Plantar fasciitis
Encyclopedia
Plantar fasciitis is a painful
inflammatory
process of the plantar fascia
, the connective tissue
on the sole (bottom surface) of the foot
.
Longstanding cases of plantar fasciitis often demonstrate more degenerative changes than inflammatory changes, in which case they are termed plantar fasciosis. The suffix "osis" implies a pathology
of chronic
degeneration
without inflammation
. Since tendon
s and ligament
s do not contain blood vessel
s, they do not actually become inflamed. Instead, injury to the tendon is usually the result of an accumulation over time of microscopic tears at the cellular level.
The plantar fascia is a thick fibrous band of connective tissue originating on the bottom surface of the calcaneus (heel bone) and extending along the sole of the foot towards the toe
s. It has been reported that plantar fasciitis occurs in two million Americans a year and in 10% of the U.S. population over a lifetime. It is commonly associated with long periods of weight bearing
. Among non-athletic populations, it is associated with a high body mass index
. The pain is usually felt on the underside of the heel
and is often most intense with the first steps of the day. Another symptom is that the sufferer has difficulty bending the foot so that the toes are brought toward the shin
(decreased dorsiflexion
of the ankle
). A symptom commonly recognized among sufferers of plantar fasciitis is an increased probability of knee
pains, especially among runners
.
The clinical examination may include checking the patient’s feet and watching the patient stand and walk. The clinical examination will take under consideration a patient's medical history, physical activity, foot pain symptoms and more. The doctor may decide to use imaging studies like radiograph
s (X-rays), diagnostic ultrasound
and MRI
.
An incidental finding associated with this condition is a heel spur
, a small bony calcification
on the calcaneus heel bone, in which case it is the underlying plantar fasciitis that produces the pain, and not the spur itself. The condition is responsible for the creation of the spur, the plantar fasciitis is not caused by the spur.
Sometimes ball-of-foot pain is mistakenly assumed to be derived from plantar fasciitis. A dull pain or numbness in the metatarsal region of the foot could instead be metatarsalgia
, also called capsulitis. Some current studies suggest that plantar fasciitis is not actually inflamed plantar fascia, but merely an inflamed flexor digitorum brevis muscle
belly. Ultrasound evidence illustrates fluid within the FDB muscle belly, not the plantar fascia.
therapy, stretching, weight loss, night splints, motion control running shoes, physical therapy
, cold therapy, heat therapy, orthotics, anti-inflammatory medications, injection of corticosteroids and surgery in refractory cases. Also, in some cases, massaging of the inflamed location serves as a temporary relief.
, i.e., foot supports, are the only non-surgical therapy to have been supported by studies rated by the Center for Evidence-Based Medicine as being of high quality. In a single-blind experiment in which patients were randomly assigned to receive off-the-shelf orthotics, personally customized orthotics, or sham orthotics made of a soft, thin foam. Patients receiving real orthotics showed statistically significant short-term improvements in functionality compared to those receiving the sham treatment. There was no statistically significant reduction in pain, and there was no long-term effect when the patients were re-evaluated after 12 months. Off-the-shelf orthotics were found to be as effective as customized ones for acute (short term) plantar fasciitis. There is some evidence that taping may supply short-term relief, but the evidence is weaker than the evidence supporting orthotics.
Some evidence shows that stretching
of the calf
and plantar fascia
may provide up to 2–4 months of benefit. One study has shown improvement over a four-month period with stretching. In cases of chronic plantar fasciitis, ultrasound therapy with 3 MHz for 10-15minutes/day may be beneficial. One study has shown high success rates with a stretch of the plantar fascia, but has been criticized because it was not blinded, and contained a bias because the analysis did not use the intention to treat
method. Because it is impractical to do double-blind experiments involving stretching, such studies are vulnerable to placebo
effects. The Center for Evidence-Based Medicine has not rated any study of stretching as being of high quality.
Pain with the first steps of the day can be markedly reduced by stretching the plantar fascia and Achilles tendon
before getting out of bed. Night splints
can be used to keep the foot in a dorsi-flexed position during sleep to improve calf muscle flexibility and decrease pain on waking. These have many different designs. The type of splint has not been shown to affect outcomes.
