Plantar fasciitis or plantar heel pain (PHP) is a
disorder
Disorder may refer to randomness, non-order, or no intelligible pattern.
Disorder may also refer to:
Healthcare
* Disorder (medicine), a functional abnormality or disturbance
* Mental disorder or psychological disorder, a psychological pattern ...
of the
plantar fascia, which is the
connective tissue
Connective tissue is one of the four primary types of animal tissue, along with epithelial tissue, muscle tissue, and nervous tissue. It develops from the mesenchyme derived from the mesoderm the middle embryonic germ layer. Connective tissue ...
which supports the
arch of the foot.
It results in
pain
Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, ...
in the
heel and bottom of the foot that is usually most severe with the first steps of the day or following a period of rest.
Pain is also frequently brought on by
bending the foot and toes up towards the shin.
The pain typically comes on gradually, and it affects both feet in about one-third of cases.
The cause of plantar fasciitis is not entirely clear.
Risk factors include overuse, such as from long periods of standing, an increase in
exercise
Exercise is a body activity that enhances or maintains physical fitness and overall health and wellness.
It is performed for various reasons, to aid growth and improve strength, develop muscles and the cardiovascular system, hone athletic s ...
, and
obesity
Obesity is a medical condition, sometimes considered a disease, in which excess body fat has accumulated to such an extent that it may negatively affect health. People are classified as obese when their body mass index (BMI)—a person's ...
.
It is also associated with
inward rolling of the foot, a tight
Achilles tendon
The Achilles tendon or heel cord, also known as the calcaneal tendon, is a tendon at the back of the lower leg, and is the thickest in the human body. It serves to attach the plantaris, gastrocnemius (calf) and soleus muscles to the calcane ...
, and a sedentary lifestyle.
It is unclear if
heel spurs have a role in causing plantar fasciitis even though they are commonly present in people who have the condition.
Plantar fasciitis is a
disorder of the insertion site of the ligament on the bone characterized by micro tears, breakdown of collagen, and scarring.
Since
inflammation
Inflammation (from la, wikt:en:inflammatio#Latin, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or Irritation, irritants, and is a protective response involving im ...
plays either a lesser or no role, a review proposed it be renamed plantar fasciosis.
The presentation of the symptoms is generally the basis for diagnosis; with
ultrasound
Ultrasound is sound waves with frequencies higher than the upper audible limit of human hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hear it. This limit varies fr ...
sometimes being useful if there is uncertainty.
Other conditions with similar symptoms include
osteoarthritis
Osteoarthritis (OA) is a type of degenerative joint disease that results from breakdown of joint cartilage and underlying bone which affects 1 in 7 adults in the United States. It is believed to be the fourth leading cause of disability in the ...
,
ankylosing spondylitis
Ankylosing spondylitis (AS) is a type of arthritis characterized by long-term inflammation of the joints of the spine typically where the spine joins the pelvis. Occasionally areas affected may include other joints such as the shoulders or hi ...
,
heel pad syndrome
Heel pad syndrome is a pain that occurs in the center of the heel. It is typically due to atrophy of the fat pad which makes up the heel. Risk factors include obesity. Other conditions with similar symptoms include plantar fasciitis. Treatment inc ...
, and
reactive arthritis.
Most cases of plantar fasciitis resolve with time and conservative methods of treatment.
For the first few weeks, those affected are usually advised to rest, change their activities, take
pain medications
An analgesic drug, also called simply an analgesic (American English), analgaesic ( British English), pain reliever, or painkiller, is any member of the group of drugs used to achieve relief from pain (that is, analgesia or pain management). It ...
, and stretch.
If this is not sufficient,
physiotherapy
Physical therapy (PT), also known as physiotherapy, is one of the allied health professions. It is provided by physical therapists who promote, maintain, or restore health through physical examination, diagnosis, management, prognosis, patie ...
