Plantar fasciitis or plantar heel pain is a disorder of the plantar fascia, which is the

connective tissue Connective tissue is one of the four primary types of animal tissue, a group of cells that are similar in structure, along with epithelial tissue, muscle tissue, and nervous tissue. It develops mostly from the mesenchyme, derived from the mesod ...

that supports the arch of the foot. It results in pain in the heel and bottom of the foot that is usually most severe with the first steps of the day or following a period of rest. Pain is also frequently brought on by bending the foot and toes up towards the shin. The pain typically comes on gradually, and it affects both feet in about one-third of cases. The cause of plantar fasciitis is not entirely clear. Risk factors include overuse, such as from long periods of standing, an increase in exercise, and

obesity Obesity is a medical condition, considered by multiple organizations to be a disease, in which excess Adipose tissue, body fat has accumulated to such an extent that it can potentially have negative effects on health. People are classifi ...

. It is also associated with inward rolling of the foot, a tight

Achilles tendon The Achilles tendon or heel cord, also known as the calcaneal tendon, is a tendon at the back of the lower leg, and is the thickest in the human body. It serves to attach the plantaris, gastrocnemius (calf) and soleus muscles to the calcane ...

, and a sedentary lifestyle. It is unclear if heel spurs have a role in causing plantar fasciitis even though they are commonly present in people who have the condition. Plantar fasciitis is a disorder of the insertion site of the ligament on the bone characterized by micro tears, breakdown of collagen, and scarring. Since

inflammation Inflammation (from ) is part of the biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. The five cardinal signs are heat, pain, redness, swelling, and loss of function (Latin ''calor'', '' ...

plays either a lesser or no role, a review proposed it be renamed plantar fasciosis. The presentation of the symptoms is generally the basis for diagnosis; with

ultrasound Ultrasound is sound with frequency, frequencies greater than 20 Hertz, kilohertz. This frequency is the approximate upper audible hearing range, limit of human hearing in healthy young adults. The physical principles of acoustic waves apply ...

sometimes being useful if there is uncertainty. Other conditions with similar symptoms include

osteoarthritis Osteoarthritis is a type of degenerative joint disease that results from breakdown of articular cartilage, joint cartilage and underlying bone. A form of arthritis, it is believed to be the fourth leading cause of disability in the world, affect ...

, ankylosing spondylitis, heel pad syndrome, and reactive arthritis. Most cases of plantar fasciitis resolve with time and conservative methods of treatment. For the first few weeks, those affected are usually advised to rest, change their activities, take pain medications, and stretch. If this is not sufficient,

physiotherapy Physical therapy (PT), also known as physiotherapy, is a healthcare profession, as well as the care provided by physical therapists who promote, maintain, or restore health through patient education, physical intervention, disease preventio ...

orthotics Orthotics () is a medical specialty that focuses on the design and application of orthoses, sometimes known as braces, calipers, or splints. An is "an externally applied device used to influence the structural and functional characteristics of ...

, splinting, or steroid injections may be options. If these measures are not effective, additional measures may include extracorporeal shockwave therapy or surgery. Between 4% and 7% of the general population has heel pain at any given time: about 80% of these are due to plantar fasciitis. Approximately 10% of people have the disorder at some point during their life. It becomes more common with age. It is unclear if one sex is more affected than the other.

Signs and symptoms

When plantar fasciitis occurs, the pain is typically sharp and usually unilateral (70% of cases). Bearing weight on the heel after long periods of rest worsens heel pain in affected individuals. Individuals with plantar fasciitis often report their symptoms are most intense during their first steps after getting out of bed or after prolonged periods of sitting. Symptoms typically improve with continued walking. Rare, but reported, symptoms include

numbness Hypoesthesia or numbness is a common side effect of various medical conditions that manifests as a reduced sense of touch or sensation, or a partial loss of sensitivity to Sensory receptor, sensory stimuli. In everyday speech this is generally r ...

, tingling, swelling, and radiating pain. Typically there are no

fever Fever or pyrexia in humans is a symptom of an anti-infection defense mechanism that appears with Human body temperature, body temperature exceeding the normal range caused by an increase in the body's temperature Human body temperature#Fever, s ...

s or night sweats. If the plantar fascia is overused in the setting of plantar fasciitis, the plantar fascia can rupture. Typical signs and symptoms of plantar fascia rupture include a clicking or snapping sound, significant local swelling, and acute pain in the bottom of the foot.