To relieve pain and inflammation, nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin
and ibuprofen
are often used but are of limited benefit. Dexamethasone or acetic acid 5% delivered by iontophoresis
combined with low Dye strapping and calf
stretching
has been shown to provide short term pain relief and increased function.
Local injection of corticosteroid
s often gives temporary or permanent relief, but may be painful, especially if not combined with a local anesthetic
and injected slowly with a small-diameter needle. Recurrence rates may be lower if injection is performed under ultrasound
guidance. Repeated steroid injections may result in rupture of the plantar fascia. While this may actually improve pain initially, it has deleterious long-term consequences.
Coblation surgery (aka Topaz procedure) has been used successfully in the treatment of recalcitrant plantar fasciitis. This procedure utilizes radiofrequency ablation and is a minimally invasive procedure.
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
inflammatory
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
process of the plantar fascia
Plantar fascia
The plantar fascia is the thick connective tissue which supports the arch on the bottom of the foot. It runs from the tuberosity of the calcaneus forward to the heads of the metatarsal bones .The often painful condition plantar fasciitis is an inflammatory condition of the plantar...
, the connective tissue
Connective tissue
"Connective tissue" is a fibrous tissue. It is one of the four traditional classes of tissues . Connective Tissue is found throughout the body.In fact the whole framework of the skeleton and the different specialized connective tissues from the crown of the head to the toes determine the form of...
on the sole (bottom surface) of the foot
Sole (foot)
The sole is the bottom of the foot.In humans the sole of the foot is anatomically referred to as the plantar aspect. The equivalent surface in ungulates is the hoof.- Human sole :...
.
Longstanding cases of plantar fasciitis often demonstrate more degenerative changes than inflammatory changes, in which case they are termed plantar fasciosis. The suffix "osis" implies a pathology
Pathology
Pathology is the precise study and diagnosis of disease. The word pathology is from Ancient Greek , pathos, "feeling, suffering"; and , -logia, "the study of". Pathologization, to pathologize, refers to the process of defining a condition or behavior as pathological, e.g. pathological gambling....
of chronic
Chronic
Chronic may refer to:* Chronic , a disease that is long-lasting and reoccurring.* Chronic toxicity, a substance with toxic effects after continuous or repeated exposure* The Chronic, a 1992 album by Dr. Dre...
degeneration
Degeneration
The idea of degeneration had significant influence on science, art and politics from the 1850s to the 1950s. The social theory developed consequently from Charles Darwin's Theory of Evolution...
without inflammation
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
. Since tendon
Tendon
A tendon is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments and fasciae as they are all made of collagen except that ligaments join one bone to another bone, and fasciae connect muscles to other...
s and ligament
Ligament
In anatomy, the term ligament is used to denote any of three types of structures. Most commonly, it refers to fibrous tissue that connects bones to other bones and is also known as articular ligament, articular larua, fibrous ligament, or true ligament.Ligament can also refer to:* Peritoneal...
s do not contain blood vessel
Blood vessel
The blood vessels are the part of the circulatory system that transports blood throughout the body. There are three major types of blood vessels: the arteries, which carry the blood away from the heart; the capillaries, which enable the actual exchange of water and chemicals between the blood and...
s, they do not actually become inflamed. Instead, injury to the tendon is usually the result of an accumulation over time of microscopic tears at the cellular level.
The plantar fascia is a thick fibrous band of connective tissue originating on the bottom surface of the calcaneus (heel bone) and extending along the sole of the foot towards the toe
Toe
Toes are the digits of the foot of a tetrapod. Animal species such as cats that walk on their toes are described as being digitigrade. Humans, and other animals that walk on the soles of their feet, are described as being plantigrade; unguligrade animals are those that walk on hooves at the tips of...
s. It has been reported that plantar fasciitis occurs in two million Americans a year and in 10% of the U.S. population over a lifetime. It is commonly associated with long periods of weight bearing
Weight bearing
In orthopedics, weight-bearing is the amount of weight a patient puts on the leg on which surgery has been performed. In general, it is described as a percentage of the body weight, because each leg of a healthy person carries the full body weight when walking, in an alternating fashion.After...
