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|Classification and external resources|
|Classification and external resources|
Plantar fasciitis (PF), also known as Plantar fasciopathy or Jogger's heel, is a common painful enthesopathy of the heel and plantar surface of the foot characterized by inflammation, fibrosis, or structural deterioration of the plantar fascia of the foot. The plantar fascia is a thick fibrous band of connective tissue that originates on the medial tubercle of the calcaneus (heel bone) and extends along the sole of the foot towards the toes and supports the arch of the foot. The condition is often caused by overuse of the plantar fascia, increases in physical activity, weight or age. Chronic cases of plantar fasciitis often demonstrate more degenerative changes than inflammatory changes and such cases are termed plantar fasciosis. The suffix "osis" implies a pathology of chronic degeneration without inflammation.
Plantar fasciitis is the most common injury of the plantar fascia and is the most common cause of heel pain. Approximately 10% of people have plantar fasciitis at some point during their lifetime. It is commonly associated with long periods of weight bearing and is much more prevalent in individuals with hyperpronation (flat feet). Among non-athletic populations, it is associated with obesity. Plantar fasciitis pain is usually felt on the underside of the heel and is often most intense with the first steps of the day. Those with plantar fasciitis often have difficulty bending the foot so that the toes are brought toward the shin (decreased dorsiflexion of the ankle) due to tightness of the gastrocnemius muscle or Achilles tendon.
The classical presentation of plantar fasciitis pain is sharp and usually unilateral (30% of cases are bilateral) heel pain exacerbated by bearing weight on the heel after prolonged periods of rest. Individuals with plantar fasciitis often report their symptoms are most intense during their first steps after getting out of bed or after sitting for a prolonged period and subsequently improves with continued walking. Numbness, tingling, swelling, or radiating pain are rarely reported symptoms.
Originally, plantar fasciitis was believed to be an inflammatory condition of the plantar fascia; however, histological changes observed in recent studies have indicated that plantar fasciitis is actually due to a noninflammatory structural degeneration of the plantar fascia rather than an inflammatory process. Due to this shift in thought about the underlying mechanisms in plantar fasciitis, many in the academic community have stated that the condition should be renamed plantar fasciosis. The structural breakdown of the plantar fascia is believed to be the result of repetitive microtrauma.
The diagnosis of plantar fasciitis is usually made by a physician after consideration of a patient's presenting history, risk factors, and clinical examination. Tenderness to palpation along the medial plantar aspect of the calcaneus may be elicited during the physical examination. Decreased dorsiflexion of the foot may be present due to tightness of the gastrocnemius muscle or the Achilles tendon and when dorsiflexed may elicit the pain due to stretching of the plantar fascia with this motion. Diagnostic imaging studies are not usually needed to diagnosis plantar fasciitis, but in some cases a physician may decide imaging studies (such as X-rays, diagnostic ultrasound or MRI) are warranted to rule out serious causes of foot pain such as 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 and may include tests such as a CBC or serological markers of inflammation, infection, or autoimmune disease such as C-reactive protein, erythrocyte sedimentation rate, anti-nuclear antibodies, rheumatoid factor, HLA-B27, uric acid, or Lyme disease antibodies. Neurological deficits may prompt an investigation with electromyography to evaluate for damage to the nerves or muscular tissue.
Lateral view x-rays of the ankle are the recommended first-line imaging modality to assess for other causes of heel pain such as stress fractures or bone spur development. Thickening of the plantar fascia aponeurosis at the heel greater than 5 millimeters as demonstrated by ultrasonography is consistent with a diagnosis of plantar fasciitis. However, authors have noted that medical imaging does not typically change how plantar fasciitis is managed and findings such as thickening of the plantar aponeurosis may be absent in symptomatic individuals or present in asymptomatic individuals thereby limiting the utility of such observations. An incidental finding associated with this condition is a heel spur, a small bony calcification on the calcaneus heel bone, which can be found in up to 50% of plantar fasciitis patients, 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 though the clinical significance of heel spurs in plantar fasciitis remains unclear. Other studies have suggested that plantar fasciitis is not actually due to inflamed plantar fascia, but may be a tendinopathy involving the flexor digitorum brevis muscle located immediately deep to the plantar fascia.
