Orthopaedic Surgery - Plantar Fasciitis

Basics

Plantar fasciitis is the most common cause of plantar heel pain, particularly pain arising near the:

Medial calcaneal tubercle, where the plantar fascia originates.

Although traditionally described as an inflammatory disorder, current understanding suggests that most cases represent a:

Degenerative fasciopathy characterized by repetitive microtearing and collagen degeneration

rather than a purely inflammatory process.

For this reason, the term:

Plantar fasciopathy

is sometimes considered more pathophysiologically accurate.

Epidemiology

Plantar fasciitis is common in the general population.

Historical U.S. estimates suggest an incidence of approximately:

1%.

It accounts for approximately:

80% of patients presenting with plantar heel pain.

Prevalence

Overall prevalence has been estimated at approximately:

0.85%.

Reported prevalence is higher in:

Women – approximately 1.2%

than in:

Men – approximately 0.5%.

Age

Prevalence increases during middle age.

Historical estimates include:

Age 18–44 years – approximately 0.5%

Age 45–64 years – approximately 1.3%

Obesity

Obesity is an important risk factor.

Patients with a:

BMI ≥30

have been reported to be approximately:

Five times more likely

to have plantar fasciitis than individuals with:

BMI <25.

Etiology

The disorder most likely develops because of:

Repeated microtrauma

and

Degenerative change at the plantar fascial origin.

Repetitive Loading

Repeated tensile loading may produce microscopic failure of the plantar fascia, particularly during:

Running

Dancing

Prolonged standing

Repetitive impact activity

Reduced Ankle Dorsiflexion

Patients with limited:

Ankle dorsiflexion

are at increased risk.

A tight:

Gastrocnemius-Achilles complex

may increase tension across the plantar fascia during gait.

Calcaneal Spurs

Calcaneal heel spurs are commonly associated with plantar fasciitis and may be seen in a substantial proportion of patients, historically:

Up to approximately 70–75%.

However, the spur itself is generally:

Not considered the cause of the pain.

Many asymptomatic individuals also have heel spurs.

Risk Factors

Important contributing factors include:

Obesity

Running or repetitive impact exercise

Prolonged standing

Reduced ankle dorsiflexion

Gastrocnemius tightness

Sudden increases in activity

Diagnosis

The diagnosis is usually:

Clinical.

Imaging is generally unnecessary during the initial evaluation unless another diagnosis is suspected.

Signs and Symptoms

The classic symptom is:

Plantar heel pain that is worst with the first few steps after rest.

First-Step Pain

Pain is typically most severe:

With the first steps in the morning

or

After prolonged sitting.

This is often referred to as:

Start-up pain.

Activity Pattern

Pain may initially improve after:

Several minutes of walking

as the fascia warms and stretches.

However, discomfort may return or worsen:

Later in the day

especially after prolonged standing or repeated weight bearing.

Laterality

Symptoms are more commonly:

Unilateral

than bilateral.

Bilateral symptoms may raise greater concern for:

Systemic inflammatory disease

or significant biomechanical abnormalities.

Physical Examination

Point of Maximum Tenderness

The most characteristic finding is tenderness over the:

Medial calcaneal tubercle

at the origin of the plantar fascia.

This localization helps distinguish plantar fasciitis from other causes of heel pain.

Plantar Fascia Palpation

Tenderness may extend distally along the:

Medial plantar fascia

but is generally maximal at the calcaneal origin.

Ankle Dorsiflexion

Assess:

Ankle dorsiflexion

with the knee both:

Extended

and

Flexed.

Restricted dorsiflexion may indicate:

Gastrocnemius or gastrocnemius-soleus tightness.

Windlass-Type Provocation

Passive dorsiflexion of the toes, particularly the:

Great toe

tightens the plantar fascia.

Reproduction of tenderness at the medial calcaneal tubercle supports the diagnosis.

Silfverskiöld Test

The Silfverskiöld test helps distinguish:

Isolated gastrocnemius tightness

from

Combined gastrocnemius-soleus contracture.

If ankle dorsiflexion improves when the knee is:

Flexed compared with extended, this suggests:

Gastrocnemius tightness.