Risk factors

Identified risk factors for plantar fasciitis include excessive running, standing on hard surfaces for prolonged periods, high arches of the feet, the presence of a leg length inequality, and

flat feet Flat feet, also called pes planus or fallen arches, is a Posture (psychology), postural deformity in which the arches of the foot collapse, with the entire sole (foot), sole of the foot coming into complete or near-complete contact with the gro ...

. The tendency of flat feet to excessively roll inward during walking or running makes them more susceptible to plantar fasciitis.

Obesity Obesity is a medical condition, considered by multiple organizations to be a disease, in which excess Adipose tissue, body fat has accumulated to such an extent that it can potentially have negative effects on health. People are classifi ...

is seen in 70% of individuals who present with plantar fasciitis and is an independent risk factor. Plantar fasciitis is commonly a result of some biomechanical imbalance that causes an increased amount of tension placed along the plantar fascia.

tightness and inappropriate footwear have also been identified as significant risk factors.

Pathophysiology

The cause of plantar fasciitis is poorly understood and appears to have several contributing factors. The plantar fascia is a thick fibrous band of connective tissue that originates from the medial tubercle and anterior aspect of the heel bone. From there, the fascia extends along the sole of the foot before inserting at the base of the toes and supports the arch of the foot. Plantar fasciitis is a non-inflammatory condition of the plantar fascia. Within the last decade, studies have observed microscopic anatomical changes indicating that plantar fasciitis is due to a non-inflammatory structural breakdown of the plantar fascia rather than an inflammatory process. Many in the academic community have stated the condition should be renamed plantar fasciosis in light of these newer findings. Repetitive microtrauma (small tears) appears to cause a structural breakdown of the plantar fascia. Microscopic examination of the plantar fascia often shows myxomatous degeneration, connective tissue calcium deposits, and disorganized collagen fibers. Disruptions in the plantar fascia's normal mechanical movement during standing and walking (known as the Windlass mechanism) place excess strain on the calcaneal tuberosity and seem to contribute to the development of plantar fasciitis. Other studies have also suggested that plantar fasciitis is not due to the inflamed plantar fascia but maybe a tendon injury involving the flexor digitorum brevis muscle located immediately deep to the plantar fascia.

Diagnosis

Projectional radiography of calcaneal spur

Plantar fasciitis is usually diagnosed by a

health care provider A health care provider is an individual health professional or a health facility organization licensed to provide health care diagnosis and treatment services including medication, surgery and medical devices. Health care providers often rece ...

after consideration of a person's presenting history, risk factors, and clinical examination. Palpation along the inner aspect of the heel bone on the sole may elicit tenderness during the physical examination. The foot may have limited dorsiflexion due to excessive tightness of the calf muscles or the

. Dorsiflexion of the foot may elicit the pain due to stretching of the plantar fascia with this motion. Diagnostic imaging studies are not usually needed to diagnose plantar fasciitis. Occasionally, a physician may decide imaging studies (such as

X-rays An X-ray (also known in many languages as Röntgen radiation) is a form of high-energy electromagnetic radiation with a wavelength shorter than those of ultraviolet rays and longer than those of gamma rays. Roughly, X-rays have a wavelength ran ...

, diagnostic ultrasound, or

MRI Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and rad ...

) are warranted to rule out serious causes of foot pain. Other diagnoses that are typically considered include 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. Under these circumstances, diagnostic tests such as a CBC or serological markers of inflammation, infection, or

autoimmune disease An autoimmune disease is a condition that results from an anomalous response of the adaptive immune system, wherein it mistakenly targets and attacks healthy, functioning parts of the body as if they were foreign organisms. It is estimated tha ...

such as C-reactive protein, erythrocyte sedimentation rate, anti-nuclear antibodies, rheumatoid factor, HLA-B27,

uric acid Uric acid is a heterocyclic compound of carbon, nitrogen, oxygen, and hydrogen with the Chemical formula, formula C5H4N4O3. It forms ions and salts known as urates and acid urates, such as ammonium acid urate. Uric acid is a product of the meta ...

