Plantar Fasciitis - Clinicals, Diagnosis, and Management

Sports Medicine

Clinicals - History

Fact Explanation
Unilateral medial heel pain of a 6 month to 2 year duration. Degenerative changes in the plantar fascia, with or without fibroblastic proliferation and
chronic inflammatory changes near the site of origin of the plantar fascia at the medial
tuberosity of the calcaneus
Up to 30% of patients may have bilateral heel pain.
Unilateral medial heel pain of a 6 month to 2 year duration.
Degenerative changes in the plantar fascia, with or without fibroblastic proliferation and
chronic inflammatory changes near the site of origin of the plantar fascia at the medial
tuberosity of the calcaneus
Up to 30% of patients may have bilateral heel pain.
Pain is severe on initial few steps and usually lessens with activity. The inflammatory cells and substances accumulate at the site during rest disperse with activity. Pain is severe on initial few steps and usually lessens with activity.
The inflammatory cells and substances accumulate at the site during rest disperse with activity.
Pain gets worse with prolonged standing. Pain occurs due to mechanical stress on degenerative lesions in plantar fascia. Pain gets worse with prolonged standing.
Pain occurs due to mechanical stress on degenerative lesions in plantar fascia.
Numbness, tingling and pain radiating towards the forefoot. Posterior tibial nerve entrapment occurs due to swelling of the surrounding tissue of the fascial insertion due to inflammation. Numbness, tingling and pain radiating towards the forefoot.
Posterior tibial nerve entrapment occurs due to swelling of the surrounding tissue of the fascial insertion due to inflammation.
Risk factors include excessive running or occupations that involve prolonged standing, pes planus and obesity. Thought to predispose to micro tears in the plantar fascia due to excessive or repeated stress. Risk factors include excessive running or occupations that involve prolonged standing, pes planus and obesity.
Thought to predispose to micro tears in the plantar fascia due to excessive or repeated stress.

Clinicals - Examination

Fact Explanation
Sharp, stabbing pain on palpation of the medial plantar calcaneal region and along the plantar fascia Commonly affected site is at the insertion of plantar fascia at calcaneum. Sharp, stabbing pain on palpation of the medial plantar calcaneal region and along the plantar fascia
Commonly affected site is at the insertion of plantar fascia at calcaneum.
Assessment of gait. Patients may walk with the affected foot in equinus. To avoid transmitting pressure on to the painful heel. Assessment of gait. Patients may walk with the affected foot in equinus.
To avoid transmitting pressure on to the painful heel.
Body Mass Index(BMI) Obesity exerts more stress over the heel and it is an important risk factor. Body Mass Index(BMI)
Obesity exerts more stress over the heel and it is an important risk factor.
Pain caused by passive flexion of the ankle or the first toe This manoeuvre stretches the plantar fascia which aggravates the pain. Pain caused by passive flexion of the ankle or the first toe
This manoeuvre stretches the plantar fascia which aggravates the pain.
Swelling of the heel Is a rare presentation and occurs due to the inflammatory reaction. Swelling of the heel
Is a rare presentation and occurs due to the inflammatory reaction.

