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Plantar Fasciitis Print

Plantar Fasciitis, Dr. Allen F. Anderson, Nashville, Orthopaedic Sports Medicine, Figure 1
Heel pain is a common complaint in both the athletic and non-athletic populations. Causes of pain include stress fractures, S1 radiculopathy (nerve compression in the back) and nerve entrapment syndromes. However, one of the most common causes of heel pain is inflammation of the plantar fascia, plantar fasciitis.
 
The plantar fascia, or plantar aponeurosis (1), is a firm band of tissue running the length of the sole of the foot that is comprised of 3 distinct bands. The central band, the portion generally referred to when speaking of the plantar fascia, runs from the plantar aspect of the posteromedial calcaneal tuberosity to insert on the toes. It is the largest of the three bands. The lateral band originates just lateral to the central band and inserts on the 5th metatarsal. The medial band, the thinnest of the three, originates just medial to the central band and covers the abductor hallicus muscle. 
 
The central band of the plantar fascia is very important in maintaining stability in the foot. The fascia inserts onto the proximal phalanges of the lesser toes, the sesamoid bones of the great toe and even the plantar skin in the area. This tight fascial band serves to connect the hindfoot to the forefoot and helps maintain the longitudinal arch of the foot. When the toes are dorsiflexed, the plantar fascia becomes taut, which in turn increases the longitudinal arch, inverts the heel and externally rotates the lower leg. This configuration provides added stability to the foot and is called the "windlass" mechanism (below).
 
Due to the high stresses imposed by activity on the plantar fascia, it is not surprising that this area is susceptible to injury. Any alteration in foot mechanics, such as flat feet or poor shoes, can increase the strain on the fascia leading to inflammation.

History

Patients generally report a gradual onset of pain in the sub-calcaneal region that is worse in the mornings. The pain generally eases with activity but may become worse with prolonged or strenuous activity. Activity following long periods of rest is usually accompanied by an increase in symptoms.

Plantar Fasciitis, Dr. Allen F. Anderson, Nashville, Orthopaedic Sports Medicine, Figure 2

Physical Examination

As with any medical problem, a thorough physical examination is necessary. One should take note of the general posture and gait of the patient, noting any abnormality in the alignment of the limb. The foot should be thoroughly inspected for presence of flatfoot or cavus foot.

Also, an examination of the neurovascular status must be performed with special attention paid to the contents of the tarsal tunnel including the posterior tibial, medial and lateral plantar and medial calcaneal nerves. All muscles and tendons crossing the ankle should be palpated and tested for integrity. The range of motion of both the tibiotalar and subtalar joints should be assessed.

Pain is usually localized to the medial portion of the calcaneal tuberosity. The entire length of the plantar fascia should be palpated with the toes in both flexion and extension. With the fascia in tension, it should be checked for any nodules which could indicate planter fibromatosis.

Diagnostic Imaging

Standard x-rays are taken in AP, lateral and oblique planes to fully evaluate the os calcis. The films should be taken while weight bearing to demonstrate the biomechanical status of the foot and allow classification of the foot as normal, flat or cavus. 45 degree oblique views of the calcaneus may also demonstrate cystic changes or calcification in the medial tuberosity. Also, any spur formation may be clearly demonstrated. Occasionally, a stress fracture may be noted.

Plantar Fasciitis, Dr. Allen F. Anderson, Nashville, Orthopaedic Sports Medicine, Figure 3

Bone scans show increased uptake in the area due to inflammatory changes at the insertion of the plantar fascia onto the calcaneus. These changes are often seen in the absence of changes on plain x-rays. Bone scans have also been used to track the recovery in that the intensity of radioisotope uptake tends to decrease as symptoms subside.

Treatment

Treatment is individualized to each patient according to his or her body type and limb alignment. Those patients with normal limb alignment are treated with non-steroidal anti-inflammatory medications, activity modification to reduce offending activities, and shoe inserts. In general, an orthotic (right) that cushions and aligns the heel, while reducing pressure on tender areas, is used. Also, calf stretching exercises, and those that stretch the plantar fascia, are very important in symptomatic relief. These are performed several times daily, especially after long periods of inactivity, such as upon awakening.

In resistant cases, a steroid injection may be helpful. In general, the injection should be directed to the point of maximum tenderness. If an anesthetic is injected with the steroid, the injection becomes diagnostic as well as therapeutic. However, steroid injections should only be used in patients who fail other non-surgical measures due to the possible complications of these injections, including necrosis of the fat pad under the heel which could predispose the plantar structures of the foot to even more pressure related problems.

If the above measures fail to relieve the symptoms, physical therapy including stretching and strengthening exercises, ultrasound, and ionophoresis may be used. Occasionally, immobilization with a night splint or full time immobilization, may be required.

In patients with normal alignment and anatomy, the orthotics and medications may be weaned as symptoms subside. However, in patients with abnormal alignment of the heel, or a flat or cavus foot, a permanent orthotic may be necessary to avoid excessive biomechanical forces.

Plantar Fasciitis, Dr. Allen F. Anderson, Nashville, Orthopaedic Sports Medicine, Figure 4

In certain individuals, non-surgical measures will fail to relieve the symptoms. These individuals may require surgical intervention to relieve their pain. It is important to fully evaluate any patient with heel pain prior to surgery to be absolutely certain of the diagnosis.

X-rays and possibly a bone scan are used to locate a spur and rule out a stress fracture. An EMG may be helpful if one suspects nerve entrapment as an associated diagnosis. Anesthetic injections may also aid in localizing the pain.

When the decision is made to perform surgery, it is usually performed through a medial incision on the heel. One must find and inspect the medial calcaneal nerve to rule out entrapment. Next the central slip of the plantar fascia is released and the calcaeal spur is removed.

Finally, one should locate and release the nerve to the abductor digiti quinti as it passes laterally through the abductor hallicus and quadratus palntae muscles.

Post-operatively, the foot is immobilized in a cast or splint for 3 weeks. Weight bearing is begun after one week and running after 2 months.

Patient Return To Sports

Generally, athletes may return to sporting activities as their symptoms permit. However, if surgery is contemplated, the athlete should be aware that 8-12 weeks will be required before he or she may return to sports.

 
© Allen F. Anderson, M.D. 2017