Heel pain is a common presenting complaint in the foot and ankle practice, and plantar fasciitis (PF) is the most common cause of chronic pain beneath the heel in adults, making up 11–15% of the foot symptoms requiring professional care among adults. It is estimated that 1 in 10 people will develop PF during their lifetime.PF, which is more common in middle-aged obese females and young male athletes, has a higher incidence in the athletic population though not all suffering require medical treatment. In the literature, PF has been described as painful heel syndrome, chronic plantar heel pain, heel spur syndrome, runner’s heel, and calcaneal periostitis. There are some factors associated with PF will help identifying at risk individuals and development of new and improved preventative and treatment strategies. Obesity is present in up to 70% of patients with PF. According to the literatures, there is a strong association between increased body mass index (BMI) and PF in a non-athletic population. The evidence suggests that unlike weight, height has no association with PF. More specifically, increased weight is associated with PF, but not necessarily with reduced height.
Heel spurs have commonly been implicated as a risk factor for PF. Current studies demonstrate a highly significant association between calcaneal spur and PF. There are also deficits in flexibility of the plantar flexor muscles may contribute to a greater fascia stretching. Some reports suggest that 81–86% of patients with PF have excessive pronation. Despite the fact that the pronated foot posture and over-pronation during gait are commonly cited as causative factors for PF, there is conflicting evidence with regard to the association of static foot posture and dynamic foot motion with PF.
Clinical features and diagnosis
The diagnosis of PF is usually clinical and rarely needs to be investigated further. The patient complains of pain in the medial side of the heel, most noticeable with initial steps after a period of inactivity and usually lessens with increasing level of activity during the day, but will tend to worsen toward the end of the day.
Symptoms may become worse following prolonged weight bearing, and often precipitated by increase in weight bearing activities. Paresthesia is uncommon. PF is usually unilateral, but up to 30% of cases have a bilateral presentation. Tightness of Achilles tendon is found in almost 80% of cases.
Occasionally the pain may spread to the whole of the foot including the toes. Tenderness can be elicited over the medial calcaneal tuberosity and may exaggerate on dorsiflexion of the toes or standing tip toe.
Imaging studies are typically not necessary for diagnosis of PF. In the clinical management of chronic heel pain, diagnostic imaging can provide objective information. This information can be particularly useful in cases that do not respond to first-line interventions, or when considering more invasive treatments (e.g. corticosteroid injection).
Lateral radiograph of the ankle should be the first imaging study. It is a good modality for assessment of heel spur, thickness of plantar fascia, and the quality of fat pad. Stress fractures, unicameral bone cysts, and giant cell tumors are usually identified with plain radiography.
Ultrasound examination is operator-dependent, but it proves to be significant when the diagnosis is unclear.
Plantar fascia thickness values have also been used to measure the effect of treatments and there is a significant correlation between decreased plantar fascia thickness and improvement in symptoms. MRI can be used in questionable cases, which fail conservative management or are suspected of other causes of heel pain, such as tarsal tunnel syndrome, soft tissue and bone tumors, osteomyelitis, subtalar arthritis, and stress fracture.
Numerous interventions have been described for treatment of PF, which include: rest, heat, ice pack, non-steroidal anti-inflammatory drugs (NSAIDS), heel pads, magnetic insole, night splints, walking cast, taping, plantar and Achilles stretching, ultrasound, steroid injection, extra-corporeal shock wave therapy, platelet-rich plasma injection, pulsed radiofrequency electromagnetic field therapy, and surgery.
Stretching may be in calf or plantar region. Numerous authors have recommended that calf stretching should be one of the interventions used for patients with PF. A calf stretch is performed with the patient stands with staggered legs facing toward a wall, with both hands stretched out.
The design of night splinting is to keep the patient’s ankle in a neutral position overnight, passively stretching the calf and plantar fascia during sleep. There is no difference between the various types of the night splints whose purpose is to allow the fascia to heal.
Recalcitrant cases where symptoms persist for more than 6–12 months, even after adequate conservative treatment are usually selected for surgery. Before surgery nerve conduction and electromyographic studies should be considered to determine if the posterior tibial nerve is compressed.