, or

Lyme disease Lyme disease, also known as Lyme borreliosis, is a tick-borne disease caused by species of ''Borrelia'' bacteria, Disease vector, transmitted by blood-feeding ticks in the genus ''Ixodes''. It is the most common disease spread by ticks in th ...

antibodies may also be obtained. Neurological deficits may prompt an investigation with

electromyography Electromyography (EMG) is a technique for evaluating and recording the electrical activity produced by skeletal muscles. EMG is performed using an instrument called an electromyograph to produce a record called an electromyogram. An electromyo ...

to check for damage to the nerves or muscles. An incidental finding associated with this condition is a

heel spur A calcaneal spur (also known as a heel spur) is a bony outgrowth from the calcaneal tuberosity (heel bone). Calcaneal spurs are typically detected by Radiography, x-ray examination. It is a form of exostosis. When a foot is exposed to constant St ...

, a small bony

calcification Calcification is the accumulation of calcium salts in a body tissue. It normally occurs in the formation of bone, but calcium can be deposited abnormally in soft tissue,Miller, J. D. Cardiovascular calcification: Orbicular origins. ''Nature M ...

on the

calcaneus In humans and many other primates, the calcaneus (; from the Latin ''calcaneus'' or ''calcaneum'', meaning heel; : calcanei or calcanea) or heel bone is a bone of the Tarsus (skeleton), tarsus of the foot which constitutes the heel. In some other ...

(heel bone), which can be found in up to 50% of those with plantar fasciitis. In such cases, it is the underlying plantar fasciitis that produces the heel 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.

Imaging

Medical imaging is not routinely needed. It is expensive and does not typically change how plantar fasciitis is managed. When the diagnosis is not clinically apparent, lateral view X-rays of the ankle are the recommended imaging modality to assess for other causes of heel pain, such as stress fractures or bone spur development. The plantar fascia has three fascicles-the central fascicle being the thickest at 4 mm, the

lateral Lateral is a geometric term of location which may also refer to: Biology and healthcare * Lateral (anatomy), a term of location meaning "towards the side" * Lateral cricoarytenoid muscle, an intrinsic muscle of the larynx * Lateral release ( ...

fascicle at 2 mm, and the medial less than a millimeter thick. In theory, plantar fasciitis becomes more likely as the plantar fascia's thickness at the calcaneal insertion increases. A thickness of more than 4.5 mm

and 4 mm on

are useful for diagnosis. Other imaging findings, such as thickening of the plantar aponeurosis, are nonspecific and have limited usefulness in diagnosing plantar fasciitis. Three-phase bone scan is a sensitive modality to detect active plantar fasciitis. Furthermore, a 3-phase bone scan can be used to monitor response to therapy, as demonstrated by decreased uptake after corticosteroid injections.

Differential diagnosis

The differential diagnosis for heel pain is extensive and includes pathological entities including, but not limited to, the following: calcaneal stress fracture,

septic arthritis Acute septic arthritis, infectious arthritis, suppurative arthritis, pyogenic arthritis, osteomyelitis, or joint infection is the invasion of a joint by an infectious agent resulting in joint inflammation. Generally speaking, symptoms typica ...

, calcaneal bursitis,

, spinal stenosis involving the nerve roots of lumbar spinal nerve 5 (L5) or sacral spinal nerve 1 (S1), calcaneal fat pad syndrome, metastasized cancers from elsewhere in the body,

hypothyroidism Hypothyroidism is an endocrine disease in which the thyroid gland does not produce enough thyroid hormones. It can cause a number of symptoms, such as cold intolerance, poor ability to tolerate cold, fatigue, extreme fatigue, muscle aches, co ...

gout Gout ( ) is a form of inflammatory arthritis characterized by recurrent attacks of pain in a red, tender, hot, and Joint effusion, swollen joint, caused by the deposition of needle-like crystals of uric acid known as monosodium urate crysta ...

, seronegative spondyloparthopathies such as reactive arthritis, ankylosing spondylitis, or

rheumatoid arthritis Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects synovial joint, joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and h ...

