Introduction
- Charles Christopher Stroud, MD
- Erick Fountain, MPT, OMPT
- Mike Pollzzie, PT, DPT, OMPT, CSCS
- Erick Fountain, MPT, OMPT
Epidemiology
- •
Ten percent of the US population presents with heel pain at some point in their lives.
- •
Age: 83% are between 25 and 65 years old. Peak incidence is between 40 and 60 years old. Older athletes are more susceptible.
- •
Sex: Studies differ on whether there is a male or female preponderance.
- •
Sport: Athletes who engage in running and sports with a significant amount of impact/jumping have an increased prevalence of this condition.
Pathophysiology
Intrinsic Factors
- •
Increased BMI (greater than 30 kg/m 2 )
- •
Increasing age: for example, degenerative process of plantar fascia
- •
Reduced ankle dorsiflexion
- •
Pes planus or pes cavus foot posture (both foot types have been described as associated with plantar fasciitis)
- •
Seronegative spondyloarthropathies
Extrinsic Factors
- •
Increases in training program/intensity; for example, rapid increase in weight-bearing activities
- •
Training errors; for example, inappropriate running technique
- •
Prolonged walking on hard surfaces
- •
Inappropriate shoes; for example, stiff, thin heel and midsole
- •
Increased weight-bearing activities
Traumatic Factors
- •
Sudden forcible load on plantar fascia (forced ankle dorsiflexion while performing pushoff maneuver) may lead to plantar fascial/disruption or injury
- •
Repetitive impact
Classic Pathological Findings
- •
Myxoid degeneration/microtears in the fascia/collagen necrosis/angiofibroblastic hyperplasia
- •
Thickening of plantar fascia origin ( Figure 42-1 )
FIGURE 42-1
Sagittal T 2 MRI sequence showing the thickened insertion of the plantar fascia and mild bone marrow edema at the insertion.
Clinical Presentation
History
- •
Gradual onset of inferior heel pain described as a sharp stab/walking on a marble or hot poker
- •
Worse with first steps in morning/loosens up with walking/worse with prolonged standing/walking and toward the end of the day
Physical Examination
Abnormal Findings
- •
Tenderness at origin of plantar fascia ( Figure 42-2 )
FIGURE 42-2
Photograph showing the location of tenderness about the inferomedial aspect of the heel in a patient with plantar fasciitis.
- •
Contracted Achilles tendon ( Figure 42-3 )
FIGURE 42-3
Photograph demonstrating a contracted Achilles tendon. This photograph shows the Achilles tendon unable to be passively dorsiflexed to a neutral position with the knee bent.
- •
May have coexistent tenderness about the first branch of the lateral plantar nerve ( Figure 42-4 )
FIGURE 42-4
Photograph showing a patient with tenderness about the first branch of the lateral plantar nerve (i.e., Baxter’s nerve).
- •
Antalgic gait may be present.
Pertinent Normal Findings
- •
Patient foot type may be either pes planus or pes cavus
- •
Lack of swelling/tenderness about the remainder of the foot
Imaging
- •
Imaging tests not needed in the initial workup of this condition
- •
If plain radiographs obtained, the presence of a calcaneal traction spur (heel spur) may or may not be present and is not the cause of this condition
- •
Radiographs are obtained for recalcitrant cases to rule out a calcaneal stress fracture or tumor
- •
Bone scan may reveal uptake at origin of plantar fascia ( Figure 42-5 )
FIGURE 42-5
Bone scan showing uptake at the origin of the left plantar fascia in a patient with symptomatology.
- •
Ultrasound, if obtained, shows a thickened, hypoechoic area at the plantar fascia insertion ( Figure 42-6 )
FIGURE 42-6
Ultrasound image showing a thickened hypoechoic area ( arrow ) at the origin of the plantar fascia in a patient with symptomology.
- •
MRI, if obtained, can show thickening/increased signal about the origin of the plantar fascia (see Figure 42-1 )
Differential Diagnosis
- •
Achilles tendinopathy: tenderness about the insertion of the Achilles tendon. The examiner may note the presence of thickening at the insertion and/or palpation of calcifications.