Investigations - Diagnosis

Fact Explanation
Lateral X-Ray of the ankle Imaging plays a limited role in routine clinical practice; although, it may be useful in selected cases to rule out other causes such as calcaneal stress fractures or to establish the diagnosis of plantar fasciitis when it is in doubt. The appearance of a sub-calcaneal spur on lateral foot radiographyis not diagnostic of plantar fasciitis,as this may even be seen in those without plantar fasciitis. Lateral X-Ray of the ankle
Imaging plays a limited role in routine clinical practice; although, it may be useful in selected cases to rule out other causes such as calcaneal stress fractures or to establish the diagnosis of plantar fasciitis when it is in doubt. The appearance of a sub-calcaneal spur on lateral foot radiographyis not diagnostic of plantar fasciitis,as this may even be seen in those without plantar fasciitis.
Ultrasonography of the plantar heel region Ultrasonography may be diagnostically useful although it is not routinely used. The plantar fascia can be easily distinguished from the hyperechoic superficial heel pad of fat and the underlying calcaneus. In plantar fasciitis there is marked increase in the thickness of the fascia to 7mm from the usual 2mm. In addition local or diffuse hypoechogenicity at the calcaneal insertion of the plantar fascia and peri-insertional edema can be seen. Ultrasonography of the plantar heel region
Ultrasonography may be diagnostically useful although it is not routinely used. The plantar fascia can be easily distinguished from the hyperechoic superficial heel pad of fat and the underlying calcaneus. In plantar fasciitis there is marked increase in the thickness of the fascia to 7mm from the usual 2mm. In addition local or diffuse hypoechogenicity at the calcaneal insertion of the plantar fascia and peri-insertional edema can be seen.
Magnetic resonance imaging (MRI) Marked increase in the thickness of the plantar fascia. Magnetic resonance imaging (MRI)
Marked increase in the thickness of the plantar fascia.
Bone Scans In the event of a normal radiograph, bone scans are useful in distinguishing plantar fasciitis from a calcaneal stress fracture. Findings are of Increased blood flow and pooling, focal increase in activity at the plantar fascial insertion. Bone Scans
In the event of a normal radiograph, bone scans are useful in distinguishing plantar fasciitis from a calcaneal stress fracture. Findings are of Increased blood flow and pooling, focal increase in activity at the plantar fascial insertion.

Investigations - Management

Fact Explanation
Lateral X-ray of the ankle Often a plain radiograph is performed before injecting steroids to exclude other differential diagnosis. Lateral X-ray of the ankle
Often a plain radiograph is performed before injecting steroids to exclude other differential diagnosis.

Management - Supportive

Fact Explanation
Rest, modification of activity, correction of training errors. Avoidance of activities such as prolonged standing. Correction of training errors and avoidance of additional strain over the affected area. Rest, modification of activity, correction of training errors.
Avoidance of activities such as prolonged standing. Correction of training errors and avoidance of additional strain over the affected area.
Application of ice for 20 mins upto 3 to 4 times a day. [1} Local vasoconstriction and analgesia. Application of ice for 20 mins upto 3 to 4 times a day. [1}
Local vasoconstriction and analgesia.
Education on choosing the right shoe size. Tight fitting shoes are a precipitating factor. Education on choosing the right shoe size.
Tight fitting shoes are a precipitating factor.
Weight reduction Reduces the amount of strain on the plantar fascia when standing. Weight reduction
Reduces the amount of strain on the plantar fascia when standing.
Orthotic devices Devices such as viscoelastic heel cups, prefabricated longitudinal arch supports and custom-made full-length shoe insoles can be used. Aids in the prevention of over pronation of the foot and unloads tensile forces from the plantar fascia. Orthotic devices
Devices such as viscoelastic heel cups, prefabricated longitudinal arch supports and custom-made full-length shoe insoles can be used. Aids in the prevention of over pronation of the foot and unloads tensile forces from the plantar fascia.
Night splints Prevents flexion of the plantar fascia during sleeping by keeping the foot and ankle in a neutral 90-degree position. Night splints
Prevents flexion of the plantar fascia during sleeping by keeping the foot and ankle in a neutral 90-degree position.
Stretching exercises and physical therapy . Progressive plantar fascia and intrinsic foot muscle stretching techniques have been shown to reduce pain in plantar fasciitis. Stretching exercises and physical therapy .
Progressive plantar fascia and intrinsic foot muscle stretching techniques have been shown to reduce pain in plantar fasciitis.