Imaging

Plain Radiographs

Weight-bearing radiographs of the foot may be obtained when symptoms are:

Atypical

Persistent

or associated with concern for another structural disorder.

They are not routinely required at the first visit.

Radiographic Findings

Radiographs are often:

Normal.

A plantar calcaneal spur may be seen but does not establish the diagnosis.

MRI

MRI is not routinely required for typical plantar fasciitis.

It is most useful for evaluating:

Persistent or atypical heel pain

and excluding alternative diagnoses.

MRI Findings

MRI may demonstrate:

Thickening of the plantar fascia

Increased signal at the fascial origin

Perifascial edema

These findings support plantar fasciopathy but should be correlated with symptoms.

Bone Scintigraphy

Bone scintigraphy may occasionally be used to evaluate for:

Calcaneal stress fracture

when other imaging is inconclusive.

MRI is now frequently preferred when an occult stress injury is suspected.

Pathological Findings

Histologic examination typically demonstrates:

Myxoid degeneration

Collagen disorganization

Microtearing

rather than prominent acute inflammation.

These findings support the concept that plantar fasciitis is primarily a:

Degenerative process.

Differential Diagnosis

Important alternative causes of plantar heel pain include:

Tarsal tunnel syndrome

Entrapment of the first branch of the lateral plantar nerve

Medial calcaneal nerve entrapment

Calcaneal apophysitis

Achilles tendinopathy

Posterior tibial tendinopathy

Calcaneal stress fracture

Calcaneal osteomyelitis

Inflammatory arthritis

Nerve Entrapment

Neuropathic heel pain may be associated with:

Burning

Tingling

Numbness

and may radiate along a nerve distribution.

This differs from the focal mechanical tenderness typical of plantar fasciitis.

Calcaneal Stress Fracture

Stress fracture should be considered when there is:

Progressively worsening pain with weight bearing

Calcaneal squeeze tenderness

Recent increase in impact activity

Calcaneal Apophysitis

In children and adolescents, heel pain may instead represent:

Calcaneal apophysitis, or Sever disease.

Systemic Inflammatory Disease

Bilateral heel pain, prolonged morning stiffness, or other joint symptoms may suggest disorders such as:

Rheumatoid arthritis

Seronegative spondyloarthropathy

or another inflammatory condition.

Treatment

General Principles

Nonoperative treatment is the:

Mainstay of management.

More than:

90% of patients

improve without surgery.

Initial Treatment

First-line treatment focuses on:

Activity modification

Stretching

Appropriate footwear

Arch support

Pain control

Activity Modification

Temporarily reduce activities that significantly aggravate symptoms, particularly:

Running

Jumping

Prolonged standing

High-impact exercise

Complete inactivity is generally unnecessary.

Plantar Fascia Stretching

Plantar fascia-specific stretching is an important component of treatment.

Stretching is particularly useful:

Before the first steps in the morning

and

After prolonged periods of rest.

Achilles and Calf Stretching

Stretching of the:

Gastrocnemius

Soleus

and

Achilles tendon

reduces tension transmitted to the plantar fascia.

Footwear and Orthoses

Prefabricated inserts with:

Arch support

may improve symptoms by redistributing plantar pressure and reducing strain on the fascia.

Custom orthoses are not always necessary.

Night Splints

Night splints maintain the ankle and toes in a relatively:

Dorsiflexed position

to reduce overnight contraction of the plantar fascia.

They may help selected patients, particularly those with:

Severe morning first-step pain.

Evidence of benefit is mixed.

Casting

Short periods of immobilization in a:

Walking boot or cast

may occasionally be used for severe, refractory symptoms.

NSAIDs

NSAIDs may provide:

Short-term pain relief

despite the predominantly degenerative rather than inflammatory nature of the disorder.

They should be used according to individual gastrointestinal, renal, and cardiovascular risk.

Treatments With Limited Evidence

Several modalities have not consistently demonstrated meaningful benefit in randomized trials, including:

Magnetic insoles

Therapeutic ultrasound

Low-level laser therapy

Various electrical devices

Corticosteroid Injection

Corticosteroid injection may produce:

Short-term pain relief

in some patients.

