Plantar Heel Pain 

  • Author: Vinod K Panchbhavi, MD, FRCS, FACS; Chief Editor: Jason H Calhoun, MD, FACS   more...
 
Updated: Dec 16, 2010
 

Background

Plantar heel pain is a commonly encountered orthopedic problem that can cause significant discomfort and a limp because of the difficulty in bearing weight. The etiologies of this condition are multiple; therefore, a careful clinical evaluation is necessary for its appropriate management. Nonsurgical or conservative care is successful in most cases.[1, 2, 3, 4, 5, 6, 7, 8, 9, 10]

For excellent patient education resources, visit eMedicine's Sports Injury Center and Foot, Ankle, Knee, and Hip Center. Also, see eMedicine's patient education articles Running and Arch Pain.

The image below depicts a custom-molded orthotic for plantar heel pain.

Custom-molded orthotic. Custom-molded orthotic.
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Pathophysiology

The specialized soft tissue at the heel functions as a shock absorber. The subcutaneous structure consists of fibrous lamellae arranged in a complex whorl containing adipose tissues that attach with vertical fibers to the dermis and the plantar aponeurosis.

The heel can absorb 110% of the body's weight during walking and 200% of the body's weight during running. The plantar fascia is a multilayered fibroaponeurotic structure that arises predominantly from the medial calcaneal tuberosity and inserts distally through several slips into the plantar plates of the metatarsophalangeal joints, the flexor tendon sheaths, and the bases of the proximal phalanges of the toes.

Dorsiflexion of the toes applies traction stress at the origin of the plantar fascia. A contracture in the triceps surae, a pes cavus, or a pes planus can increase the traction load at the origin of the plantar fascia during weight-bearing activities.

Other anatomic factors that can have similar effects are overpronation, discrepancy in leg length, excessive lateral tibial torsion, and excessive femoral anteversion. However, overuse, not anatomy, is the most common cause of plantar fasciitis in athletes. The pain of plantar fasciitis is caused by collagen degeneration associated with repetitive microtears of the plantar fascia.

An inflammatory response and reparative process can double the thickness of the plantar fascia, which is normally approximately 3 mm. Biopsy specimens reveal collagen necrosis, angiofibroblastic hyperplasia, chondroid metaplasia, and calcification.

The heel pain can also have a neurologic basis. The tibial nerve, with nerve roots from L4-5 and S2-4, courses in the medial aspect of the hindfoot, through the tarsal tunnel, under the flexor retinaculum, and over the medial surface of the calcaneus. The calcaneal branch, arising directly from the tibial nerve, carries sensation from the medial and plantar heel dermis.

The tibial nerve divides into lateral and medial plantar nerves, which proceed into the plantar aspect of the foot through a foramen within the origin of the abductor hallucis muscles, which forms the distal tarsal tunnel. The first branch of the lateral plantar nerve changes course from a vertical to a horizontal direction around the medial plantar heel. It passes deep to the abductor hallucis muscle fascia and the plantar fascia and is the nerve supply to the abductor digiti minimi muscle. The tibial nerve and its branches in the hindfoot can be involved with compressive neuropathies. A valgus heel can stretch in the tibial nerve.

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Epidemiology

Frequency

United States

More than 2 million Americans seek treatment for plantar heel pain each year.

International

In both athletic and nonathletic populations, the incidence of plantar fasciitis is reported to be approximately 10%.

Sex

Proximal plantar fasciitis is twice as common in women as in men.

Age

The average age of a patient with proximal plantar fasciitis is approximately 45 years.

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Contributor Information and Disclosures
Author

Vinod K Panchbhavi, MD, FRCS, FACS  Professor of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Department of Orthopedics, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FRCS, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Foot and Ankle Society, Royal College of Surgeons of England, and Texas Orthopaedic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Heidi M Stephens, MD, MBA  Associate Professor, Department of Surgery, Division of Orthopedic Surgery, University of South Florida College of Medicine; Courtesy Joint Associate Professor, Department of Environmental and Occupational Health, University of South Florida College of Public Health

Heidi M Stephens, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, and Florida Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Shepard R Hurwitz, MD  Executive Director, American Board of Orthopaedic Surgery

Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FACS  Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center

Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association

Disclosure: Nothing to disclose.

References

  1. McPoil TG, Martin RL, Cornwall MW, et al. Heel pain--plantar fasciitis: clinical practice guidelines 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. Apr 2008;38(4):A1-A18. [Medline].

  2. Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treatment. J Am Acad Orthop Surg. Jun 2008;16(6):338-46. [Medline].

  3. Alshami AM, Souvlis T, Coppieters MW. A review of plantar heel pain of neural origin: differential diagnosis and management. Man Ther. May 2008;13(2):103-11. [Medline].