. Among non-athletic populations, it is associated with a high body mass index
Body mass index
The body mass index , or Quetelet index, is a heuristic proxy for human body fat based on an individual's weight and height. BMI does not actually measure the percentage of body fat. It was invented between 1830 and 1850 by the Belgian polymath Adolphe Quetelet during the course of developing...
. The pain is usually felt on the underside of the heel
Heel
In human anatomy, the heel is the prominence at the posterior end of the foot. It is based on the projection of one bone, the calcaneus or heel bone, behind the articulation of the bones of the lower leg.- Human anatomy :...
and is often most intense with the first steps of the day. Another symptom is that the sufferer has difficulty bending the foot so that the toes are brought toward the shin
Shin
Shin may refer to:* Shinbone, the larger of the two bones in the leg below the knee in vertebrates* Shin , the twenty-first letter in many Semitic alphabets* Shin , origin of Shin name, which means "new"...
(decreased dorsiflexion
Dorsiflexion
Dorsiflexion is the movement which decreases the angle between the dorsum of the foot and the leg, so that the toes are brought closer to the shin. The movement moving in opposite directions is called plantarflexion...
of the ankle
Ankle
The ankle joint is formed where the foot and the leg meet. The ankle, or talocrural joint, is a synovial hinge joint that connects the distal ends of the tibia and fibula in the lower limb with the proximal end of the talus bone in the foot...
). A symptom commonly recognized among sufferers of plantar fasciitis is an increased probability of knee
Knee
The knee joint joins the thigh with the leg and consists of two articulations: one between the fibula and tibia, and one between the femur and patella. It is the largest joint in the human body and is very complicated. The knee is a mobile trocho-ginglymus , which permits flexion and extension as...
pains, especially among runners
Running
Running is a means of terrestrial locomotion allowing humans and other animals to move rapidly on foot. It is simply defined in athletics terms as a gait in which at regular points during the running cycle both feet are off the ground...
.
Diagnosis
The diagnosis of plantar fasciitis is usually made by clinical examination alone.The clinical examination may include checking the patient’s feet and watching the patient stand and walk. The clinical examination will take under consideration a patient's medical history, physical activity, foot pain symptoms and more. The doctor may decide to use imaging studies like radiograph
Radiography
Radiography is the use of X-rays to view a non-uniformly composed material such as the human body. By using the physical properties of the ray an image can be developed which displays areas of different density and composition....
s (X-rays), diagnostic ultrasound
Medical ultrasonography
Diagnostic sonography is an ultrasound-based diagnostic imaging technique used for visualizing subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions...
and MRI
Magnetic resonance imaging
Magnetic resonance imaging , nuclear magnetic resonance imaging , or magnetic resonance tomography is a medical imaging technique used in radiology to visualize detailed internal structures...
.
An incidental finding associated with this condition is a heel spur
Heel spur
A calcaneal spur is a small osteophyte located on the calcaneus . Calcaneal spurs are typically detected by a radiological examination ....
, a small bony calcification
Calcification
Calcification is the process in which calcium salts build up in soft tissue, causing it to harden. Calcifications may be classified on whether there is mineral balance or not, and the location of the calcification.-Causes:...
on the calcaneus heel bone, in which case it is the underlying plantar fasciitis that produces the pain, and not the spur itself. The condition is responsible for the creation of the spur, the plantar fasciitis is not caused by the spur.
Sometimes ball-of-foot pain is mistakenly assumed to be derived from plantar fasciitis. A dull pain or numbness in the metatarsal region of the foot could instead be metatarsalgia
Metatarsalgia
Metatarsalgia is a general term used to refer to any painful foot condition affecting the metatarsal region of the foot. This is a common problem that can affect the joints and bones of the metatarsals. Metatarsalgia is most often localized to the first metatarsal head...