(more likely if pain is present in both heels), plantar fascia rupture, and compression neuropathies such as tarsal tunnel syndrome or impingement of the medial calcaneal nerve. A determination about a diagnosis of plantar fasciitis can usually be made based on a person's medical history and physical examination., which cites * When a physician suspects a fracture, infection, or some other serious underlying condition, they may order an X-ray to investigate. X-rays are unnecessary to screen for plantar fasciitis for people who stand or walk a lot at work unless imaging is otherwise indicated.

Treatment

Non-surgical

About 90% of plantar fasciitis cases improve within six months with conservative treatment, and within a year regardless of treatment. The recommended first treatment is a four- to six-week course which combines three elements: daily stretching, daily foot taping (using a special tape around the foot for supporting the

arch An arch is a curved vertical structure spanning an open space underneath it. Arches may support the load above them, or they may perform a purely decorative role. As a decorative element, the arch dates back to the 4th millennium BC, but stru ...

) and individually tailored education on choosing footwear and other ways of managing the condition. Reduction in pain and stress on the plantar fascia can be done by strengthening the muscles in the foot that support the arches through barefoot exercising, without footwear, compared to exercising in common footwear. If plantar fasciitis fails to respond to conservative treatment for at least three months, then extracorporeal shockwave therapy (ESWT) may be considered. Evidence from

meta-analyses Meta-analysis is a method of synthesis of quantitative data from multiple independent studies addressing a common research question. An important part of this method involves computing a combined effect size across all of the studies. As such, th ...

suggests significant pain relief lasts up to one year after the procedure. However, debate about the therapy's efficacy has persisted. ESWT is performed with or without

anesthesia Anesthesia (American English) or anaesthesia (British English) is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prev ...

though studies suggest giving anesthesia diminishes the procedure's effectiveness. Complications from ESWT are rare and typically benign when present. Known complications of ESWT include the development of a mild

hematoma A hematoma, also spelled haematoma, or blood suffusion is a localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillaries. A hematoma is ...

or an ecchymosis, redness around the site of the procedure, or

migraine Migraine (, ) is a complex neurological disorder characterized by episodes of moderate-to-severe headache, most often unilateral and generally associated with nausea, and light and sound sensitivity. Other characterizing symptoms may includ ...

The third line of treatment, if shockwave therapy is not effective after around 8 weeks, is using customised foot orthoses which can offer short-term relief from pain. Affected people use further different treatments for plantar fasciitis but many have little evidence to support their use and are not adequately studied. Other conservative approaches include rest,

massage Massage is the rubbing or kneading of the body's soft tissues. Massage techniques are commonly applied with hands, fingers, elbows, knees, forearms, feet, or a device. The purpose of massage is generally for the treatment of body stress or pa ...

, heat, ice, and calf-strengthening exercises, weight reduction in the overweight or obese, and

nonsteroidal anti-inflammatory drugs A nonsteroidal compound is a drug that is not a steroid nor a steroid derivative. Nonsteroidal anti-inflammatory drugs (NSAIDs) are distinguished from corticosteroids as a class of anti-inflammatory agents. List of nonsteroidal steroid receptor mod ...

(NSAIDs) such as

aspirin Aspirin () is the genericized trademark for acetylsalicylic acid (ASA), a nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain, fever, and inflammation, and as an antithrombotic. Specific inflammatory conditions that aspirin is ...

ibuprofen Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is used to relieve pain, fever, and inflammation. This includes dysmenorrhea, painful menstrual periods, migraines, and rheumatoid arthritis. It can be taken oral administration, ...

. The use of NSAIDs to treat plantar fasciitis is common, but their use fails to resolve the pain in 20% of people.

Corticosteroid Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are invo ...

injections are sometimes used for cases of plantar fasciitis that have proven resistant to more conservative measures. There is tentative evidence that injected corticosteroids are effective for short-term pain relief up to one month, but not after that. Another treatment technique is known as plantar iontophoresis. This technique involves applying anti-inflammatory substances such as

dexamethasone Dexamethasone is a fluorinated glucocorticoid medication used to treat rheumatic problems, a number of skin diseases, severe allergies, asthma, chronic obstructive pulmonary disease (COPD), croup, brain swelling, eye pain following eye su ...

acetic acid Acetic acid , systematically named ethanoic acid , is an acidic, colourless liquid and organic compound with the chemical formula (also written as , , or ). Vinegar is at least 4% acetic acid by volume, making acetic acid the main compone ...

topically to the foot and transmitting these substances through the skin with an electric current. Some evidence supports the use of night splints for 1–3 months to relieve plantar fasciitis pain that has persisted 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 during sleep.