- •
Calcaneal apophysitis: tenderness medial and laterally in a skeletally immature patient
- •
Calcaneal stress fracture: pain with side-to-side compression of the heel; diffuse swelling of the heel
- •
Plantar fibromatosis: single or multiple nodules palpated within the central cord of the plantar fascia
- •
Entrapment of the first branch of the lateral plantar nerve: neuritic symptoms throughout the day, tenderness about the medial/inferior heel, positive Tinel’s sign/radiating pain with percussion of the nerve
- •
Tarsal tunnel syndrome: neuritic symptoms, tenderness along the course of the posterior tibial nerve, positive compression/percussion sign with reproduction of symptoms
- •
S1 radiculopathy: subjective heel pain with no localizable symptoms; presence of radiating back pain
- •
Peripheral neuropathy: more global pain, history of diabetic neuropathy, decreased sensation to 5.07 monofilament testing, no localizable symptoms
- •
Central fat pad atrophy: tenderness about plantar central heel with attenuation of fat pad
Treatment
Nonoperative Management
- •
NSAIDs: not well studied as an effective modality
- •
Orthoses/heel cups/Inserts: no difference in custom versus off-the-shelf inserts
- •
Physiotherapy: Achilles/plantar fascia stretches
- •
Night splint: conflicting results in literature but generally accepted as effective
- •
Casting/walking boots: subjective improvement but not well studied
- •
Extracorporeal shockwave treatment: has been shown to improve symptoms in recalcitrant cases
- •
Corticosteroid injections: can provide short-term relief. Efficacy has not been well studied.
Guidelines for Choosing Among Nonoperative Treatments
- •
If severely antalgic gait: begin with short course of boot brace immobilization. If nonantalgic gait, begin with Achilles and focused plantar fascia stretches
- •
If no improvement after a 6-week course, consider night splint
- •
If no improvement after a 6-week course, consider formal physical therapy
- •
If no improvement after a 6-week course, consider orthotics
- •
If no improvement after a 6-week course, consider injection
- •
If no improvement after a 6-week course, consider shockwave treatment
Surgical Indications
- •
Recalcitrant, ongoing, unrelenting pain that has failed to improve with conservative treatment, usually 6 to 12 months
Aspects of History, Demographics, or Exam Findings That Affect Choice of Treatment
- •
All patients, whether athletes or not, are treated in a similar fashion
- •
Conservative treatment has been shown to be effective in approximately 90% of patients
Aspects of Clinical Decision Making When Surgery Is Indicated
- •
Failure of prolonged course of nonsurgical treatment, usually 6 to 12 months
Evidence
Multiple Choice Questions
- QUESTION 1.
Which of the following is one of the strategic historical features in patients with plantar fasciitis?
- A.
Pain at rest
- B.
Radiating numbness into the arch
- C.
Pain with the first steps in the morning
- D.
A contracted Achilles tendon
- A.
- QUESTION 2.
Which of the following is one of the strategic physical exam findings in patients with plantar fasciitis?
- A.
Tenderness at the inferomedial aspect of the heel
- B.
A positive Tinel’s sign over the plantar fascia origin
- C.
Swelling about the medial heel
- D.
A unilateral pes planus foot deformity
- A.
- QUESTION 3.
What are the histological findings noted in the surgical specimens in patients with plantar fasciitis?
- A.
Edema
- B.
Microfibrillar tearing
- C.
Tendon thickening
- D.
Myxoid degeneration
- E.
All of the above
- A.
- QUESTION 4.
Which of the following is not in the differential diagnoses in the patients who presents with heel pain?
- A.
Calcaneal stress fracture
- B.
Radiculopathy
- C.
Posterior ankle impingement
- D.
Tarsal tunnel syndrome
- A.
- QUESTION 5.
Which of the following is not one of the conservative treatment options in a patient with plantar fasciitis?
- A.
Boot brace immobilization
- B.
Sclerosing alcohol injections
- C.
Formal course of physiotherapy
- D.
Specific plantar fascia stretching exercises
- A.
Answer Key
- QUESTION 1.
Correct answer: C (see Clinical Presentation )
- QUESTION 2.
Correct answer: A (see Clinical Presentation )
- QUESTION 3.
Correct answer: E (see Pathophysiology )
- QUESTION 4.
Correct answer: C (see Differential Diagnosis )
- QUESTION 5.
Correct answer: B (see Treatment )
Nonoperative Rehabilitation of Plantar Fasciitis
- Charles Christopher Stroud, MD
- Erick Fountain, MPT, OMPT
- Mike Pollzzie, PT, DPT, OMPT, CSCS
- Erick Fountain, MPT, OMPT
- •
Protected weight bearing until normal gait
- •
Pain reduction and restoration of motion
- •
Progressive strengthening and functional assessment
- •
Return to specific functional demands or sport-specific activity level
Phase I (weeks 0 to 2)
Protection
- •
If the patient has a continuous antalgic gait, a boot brace with or without crutches, depending on the level of pain, is supplied. If the gait is nonantalgic, no boot brace is needed.
| PHASE I (weeks 0 to 2) | PHASE II (weeks 2 to 4) | PHASE III (weeks 4 to 8) | PHASE IV (weeks 8 to 12) |
|---|---|---|---|
|
|
|
|
Management of Pain and Swelling
- •
Ice and/or heat, NSAIDs taken as needed, protected weight bearing if necessary.