, also called capsulitis. Some current studies suggest that plantar fasciitis is not actually inflamed plantar fascia, but merely an inflamed flexor digitorum brevis muscle
Flexor digitorum brevis muscle
The flexor digitorum brevis lies in the middle of the sole of the foot, immediately above the central part of the plantar aponeurosis, with which it is firmly united....
belly. Ultrasound evidence illustrates fluid within the FDB muscle belly, not the plantar fascia.
Treatment
Treatment options for plantar fasciitis include rest, massageMassage
Massage is the manipulation of superficial and deeper layers of muscle and connective tissue to enhance function, aid in the healing process, and promote relaxation and well-being. The word comes from the French massage "friction of kneading", or from Arabic massa meaning "to touch, feel or handle"...
therapy, stretching, weight loss, night splints, motion control running shoes, physical therapy
Physical therapy
Physical therapy , often abbreviated PT, is a health care profession. Physical therapy is concerned with identifying and maximizing quality of life and movement potential within the spheres of promotion, prevention, diagnosis, treatment/intervention,and rehabilitation...
, cold therapy, heat therapy, orthotics, anti-inflammatory medications, injection of corticosteroids and surgery in refractory cases. Also, in some cases, massaging of the inflamed location serves as a temporary relief.
Medical
OrthoticsOrthotics
Orthotics is a specialty within the medical field concerned with the design, manufacture and application of orthoses. An orthosis is an orthopedic device that supports or corrects the function of a limb or the torso...
, i.e., foot supports, are the only non-surgical therapy to have been supported by studies rated by the Center for Evidence-Based Medicine as being of high quality. In a single-blind experiment in which patients were randomly assigned to receive off-the-shelf orthotics, personally customized orthotics, or sham orthotics made of a soft, thin foam. Patients receiving real orthotics showed statistically significant short-term improvements in functionality compared to those receiving the sham treatment. There was no statistically significant reduction in pain, and there was no long-term effect when the patients were re-evaluated after 12 months. Off-the-shelf orthotics were found to be as effective as customized ones for acute (short term) plantar fasciitis. There is some evidence that taping may supply short-term relief, but the evidence is weaker than the evidence supporting orthotics.
Some evidence shows that stretching
Stretching
Stretching is a form of physical exercise in which a specific skeletal muscle is deliberately elongated, often by abduction from the torso, in order to improve the muscle's felt elasticity and reaffirm comfortable muscle tone. The result is a feeling of increased muscle control, flexibility and...
of the calf
Calf (anatomy)
In human anatomy the calf is the back portion of the lower leg . In terms of muscle systems, the calf corresponds to the posterior compartment of the leg. Within the posterior compartment, the two largest muscles are known together as the calf muscle and attach to the heel via the Achilles tendon...
and plantar fascia
Plantar fascia
The plantar fascia is the thick connective tissue which supports the arch on the bottom of the foot. It runs from the tuberosity of the calcaneus forward to the heads of the metatarsal bones .The often painful condition plantar fasciitis is an inflammatory condition of the plantar...
may provide up to 2–4 months of benefit. One study has shown improvement over a four-month period with stretching. In cases of chronic plantar fasciitis, ultrasound therapy with 3 MHz for 10-15minutes/day may be beneficial. One study has shown high success rates with a stretch of the plantar fascia, but has been criticized because it was not blinded, and contained a bias because the analysis did not use the intention to treat
Intention to treat analysis
In epidemiology, an intention to treat analysis is an analysis based on the initial treatment intent, not on the treatment eventually administered. ITT analysis is intended to avoid various misleading artifacts that can arise in intervention research...
method. Because it is impractical to do double-blind experiments involving stretching, such studies are vulnerable to placebo
Placebo
A placebo is a simulated or otherwise medically ineffectual treatment for a disease or other medical condition intended to deceive the recipient...
effects. The Center for Evidence-Based Medicine has not rated any study of stretching as being of high quality.