The differential diagnosis for heel pain is extensive and includes pathological entities including, but not limited to: calcaneal stress fracture, calcaneal bursitis, spinal stenosis involving the nerve roots of lumbar spinal nerve 5 (L5) or sacral spinal nerve 1 (S1), calcaneal fat pad syndrome, seronegative spondyloparthopathies, plantar fascia rupture, and compression neuropathies such as tarsal tunnel syndrome or impingement of the medial calcaneal nerve.
Most cases (90%) of plantar fasciitis are self-limiting and will improve within the span of six months with conservative treatment or within the span of a year regardless of treatment. Many treatments have been proposed for the treatment of plantar fasciitis, but the effectiveness of most of these treatments has not been adequately investigated and consequently there is little evidence to support recommendations for such treatments. First-line conservative approaches such as rest, heat, ice, calf-strengthening exercises, plantar fascia stretching techniques, achilles tendon stretching techniques, weight reduction in overweight or obese patients, and nonsteroidal anti-inflammatory drugs (NSAIDS) such as aspirin or ibuprofen are considered first-line treatments for plantar fasciitis. NSAIDs are commonly used to treat plantar fasciitis, but fail to resolve the pain in 20% of patients.
Recent meta-analyses have found extracorporeal shockwave therapy to be an effective treatment modality for plantar fasciitis pain unresponsive to conservative nonsurgical measures for at least three months with evidence suggesting significant pain relief lasting up to one year. Corticosteroid injections are sometimes used for cases of plantar fasciitis refractory to more conservative measures and may be an effective modality for pain relief, but have notable risks such as plantar fascia rupture, skin infection, nerve or muscle injury, or atrophy of the plantar fat pad. Custom orthotic devices have been demonstrated as an effective method to reduce plantar fasciitis pain for up to 12 weeks; the long-term effectiveness of custom orthotics for plantar fasciitis pain reduction requires additional study. Orthotic devices and low-dye taping are proposed to reduce pronation of the foot and therefore reduce load on the plantar fascia resulting in pain improvement.
Another form of treatment is plantar iontophoresis, a technique which involves applying anti-inflammatory substances such as dexamethasone or acetic acid topically to the foot and transmitting these substances through the skin with an electrical current. Botulinum Toxin A injections as well as other injection techniques such as those of platelet-rich plasma and prolotherapy have recently garnered attention as possibly effective agents for the treatment of pain associated with plantar fasciitis. Moderate evidence exists to support the use of 1–3 months of night splints for relief of plantar fasciitis pain persisting 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 overnight during sleep. Other treatment approaches may include supportive footwear, arch taping, and physical therapy.
Plantar fasciotomy is often considered after treatment failure by conservative measures for at least six months and is viewed as a last resort. Surgery carries the risk of nerve injury, infection, rupture of the plantar fascia, and failure to improve the pain. This 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.
Continued overuse of the plantar fascia in the setting of plantar fasciitis may result in rupture of the plantar fascia; typical signs and symptoms of plantar fascia rupture include a clicking or snapping sound, considerable local swelling, and acute pain in the plantar fascia region.
Plantar fasciitis occurs more often in runners, people who stand on hard surfaces for prolonged periods of time, people with high arches of the foot, or in those susceptible to hyperpronation of the foot. Obesity has been observed in 70% of individuals who present with plantar fasciitis and studies have indicated a strong association between an increased body mass index and the development of plantar fasciitis in the non-athletic population; this association between weight and plantar fasciitis has not been observed in the athletic population.
Plantar fasciitis is the most common type of plantar fascia injury and tends to occur more often in women, the middle-aged, military recruits, older athletes, the obese, and young male athletes. Plantar fasciitis is estimated to affect 1 in 10 people at some point during their lifetime and its annual economic burden is estimated to be between 192 to 376 million dollars. Each year, pain from plantar fasciitis is responsible for 1–2 million physician office visits.