However, benefit is often temporary.

Injection Risks

Potential complications include:

Plantar fascia rupture

Heel fat-pad atrophy

Skin depigmentation

Nerve injury

Because of these risks, repeated corticosteroid injections should generally be avoided.

Extracorporeal Shock Wave Therapy

Extracorporeal shock wave therapy may be considered for:

Persistent symptoms lasting more than approximately 6 months

despite appropriate conservative management.

Shock Wave Outcomes

Historical studies have reported improvement in:

A substantial proportion of patients, with some series describing benefit in up to approximately 80%.

Response rates vary according to:

Technique

Energy level

Patient selection

Physical Therapy

Physical therapy may focus on:

Plantar fascia stretching

Calf stretching

Ankle mobility

Foot intrinsic strengthening

Progressive loading

Gait and activity modification

Progressive Strengthening

Modern rehabilitation often includes progressive strengthening of:

Foot intrinsic muscles

Calf complex

and surrounding lower-extremity musculature.

This may improve load tolerance and reduce recurrence.

Surgery

Surgery is reserved for:

Persistent disabling symptoms despite prolonged nonoperative management.

A minimum of approximately:

9–12 months of comprehensive conservative treatment

is generally recommended before considering operative intervention.

Plantar Fasciotomy

Partial plantar fascia release may be performed for:

Refractory plantar fasciitis.

Partial Versus Complete Release

Complete release of the fascia should generally be avoided because it can:

Destabilize the longitudinal arch

and alter normal foot biomechanics.

For this reason, a:

Partial release

is typically preferred.

Surgical Outcomes

Surgical results are variable.

A significant proportion of patients may continue to experience symptoms even after:

Plantar fasciotomy.

Therefore, surgery should be reserved for carefully selected cases.

Nerve Decompression

In selected patients with suspected concomitant nerve entrapment, plantar fascia surgery may be combined with:

Nerve decompression.

Gastrocnemius Recession

Gastrocnemius recession may be considered in patients with:

Documented gastrocnemius tightness

and persistent plantar fasciitis despite:

Stretching and physical therapy.

Gastrocnemius Recession Outcomes

Some studies have reported:

Higher patient satisfaction

Faster return to activity

Improved pain and functional scores

compared with plantar fasciotomy in appropriately selected patients with gastrocnemius contracture.

Follow-Up

Patients should be followed until:

Symptoms substantially improve or resolve

and normal activity is restored.

Recovery may be gradual and often requires:

Several months.

Prognosis

The prognosis is generally:

Excellent.

More than:

90% of patients

respond to nonoperative management.

Duration of Symptoms

Symptoms may persist for:

Many months

even with appropriate treatment.

The prolonged course does not necessarily indicate treatment failure.

Complications

Plantar Fascia Rupture

Rupture may occur spontaneously but is particularly associated with:

Corticosteroid injection

or excessive loading.

Midfoot Arch Destabilization

Excessive surgical release of the plantar fascia may alter:

Arch mechanics

and contribute to:

Midfoot pain or instability.

Altered Biomechanics

Loss of normal plantar fascia tension can produce:

Abnormal load distribution across the foot.

Nerve Injury

Surgical treatment may rarely injure:

Branches of the plantar nerves

or

Calcaneal sensory nerves.

Patient Monitoring

Most patients should undergo continued conservative care for approximately:

9–12 months

before operative treatment is considered.

Monitoring should focus on:

Pain severity

Morning first-step symptoms

Walking tolerance

Ankle dorsiflexion

Response to stretching and orthoses

Ability to return to activity

Key Principle

Plantar fasciitis is the most common cause of plantar heel pain and is better understood as a degenerative plantar fasciopathy caused by repetitive microtrauma rather than a purely inflammatory disorder.

The characteristic presentation is:

Medial plantar heel pain that is worst with the first steps after rest.

Treatment is overwhelmingly nonoperative and emphasizes:

Plantar fascia and calf stretching, activity modification, supportive footwear or orthoses, and gradual restoration of load tolerance.

Surgery is reserved for:

Persistent disabling symptoms after prolonged, well-performed conservative treatment.