,
orthotics
Orthotics ( el, Ορθός, translit=ortho, lit=to straighten, to align) is a medical specialty that focuses on the design and application of orthoses, or braces. An is "an externally applied device used to influence the structural and functi ...
,
splinting, or
steroid injections may be options.
If these measures are not effective, additional measures may include
extracorporeal shockwave therapy or surgery.
Between 4% and 7% of the general population has heel pain at any given time: about 80% of these are due to plantar fasciitis.
Approximately 10% of people have the disorder at some point during their life.
It becomes more common with age.
It is unclear if one sex is more affected than the other.
Signs and symptoms
When plantar fasciitis occurs, the pain is typically sharp
and usually unilateral (70% of cases).
Bearing weight on the heel after long periods of rest worsens heel pain in affected individuals.
Individuals with plantar fasciitis often report their symptoms are most intense during their first steps after getting out of bed or after prolonged periods of sitting.
Symptoms typically improve with continued walking.
Rare, but reported symptoms include
numbness
Hypoesthesia or numbness is a common side effect of various medical conditions that manifests as a reduced sense of touch or sensation, or a partial loss of sensitivity to sensory stimuli. In everyday speech this is generally referred to as nu ...
,
tingling,
swelling, or radiating pain.
Typically there are no
fever
Fever, also referred to as pyrexia, is defined as having a temperature above the normal range due to an increase in the body's temperature set point. There is not a single agreed-upon upper limit for normal temperature with sources using val ...
s or night sweats.
If the
plantar fascia is overused in the setting of plantar fasciitis, the plantar fascia can rupture. Typical signs and symptoms of plantar fascia rupture include a clicking or snapping sound, significant local swelling, and acute pain in the bottom of the foot.
Risk factors
Identified risk factors for plantar fasciitis include excessive running, standing on hard surfaces for prolonged periods,
high arches of the feet, the presence of a
leg length inequality
Unequal leg length (also termed leg length inequality, LLI or leg length discrepancy, LLD) is where the legs are either different lengths or appear to be different lengths because of misalignment. It has been estimated that at least 0.1% of the po ...
, and
flat feet. The tendency of flat feet to excessively
roll inward during walking or running makes them more susceptible to plantar fasciitis.
Obesity
Obesity is a medical condition, sometimes considered a disease, in which excess body fat has accumulated to such an extent that it may negatively affect health. People are classified as obese when their body mass index (BMI)—a person's ...
is seen in 70% of individuals who present with plantar fasciitis and is an independent risk factor.
Plantar fasciitis is commonly a result of some biomechanical imbalance that causes an increased amount of tension placed along the plantar fascia.
Studies consistently find a strong association between increased
body mass index
Body mass index (BMI) is a value derived from the mass (weight) and height of a person. The BMI is defined as the body mass divided by the square of the body height, and is expressed in units of kg/m2, resulting from mass in kilograms and he ...
and plantar fasciitis in the non-athletic population. This association between weight and plantar fasciitis is not present in the athletic population.
Achilles tendon
The Achilles tendon or heel cord, also known as the calcaneal tendon, is a tendon at the back of the lower leg, and is the thickest in the human body. It serves to attach the plantaris, gastrocnemius (calf) and soleus muscles to the calcane ...
tightness and inappropriate footwear have also been identified as significant risk factors.
Pathophysiology
The cause of plantar fasciitis is poorly understood and appears to have several contributing factors.
The plantar fascia is a
thick fibrous band of connective tissue that originates from the
medial tubercle and anterior aspect of the
heel bone. From there, the fascia extends along the
sole of the foot before inserting at the base of the
toes and supports the
arch of the foot.
Plantar fasciitis is a non-inflammatory condition of the plantar fascia. Within the last decade, studies have observed
microscopic anatomical changes indicating that plantar fasciitis is due to a non-inflammatory structural breakdown of the plantar fascia rather than an inflammatory process.
Many in the academic community have stated the condition should be renamed plantar fasciosis in light of these newer findings.