Pain with the first steps of the day can be markedly reduced by stretching the plantar fascia and Achilles tendon
Achilles tendon
The Achilles tendon , also known as the calcaneal tendon or the tendo calcaneus, is a tendon of the posterior leg. It serves to attach the plantaris, gastrocnemius and soleus muscles to the calcaneus bone.- Anatomy :The Achilles is the tendonous extension of 3 muscles in the lower leg:...
before getting out of bed. Night splints
Splint (medicine)
A splint is a device used for support or immobilization of limbs or of the spine.It can be used:* By the emergency medical services or by volunteer first responders, to immobilize a fractured limb before the transportation; it is then a temporary immobilization;* By allied health professionals such...
can be used to keep the foot in a dorsi-flexed position during sleep to improve calf muscle flexibility and decrease pain on waking. These have many different designs. The type of splint has not been shown to affect outcomes.
To relieve pain and inflammation, nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin
Aspirin
Aspirin , also known as acetylsalicylic acid , is a salicylate drug, often used as an analgesic to relieve minor aches and pains, as an antipyretic to reduce fever, and as an anti-inflammatory medication. It was discovered by Arthur Eichengrun, a chemist with the German company Bayer...
and ibuprofen
Ibuprofen
Ibuprofen is a nonsteroidal anti-inflammatory drug used for relief of symptoms of arthritis, fever, as an analgesic , especially where there is an inflammatory component, and dysmenorrhea....
are often used but are of limited benefit. Dexamethasone or acetic acid 5% delivered by iontophoresis
Iontophoresis
Iontophoresis is a technique using a small electric charge to deliver a medicine or other chemical through the skin. It is basically an injection without the needle...
combined with low Dye strapping and calf
Calf (anatomy)
In human anatomy the calf is the back portion of the lower leg . In terms of muscle systems, the calf corresponds to the posterior compartment of the leg. Within the posterior compartment, the two largest muscles are known together as the calf muscle and attach to the heel via the Achilles tendon...
stretching
Stretching
Stretching is a form of physical exercise in which a specific skeletal muscle is deliberately elongated, often by abduction from the torso, in order to improve the muscle's felt elasticity and reaffirm comfortable muscle tone. The result is a feeling of increased muscle control, flexibility and...
has been shown to provide short term pain relief and increased function.
Local injection of corticosteroid
Corticosteroid
Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex. Corticosteroids are involved in a wide range of physiologic systems such as stress response, immune response and regulation of inflammation, carbohydrate metabolism, protein catabolism, blood electrolyte...
s often gives temporary or permanent relief, but may be painful, especially if not combined with a local anesthetic
Local anesthetic
A local anesthetic is a drug that causes reversible local anesthesia, generally for the aim of having local analgesic effect, that is, inducing absence of pain sensation, although other local senses are often affected as well...
and injected slowly with a small-diameter needle. Recurrence rates may be lower if injection is performed under ultrasound
Ultrasound
Ultrasound is cyclic sound pressure with a frequency greater than the upper limit of human hearing. Ultrasound is thus not separated from "normal" sound based on differences in physical properties, only the fact that humans cannot hear it. Although this limit varies from person to person, it is...
guidance. Repeated steroid injections may result in rupture of the plantar fascia. While this may actually improve pain initially, it has deleterious long-term consequences.
Surgery
Surgery carries the risk of nerve injury, infection, rupture of the plantar fascia, and failure to improve the pain. Traditional surgical procedures, such as plantar fascia release, are a last resort, and often lead to further complications such as a lowering of the arch and pain in the supero-lateral side of the foot due to compression of the cuboid bone. This will allow decompression of the nearby FDB muscle belly that is inflamed, yet does not fix the underlying problem. This basically allows more space for the inflamed muscle belly, thus, relieving pain/pressure. An ultrasound-guided needle fasciotomy can be used as a minimally invasive surgical intervention for plantar fasciitis. A needle is inserted into the plantar fascia and moved back and forwards to disrupt the fibrous tissue.Coblation surgery (aka Topaz procedure) has been used successfully in the treatment of recalcitrant plantar fasciitis. This procedure utilizes radiofrequency ablation and is a minimally invasive procedure.