Management - Specific

Fact Explanation
NSAIDs Has an analgesic and anti-inflammatory effect. NSAIDs
Has an analgesic and anti-inflammatory effect.
Corticosteroid injections Used for their anti inflammatory effect. Steroid injections are of benefit if administrated early in the illness. Usually reserved for patients who do not improve with conservative methods. Steroids can be injected via plantar or medial approaches.
Has a 70% success rate. Fat pad atrophy and fascial rupture are potential side effects.
Corticosteroid injections
Used for their anti inflammatory effect. Steroid injections are of benefit if administrated early in the illness. Usually reserved for patients who do not improve with conservative methods. Steroids can be injected via plantar or medial approaches.
Has a 70% success rate. Fat pad atrophy and fascial rupture are potential side effects.
Extracorporeal shock wave therapy. Treatment options for chronic plantar fasciitis.
Mechanism of action is thought to be by neo-vascularization and modulation of endogenous Nitrous Oxide( NO).
Extracorporeal shock wave therapy.
Treatment options for chronic plantar fasciitis.
Mechanism of action is thought to be by neo-vascularization and modulation of endogenous Nitrous Oxide( NO).
Plantar fasciotomy Performed in patients in whom conservative measures have failed. The fascia is incised to relieve tension. Plantar fasciotomy
Performed in patients in whom conservative measures have failed. The fascia is incised to relieve tension.
Prolotherapy with platelet-rich plasma The platelet rich plasma contains growth factors that stimulate healing in degenerating tissue. Currently, there is evidence for the use of platelet-rich plasma in non-healing tendinopathies. Prolotherapy with platelet-rich plasma
The platelet rich plasma contains growth factors that stimulate healing in degenerating tissue. Currently, there is evidence for the use of platelet-rich plasma in non-healing tendinopathies.

Concise, fact-based medical articles to refresh your knowledge

Access a wealth of content and skim through a smartly presented catalog of diseases and conditions.