Repetitive
microtrauma (small tears) appears to cause a structural breakdown of the plantar fascia.
Microscopic examination of the plantar fascia often shows
myxomatous degeneration, connective tissue
calcium deposits, and disorganized collagen fibers.
Disruptions in the plantar fascia's normal mechanical movement during standing and walking (known as the Windlass mechanism) place excess strain on the
calcaneal tuberosity and seem to contribute to the development of plantar fasciitis.
Other studies have also suggested that plantar fasciitis is not due to the inflamed plantar fascia but maybe a
tendon injury involving the
flexor digitorum brevis muscle located immediately deep to the plantar fascia.
Diagnosis
Plantar fasciitis is usually diagnosed by a
health care provider
A health care provider is an individual health professional or a health facility organization licensed to provide health care diagnosis and treatment services including medication, surgery and medical devices. Health care providers often recei ...
after consideration of a person's presenting history, risk factors, and clinical examination.
Palpation along the inner aspect of the heel bone on the sole may elicit tenderness during the physical examination.
The foot may have limited
dorsiflexion due to excessive tightness of the
calf muscles
Calf most often refers to:
* Calf (animal), the young of domestic cattle.
* Calf (leg), in humans (and other primates), the back portion of the lower leg
Calf or calves may also refer to:
Biology and animal byproducts
*Veal, meat from calves
*C ...
or the
Achilles tendon
The Achilles tendon or heel cord, also known as the calcaneal tendon, is a tendon at the back of the lower leg, and is the thickest in the human body. It serves to attach the plantaris, gastrocnemius (calf) and soleus muscles to the calcane ...
.
Dorsiflexion of the foot may elicit the pain due to stretching of the plantar fascia with this motion.
Diagnostic imaging studies are not usually needed to diagnose plantar fasciitis.
Occasionally, a physician may decide imaging studies (such as
X-rays
X-rays (or rarely, ''X-radiation'') are a form of high-energy electromagnetic radiation. In many languages, it is referred to as Röntgen radiation, after the German scientist Wilhelm Conrad Röntgen, who discovered it in 1895 and named it ' ...
,
diagnostic ultrasound, or
MRI) are warranted to rule out serious causes of foot pain.
Other diagnoses that are typically considered include fractures, tumors, or systemic disease if plantar fasciitis pain fails to respond appropriately to conservative medical treatments.
Bilateral heel pain or heel pain in the context of a systemic illness may indicate a need for a more in-depth diagnostic investigation. Under these circumstances, diagnostic tests such as a
CBC or serological markers of inflammation, infection, or
autoimmune disease
An autoimmune disease is a condition arising from an abnormal immune response to a functioning body part. At least 80 types of autoimmune diseases have been identified, with some evidence suggesting that there may be more than 100 types. Nearly ...
such as
C-reactive protein
C-reactive protein (CRP) is an annular (ring-shaped) pentameric protein found in blood plasma, whose circulating concentrations rise in response to inflammation. It is an acute-phase protein of hepatic origin that increases following interleukin ...
,
erythrocyte sedimentation rate,
anti-nuclear antibodies,
rheumatoid factor
Rheumatoid factor (RF) is the autoantibody that was first found in rheumatoid arthritis. It is defined as an antibody against the Fc portion of IgG and different RFs can recognize different parts of the IgG-Fc. RF and IgG join to form immune com ...
,
HLA-B27,
uric acid
Uric acid is a heterocyclic compound of carbon, nitrogen, oxygen, and hydrogen with the formula C5H4N4O3. It forms ions and salts known as urates and acid urates, such as ammonium acid urate. Uric acid is a product of the metabolic breakdown ...
, or
Lyme disease
Lyme disease, also known as Lyme borreliosis, is a vector-borne disease caused by the '' Borrelia'' bacterium, which is spread by ticks in the genus '' Ixodes''. The most common sign of infection is an expanding red rash, known as erythema ...
antibodies may also be obtained.
Neurological deficits may prompt an investigation with
electromyography to check for damage to the nerves or muscles.