Surgery

Plantar fasciotomy is a surgical treatment and the last resort for refractory plantar fasciitis pain. If plantar fasciitis does not resolve after six months of conservative treatment, then the procedure is considered as a last resort. Minimally invasive and endoscopic approaches to plantar fasciotomy exist but require a specialist who is familiar with specific equipment. The availability of these surgical techniques is limited as of 2012. A 2012 study found 76% of people who underwent endoscopic plantar fasciotomy had complete relief of their symptoms and had few complications (level IV evidence).

Heel spur A calcaneal spur (also known as a heel spur) is a bony outgrowth from the calcaneal tuberosity (heel bone). Calcaneal spurs are typically detected by Radiography, x-ray examination. It is a form of exostosis. When a foot is exposed to constant St ...

removal during plantar fasciotomy does not appear to improve the surgical outcome. Plantar heel pain may occur for multiple reasons. In select cases, surgeons may perform a release of the lateral plantar nerve alongside the plantar fasciotomy. Possible complications of plantar fasciotomy include nerve injury, instability of the medial longitudinal arch of the foot, fracture of the

, prolonged recovery time, infection, rupture of the plantar fascia, and failure to improve the pain. Coblation surgery has recently been proposed as an alternative surgical approach for the treatment of recalcitrant plantar fasciitis. Gastrocnemius recession is a surgical procedure that involves lengthening the

gastrocnemius muscle The gastrocnemius muscle (plural ''gastrocnemii'') is a superficial two-headed muscle that is in the back part of the lower leg of humans. It is located superficial to the soleus in the posterior (back) compartment of the leg. It runs from its t ...

to reduce tension in the Achilles tendon and plantar fascia. This technique improves the ankle's range of motion, reduces pain, and can help patients return to work, sports, and weight-bearing activities more comfortably. The procedure is particularly beneficial for individuals with limited ankle dorsiflexion (upward bending) due to tight calf muscles, which can exacerbate plantar fasciitis symptoms.

Unproven treatments

Botulinum toxin Botulinum toxin, or botulinum neurotoxin (commonly called botox), is a neurotoxic protein produced by the bacterium ''Clostridium botulinum'' and related species. It prevents the release of the neurotransmitter acetylcholine from axon en ...

A injections as well as similar techniques such as platelet-rich plasma injections and prolotherapy remain controversial. Dry needling is also being researched for treatment of plantar fasciitis. A

systematic review A systematic review is a scholarly synthesis of the evidence on a clearly presented topic using critical methods to identify, define and assess research on the topic. A systematic review extracts and interprets data from published studies on ...

of available research found limited evidence of effectiveness for this technique. The studies were reported to be inadequate in quality and too diverse in methodology for a firm conclusion. A combination of plantar fasciitis stretching and the use of botulinum toxin showed an increase in improvement and functionability in patients.

Epidemiology

Plantar fasciitis is the most common type of plantar fascia injury and is the most common reason for heel pain, responsible for 80% of cases. The condition tends to occur more often in women, military recruits, older athletes, dancers, people with obesity, and young male athletes. Plantar fasciitis is estimated to affect 1 in 10 people at some point during their lifetime and most commonly affects people between 40 and 60 years of age. In the United States alone, more than two million people receive treatment for plantar fasciitis. The cost of treating plantar fasciitis in the United States is estimated to be $284 million each year.

Prognosis

According to studies following patients with plantar fasciitis over several years, 20% to 75% of individuals no longer have any symptoms within a maximum of one year after the onset of symptoms. Having a

(bony protrusion at the heel) in addition to heel pain does not worsen the prognosis of recovery. Individuals with and without heel spurs recover at the same rate.

References

External links

* {{DEFAULTSORT:Plantar Fasciitis Articles containing video clips Disorders of fascia Foot diseases Fasciitis, plantar Overuse injuries Wikipedia emergency medicine articles ready to translate Soft tissue disorders Wikipedia medicine articles ready to translate