Techniques for Progressive Increase in Range of Motion
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
If the patient is in a boot, then gentle, progressive active range of motion of the knee, ankle and foot (out of boot) is performed. If no boot, than begin Achilles and plantar fascia specific stretches ( Figure 42-7 ).
FIGURE 42-7
A, Stretch of the gastroc-soleus complex with a towel. B, Stretch of gastroc-soleus complex against a wall with foot pointed forward and knee straight (affected leg back). C, Stretch of gastroc-soleus complex against the wall with foot pointed forward and knee bent (affected leg is forward). D, Stretch of gastroc-soleus complex using a stair for a more aggressive stretch. E, Stretch of the plantar fascia. Note that the knee is bent and one arm is used for the stretch and the other finger is used to palpate the plantar fascia. Each stretch should be performed to a count of 10, three sets and three times per day.
Other Therapeutic Exercises
- •
Patient can continue with general upper body workouts.
- •
Patient can continue with general core strengthening.
- •
Patient can continue with general hip/thigh exercises.
Activation of Primary Muscles Involved
- •
Patients should perform the preceding to the point that they “feel” the stretch and not pain.
Milestones for Progression to the Next Phase
- •
Achieve nonantalgic gait with or without protective walking boot.
- •
Discontinue crutches if used.
- •
Wean out of walking boot if used.
Phase II (weeks 2 to 4)
Management of Pain and Swelling
- •
As-needed usage of NSAIDs
- •
The use of IFC, TENS unit, iontophoresis, contrast baths can be used if enrolled in formal physical therapy.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
If a formal physical therapy program is used, than talocrural/subtalar glide maneuvers and subtalar joint distraction can be used. Efficacy not well documented
Soft Tissue Techniques
- •
Deep soft tissue massage techniques can be used by the therapist, although their efficacy not well documented.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Specific weight-bearing and non–weight-bearing stretches of the gastroc-soleus complex and of the plantar fascia as noted in the preceding section (see Figure 42-7 ).
Other Therapeutic Exercises
- •
Continue with patients regular conditioning exercises
- •
Add an aggressive and progressive program of hip/core/thigh strengthening exercises; for example, step-ups and step downs, box touches, toe touches, forward/backward/side monster walks, bridge exercises, assisted to full body split squats ( Figure 42-8 ).
FIGURE 42-8
A, Split squat exercise. B, Assisted split squat crossover. C, Box touches. D, Bridge exercise. E, Toe touch. F, Monster walk with band. G, Step up/down.
Activation of Primary Muscles Involved
- •
Progressive motion/stretching of the gastroc-soleus complex and great/lesser toe dorsiflexors and plantar flexors. Four-way resistance band exercises of the ankle are used ( Figure 42-9 ).
FIGURE 42-9
Four-way resistance exercises of the ankle using a band are demonstrated. Resisted eversion is noted here. Each exercise should be performed 10 times, three sets and two times per day.
Sensorimotor Exercises
- •
Single/double leg balance exercises, progressing from even to uneven surfaces. These exercises can be performed with the use of a DynaDisc, BAPS board, or BOSU ( Figure 42-10 ; see also Figure 42-19 in the next section).
FIGURE 42-10
Double leg balance exercise on the BOSU is shown.
Open and Closed Kinetic Chain Exercises
- •
CKC exercises (single/double leg split squat) are performed in the PT facility ( Figure 42-11 ), whereas OKC (band exercises) are performed via a home exercise program.
FIGURE 42-11
Split squat exercise is shown.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
The preceding exercises are performed progressing from lower to high repetitions while increasing load/resistance over ensuing weeks.
Neuromuscular Dynamic Stability Exercises
- •
Core ball exercises, single leg balance exercises, rotational exercises ( Figure 42-12 ).
Related posts:
Epiphyseolysis and Osteochondritis
Cervical Spine Disc Injuries
Lateral Collateral Ligament and Posterolateral Ligament Injuries
Triangular Fibrocartilage Complex Injuries
Leg Pain in the Athlete: Stress Fractures, Medial Tibial Stress Syndrome, and External Compartment Syndromes
Ulnar Collateral Ligament Injuries
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