An incidental finding associated with this condition is a
heel spur, a small bony
calcification
Calcification is the accumulation of calcium salts in a body tissue. It normally occurs in the formation of bone, but calcium can be deposited abnormally in soft tissue,Miller, J. D. Cardiovascular calcification: Orbicular origins. ''Nature M ...
on the
calcaneus
In humans and many other primates, the calcaneus (; from the Latin ''calcaneus'' or ''calcaneum'', meaning heel) or heel bone is a bone of the tarsus of the foot which constitutes the heel. In some other animals, it is the point of the hock.
...
(heel bone), which can be found in up to 50% of those with plantar fasciitis.
In such cases, it is the underlying plantar fasciitis that produces the heel pain, and not the spur itself.
The condition is responsible for the creation of the spur though the clinical significance of heel spurs in plantar fasciitis remains unclear.
Imaging
Medical imaging is not routinely needed. It is expensive and does not typically change how plantar fasciitis is managed.
When the diagnosis is not clinically apparent, lateral view X-rays of the ankle are the recommended imaging modality to assess for other causes of heel pain, such as
stress fractures or bone spur development.
The plantar fascia has three fascicles-the central fascicle being the thickest at 4 mm, the
lateral fascicle at 2 mm, and the
medial
Medial may refer to:
Mathematics
* Medial magma, a mathematical identity in algebra Geometry
* Medial axis, in geometry the set of all points having more than one closest point on an object's boundary
* Medial graph, another graph that re ...
less than a millimeter thick. In theory, plantar fasciitis becomes more likely as the plantar fascia's thickness at the calcaneal insertion increases. A thickness of more than 4.5 mm
ultrasound
Ultrasound is sound waves with frequencies higher than the upper audible limit of human hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hear it. This limit varies fr ...
and 4 mm on
MRI are useful for diagnosis. Other imaging findings, such as thickening of the plantar aponeurosis, are nonspecific and have limited usefulness in diagnosing plantar fasciitis.
Three-phase bone scan is a sensitive modality to detect active plantar fasciitis. Furthermore, a
3-phase bone scan can be used to monitor response to therapy, as demonstrated by decreased uptake after corticosteroid injections.
Differential diagnosis
The differential diagnosis for heel pain is extensive and includes pathological entities including, but not limited to, the following:
calcaneal stress fracture,
septic arthritis,
calcaneal bursitis,
osteoarthritis
Osteoarthritis (OA) is a type of degenerative joint disease that results from breakdown of joint cartilage and underlying bone which affects 1 in 7 adults in the United States. It is believed to be the fourth leading cause of disability in the ...
,
spinal stenosis involving the nerve roots of
lumbar spinal nerve 5 (L5) or
sacral spinal nerve 1 (S1), calcaneal fat pad syndrome, metastasized cancers from elsewhere in the body,
hypothyroidism
Hypothyroidism (also called ''underactive thyroid'', ''low thyroid'' or ''hypothyreosis'') is a disorder of the endocrine system in which the thyroid gland does not produce enough thyroid hormone. It can cause a number of symptoms, such as ...
,
gout
Gout ( ) is a form of inflammatory arthritis characterized by recurrent attacks of a red, tender, hot and swollen joint, caused by deposition of monosodium urate monohydrate crystals. Pain typically comes on rapidly, reaching maximal intens ...
,
seronegative spondyloparthopathies such as
reactive arthritis,
ankylosing spondylitis
Ankylosing spondylitis (AS) is a type of arthritis characterized by long-term inflammation of the joints of the spine typically where the spine joins the pelvis. Occasionally areas affected may include other joints such as the shoulders or hi ...
, or
rheumatoid arthritis
Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects synovial joint, joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and ...
(more likely if pain is present in both heels),
plantar fascia rupture, and
compression neuropathies such as
tarsal tunnel syndrome or impingement of the
medial calcaneal nerve.
