenderness at the plantar fascial origin, ankle dorsiflexion, activity tolerance, and adherence to stretching and footwear modification.

Persistent atypical pain, neurologic symptoms, focal bony tenderness, or failure to improve should prompt reconsideration of the diagnosis and evaluation for alternative causes such as stress fracture, nerve entrapment, or inflammatory disease.