  1. ACEVEDO,J.I, J.L.BESKIL. Complications of plantar fascia rupture associated with corticosteroid injection.Foot Ankle Int,1998 Feb,19(2),91-7.[viewed 5 March 2014].Available from: http://fai.sagepub.com/content/19/2/91.short
  2. BERKOWITZ,J.F, R.KIER, S.RUDICEL.Plantar fasciitis: MR imaging. Radiology,1991,179,665-7.[viewed 5 March 2014].Available from:http://pubs.rsna.org/doi/abs/10.1148/radiology.179.3.2027971?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed&
  3. BUCHBINDER,R. Clinical practice. Plantar fasciitis. N Engl J Med,2004 May,20,350(21),2159- 2166 [viewed 5 March 2014].Available from: http://www.nejm.org/doi/pdf/10.1056/NEJMcp032745
  4. CHIA,K.K. et al. Comparative trial of the foot pressure patterns between corrective orthotics, formthotics, bone spur pads and flat insoles in patients with chronic plantar fasciitis.Ann Acad Med Singapore,2009,38(10),869-875.[viewed 5 March 2014].Available from: http://www.annals.edu.sg/pdf/38VolNo10Oct2009/V38N10p869.pdf
  5. CLINTON,J.D, A.P. MORRELB.Chiropractic management of pediatric plantar fasciitis.J Chiropr Med. Mar 2012,11(1), 58ā€“63. [viewed 5 March 2014].Available from: doi: 10.1016/j.jcm.2011.06.009
  6. GIBBON,WW, G.LONG.Ultrasound of the plantar aponeurosis (fascia). Skeletal Radiology,1999,28,21-6.[viewed 5 March 2014].Available from:DOI 10.1007/s002560050467
  7. GOFF,J.D, R.C.CRAWFORD.Diagnosis and treatment of plantar fasciitis.American Family Physician,2011 Sep,15,84(6),676-82.[viewed 5 March 2014].Available from: http://pubs.rsna.org/doi/abs/10.1148/radiology.179.3.2027971?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed&
  8. GOFF,J.D. Diagnosis and treatment of plantar fasciitis.Am Fam Physician. 2011 Sep 15,84(6),676-82. [viewed 5 March 2014].Available from: http://www.aafp.org/afp/2011/0915/p676.html
  9. GOFF,J.D. Diagnosis and treatment of plantar fasciitis.Am Fam Physician. 2011 Sep 15,84(6),676-82. [viewed 5 March 2014].Available from: http://www.aafp.org/afp/2011/0915/p676.html
  10. GROSHAR,D. et al. Plantar fasciitis: detection with ultrasonography versus bone scintigraphy.The International Journal of clinical foot science,2000,10,164-8.[viewed 5 March 2014].Available from: http://dx.doi.org/10.1054/foot.2000.0621
  11. HYLAND,M.R. et al. Randomized controlled trial of calcaneal taping, sham taping, and plantar fascia stretching for the short-term management of plantar heel pain. J Orthop Sports Phys Ther. ,2006,36(6),364-371.[viewed 5 March 2014].Available from: doi:10.2519/jospt.2006.2078
  12. JARDE O. et al. Degenerative lesions of the plantar fascia: surgical treatment by fasciectomy and excision of the heel spur: a report on 38 cases. Acta Orthop Belg., 2003,69,267-74 [viewed 5 March 2014]. Available from:http://actaorthopaedicabelgica.be/acta/download/2003-3/09-jarde-vernois-.pdf
  13. KALACI,A. Treatment of plantar fasciitis using four different local injection modalities: a randomized prospective clinical trial.J Am Podiatr Med Assoc.,2009,99(2),108-11 [viewed 5 March 2014].Available from: http://www.japmaonline.org/content/99/2/108.long
  14. KARABAY,N. Ultrasonographic evaluation in plantar fasciitis.J Foot Ankle Surg. 2007 Nov-Dec;46(6):442-6. [viewed 5 March 2014].Available from: http://www.jfas.org/article/S1067-2516(07)00291-8/abstract
  15. LEACH R.E. et al. Results of surgery in athletes with plantar fasciitis. Foot Ankle,Dec 1986;7(3):156-61.[viewed 5 March 2014].Available from:http://fai.sagepub.com/content/7/3/156.full.pdf
  16. LEMONT H. et al.Plantar fasciitis: a degenerative process (fasciosis) without inflammation.J Am Podiatr Med Assoc. 2003,93,234-7 [viewed 5 March 2014].Available from:http://fai.sagepub.com/content/7/3/156.full.pdf
  17. MCGONAGLE,D. et al. The role of biomechanical factors and HLA-B27 in magnetic resonance imaging-determined bone changes in plantar fascia enthesopathy. Arthritis Rheum,2002,46,489-93. [viewed 5 March 2014].Available from: DOI:10.1002/art.10125
  18. MCPOIL T.G. et al. Heel pain-plantar fasciitis: clinical practice guildelines linked to the international classification of function, disability, and health from the orthopaedic section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008:38(4):A1-A18. ,2008,38,A,1ā€“18.[viewed 5 March 2014].Available from: doi:10.2519/jospt.2008.0302
  19. OTHMAN,A.M, E.M.RAGAB. Endoscopic plantar fasciotomy versus extracorporeal shock wave therapy for treatment of chronic plantar fasciitis. Arch Orthop Trauma Surg,2010,130(11),1343-1347.[viewed 5 March 2014].Available from: doi: 10.1007/s00402-009-1034-2.
  20. ROME,K. Anthropometric and biomechanical risk factors in the development of plantar heel pain-a review of the literature.Physical Therapy Reviews, 08/1997; 2(3):123-134. [viewed 5 March 2014].Available from:DOI:10.1179/108331997787247518
  21. ROMPE,J.D. et al. Shock wave therapy for chronic plantar fasciopathy. Br Med Bull,2007,81-82,183-208.[viewed 5 March 2014].Available from: doi: 10.1093/bmb/ldm005
  22. ROXAS M. Plantar fasciitis: Diagnosis and therapeutic considerations. Alternative Medicine Review,2005,10,83ā€“93. [viewed 5 March 2014].Available from:http://www.altmedrev.com/publications/10/2/83.pdf
  23. RYAN,M.B. et al. Sonographically guided intratendinous injections of hyperosmolar dextrose/lidocaine: a pilot study for the treatment of chronic plantar fasciitis. Br J Sports Med.,2009,43(4),303-306.[viewed 5 March 2014].Available from: doi: 10.1136/bjsm.2008.050021
  24. SAMPSON S. et al. Platelet rich plasma injection grafts for musculoskeletal injuries: a review. Curr Rev Musculoskelet Med,2008,1(3-4),165-174.[viewed 5 March 2014].Available from:doi: 10.1007/s12178-008-9032-5
  25. THOMAS,J.L, et al.The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010.J Foot Ankle Surg. 2010 May-Jun,49(3 Suppl),S1-19. [viewed 5 March 2014].Available from: doi: 10.1053/j.jfas.2010.01.001.