A determination about a diagnosis of plantar fasciitis can usually be made based on a person's medical history and physical examination.
[, which cites
* ] When a physician suspects a fracture, infection, or some other serious underlying condition, they may order an X-ray to investigate.
X-rays are unnecessary to screen for plantar fasciitis for people who stand or walk a lot at work unless imaging is otherwise indicated.
Treatment
Non-surgical
About 90% of plantar fasciitis cases improve within six months with conservative treatment,
and within a year regardless of treatment.
The recommended first treatment is a 4-6 week course which combines three elements: daily
stretching
Stretching is a form of physical exercise in which a specific muscle or tendon (or muscle group) is deliberately flexed or stretched in order to improve the muscle's felt elasticity and achieve comfortable muscle tone. The result is a feelin ...
, daily foot taping (using a special tape around the foot for supporting the
arch
An arch is a vertical curved structure that spans an elevated space and may or may not support the weight above it, or in case of a horizontal arch like an arch dam, the hydrostatic pressure against it.
Arches may be synonymous with vau ...
) and individually tailored education on choosing footwear and other ways of managing the condition.
If plantar fasciitis fails to respond to conservative treatment for at least three months, then
extracorporeal shockwave therapy (ESWT) may be considered.
Evidence from
meta-analyses
A meta-analysis is a statistical analysis that combines the results of multiple scientific studies. Meta-analyses can be performed when there are multiple scientific studies addressing the same question, with each individual study reporting me ...
suggests significant pain relief lasts up to one year after the procedure.
However, debate about the therapy's efficacy has persisted.
ESWT is performed with or without
anesthesia
Anesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prevention of pain), paralysis (muscle relaxation), a ...
though studies suggest giving anesthesia diminishes the procedure's effectiveness.
Complications from ESWT are rare and typically benign when present.
Known complications of ESWT include the development of a mild
hematoma or an
ecchymosis,
redness
Red is the color at the long wavelength end of the visible spectrum of light, next to orange and opposite violet. It has a dominant wavelength of approximately 625–740 nanometres. It is a primary color in the RGB color model and a second ...
around the site of the procedure, or
migraine
Migraine (, ) is a common neurological disorder characterized by recurrent headaches. Typically, the associated headache affects one side of the head, is pulsating in nature, may be moderate to severe in intensity, and could last from a few ho ...
.
The third line of treatment, if shockwave therapy is not effective after around 8 weeks, is using customised foot
orthoses which can offer short-term relief from pain.
Affected people use further different treatments for plantar fasciitis but many have little evidence to support their use and are not adequately studied.
Other conservative approaches include rest,
massage
Massage is the manipulation of the body's soft tissues. Massage techniques are commonly applied with hands, fingers, elbows, knees, forearms, feet or a device. The purpose of massage is generally for the treatment of body stress or pain. In E ...
, heat, ice, and
calf-strengthening exercises, weight reduction in the overweight or obese, and
nonsteroidal anti-inflammatory drugs
Non-steroidal anti-inflammatory drugs (NSAID) are members of a therapeutic drug class which reduces pain, decreases inflammation, decreases fever, and prevents blood clots. Side effects depend on the specific drug, its dose and duration of ...
(NSAIDs) such as
aspirin
Aspirin, also known as acetylsalicylic acid (ASA), is a nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain, fever, and/or inflammation, and as an antithrombotic. Specific inflammatory conditions which aspirin is used to treat in ...
or
ibuprofen
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is used for treating pain, fever, and inflammation. This includes painful menstrual periods, migraines, and rheumatoid arthritis. It may also be used to close a patent ductus ...
.
The use of NSAIDs to treat plantar fasciitis is common, but their use fails to resolve the pain in 20% of people.
Corticosteroid
Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are in ...
injections are sometimes used for cases of plantar fasciitis that have proven resistant to more conservative measures. There is tentative evidence that injected corticosteroids are effective for short-term pain relief up to one month, but not after that.
Another treatment technique is known as plantar
iontophoresis
Iontophoresis is a process of transdermal drug delivery by use of a voltage gradient on the skin. Molecules are transported across the stratum corneum by electrophoresis and electroosmosis and the electric field can also increase the permeability ...
. This technique involves applying anti-inflammatory substances such as
dexamethasone
Dexamethasone is a glucocorticoid medication used to treat rheumatic problems, a number of skin diseases, severe allergies, asthma, chronic obstructive lung disease, croup, brain swelling, eye pain following eye surgery, superior vena cav ...
or
acetic acid
Acetic acid , systematically named ethanoic acid , is an acidic, colourless liquid and organic compound with the chemical formula (also written as , , or ). Vinegar is at least 4% acetic acid by volume, making acetic acid the main componen ...
topically to the foot and transmitting these substances through the skin with an electric current.
Some evidence supports the use of night splints for 1–3 months to relieve plantar fasciitis pain that has persisted for six months.
The night splints are designed to position and maintain the ankle in a neutral position, thereby passively stretching the calf and plantar fascia during sleep.
Surgery
Plantar
fasciotomy is a surgical treatment and the last resort for refractory plantar fasciitis pain. If plantar fasciitis does not resolve after six months of conservative treatment, then the procedure is considered as a last resort.
Minimally invasive and endoscopic approaches to plantar fasciotomy exist but require a specialist who is familiar with specific equipment. The availability of these surgical techniques is limited as of 2012.
A 2012 study found 76% of people who underwent endoscopic plantar fasciotomy had complete relief of their symptoms and had few complications (level IV evidence).
Heel spur removal during plantar fasciotomy does not appear to improve the surgical outcome.
Plantar heel pain may occur for multiple reasons. In select cases, surgeons may perform a release of the
lateral plantar nerve alongside the plantar fasciotomy.
Possible complications of plantar fasciotomy include nerve injury, instability of the
medial longitudinal arch of the foot,
fracture of the
calcaneus
In humans and many other primates, the calcaneus (; from the Latin ''calcaneus'' or ''calcaneum'', meaning heel) or heel bone is a bone of the tarsus of the foot which constitutes the heel. In some other animals, it is the point of the hock.
...
, prolonged recovery time, infection, rupture of the plantar fascia, and failure to improve the pain.
Coblation surgery has recently been proposed as an alternative surgical approach for the treatment of recalcitrant plantar fasciitis.
Unproven treatments
Botulinum toxin
Botulinum toxin, or botulinum neurotoxin (BoNT), is a neurotoxic protein produced by the bacterium ''Clostridium botulinum'' and related species. It prevents the release of the neurotransmitter acetylcholine from axon endings at the neuromu ...
A injections as well as similar techniques such as
platelet-rich plasma injections and
prolotherapy remain controversial.
Dry needling is also being researched for treatment of plantar fasciitis.
A
systematic review
A systematic review is a scholarly synthesis of the evidence on a clearly presented topic using critical methods to identify, define and assess research on the topic. A systematic review extracts and interprets data from published studies on t ...
of available research found limited evidence of effectiveness for this technique.
[ The studies were reported to be inadequate in quality and too diverse in methodology to enable reaching a firm conclusion.]
Epidemiology
Plantar fasciitis is the most common type of plantar fascia injury and is the most common reason for heel pain, responsible for 80% of cases. The condition tends to occur more often in women, military recruits, older athletes, dancers, people with obesity, and young male athletes.
Plantar fasciitis is estimated to affect 1 in 10 people at some point during their lifetime and most commonly affects people between 40 and 60 years of age. In the United States alone, more than two million people receive treatment for plantar fasciitis. The cost of treating plantar fasciitis in the United States is estimated to be $284 million each year.
References
Further reading
*
External links
*
{{DEFAULTSORT:Plantar Fasciitis
Articles containing video clips
Disorders of fascia
Foot diseases
Fasciitis, plantar
Overuse injuries
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Soft tissue disorders
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