  4. Aldridge T. Diagnosing heel pain in adults. Am Fam Physician. Jul 15 2004;70(2):332-8. [Medline]. [Full Text].

  5. Ogden JA, Alvarez RG, Levitt RL, Johnson JE, Marlow ME. Electrohydraulic high-energy shock-wave treatment for chronic plantar fasciitis. J Bone Joint Surg Am. Oct 2004;86-A(10):2216-28. [Medline].

  6. Riddle DL, Pulisic M, Sparrow K. Impact of demographic and impairment-related variables on disability associated with plantar fasciitis. Foot Ankle Int. May 2004;25(5):311-7. [Medline].

  7. Crawford F, Thomson C. Interventions for treating plantar heel pain. Cochrane Database Syst Rev. 2003;CD000416. [Medline].

  8. Tisdel CL, Donley BG, Sferra JJ. Diagnosing and treating plantar fasciitis: a conservative approach to plantar heel pain. Cleve Clin J Med. Apr 1999;66(4):231-5. [Medline].

  9. Gudeman SD, Eisele SA, Heidt RS Jr, Colosimo AJ, Stroupe AL. Treatment of plantar fasciitis by iontophoresis of 0.4% dexamethasone. A randomized, double-blind, placebo-controlled study. Am J Sports Med. May-Jun 1997;25(3):312-6. [Medline].

  10. Singh D, Angel J, Bentley G, Trevino SG. Fortnightly review. Plantar fasciitis. BMJ. Jul 19 1997;315(7101):172-5. [Medline]. [Full Text].

  11. Scher DL, Belmont PJ Jr, Bear R, Mountcastle SB, Orr JD, Owens BD. The incidence of plantar fasciitis in the United States military. J Bone Joint Surg Am. Dec 2009;91(12):2867-72. [Medline].

  12. Prichasuk S, Subhadrabandhu T. The relationship of pes planus and calcaneal spur to plantar heel pain. Clin Orthop Relat Res. Sep 1994;306:192-6. [Medline].

  13. McMillan AM, Landorf KB, Barrett JT, Menz HB, Bird AR. Diagnostic imaging for chronic plantar heel pain: a systematic review and meta-analysis. J Foot Ankle Res. Nov 13 2009;2:32. [Medline]. [Full Text].

  14. Sorrentino F, Iovane A, Vetro A, et al. Role of high-resolution ultrasound in guiding treatment of idiopathic plantar fasciitis with minimally invasive techniques. Radiol Med (Torino). Jun 3 2008;[Medline].

  15. Berkowitz JF, Kier R, Rudicel S. Plantar fasciitis: MR imaging. Radiology. Jun 1991;179(3):665-7. [Medline]. [Full Text].

  16. Ko PH, Hsiao TY, Kang JH, Wang TG, Shau YW, Wang CL. Relationship between plantar pressure and soft tissue strain under metatarsal heads with different heel heights. Foot Ankle Int. Nov 2009;30(11):1111-6. [Medline].

  17. Gross MT, Byers JM, Krafft JL, Lackey EJ, Melton KM. The impact of custom semirigid foot orthotics on pain and disability for individuals with plantar fasciitis. J Orthop Sports Phys Ther. Apr 2002;32(4):149-57. [Medline].

  18. Seligman DA, Dawson DR. Customized heel pads and soft orthotics to treat heel pain and plantar fasciitis. Arch Phys Med Rehabil. Oct 2003;84(10):1564-7. [Medline].

  19. Ryan M, Fraser S, McDonald K, Taunton J. Examining the degree of pain reduction using a multielement exercise model with a conventional training shoe versus an ultraflexible training shoe for treating plantar fasciitis. Phys Sportsmed. Dec 2009;37(4):68-74. [Medline].

  20. Rompe JD, Cacchio A, Weil L Jr, Furia JP, Haist J, Reiners V. Plantar fascia-specific stretching versus radial shock-wave therapy as initial treatment of plantar fasciopathy. J Bone Joint Surg Am. Nov 3 2010;92(15):2514-22. [Medline].

  21. DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am. Jul 2003;85-A(7):1270-7. [Medline].

  22. Berlet GC, Anderson RB, Davis H, Kiebzak GM. A prospective trial of night splinting in the treatment of recalcitrant plantar fasciitis: the Ankle Dorsiflexion Dynasplint. Orthopedics. Nov 2002;25(11):1273-5. [Medline].

  23. Tisdel CL, Harper MC. Chronic plantar heel pain: treatment with a short leg walking cast. Foot Ankle Int. Jan 1996;17(1):41-2. [Medline].

  24. Yucel I, Ozturan KE, Demiraran Y, Degirmenci E, Kaynak G. Comparison of high-dose extracorporeal shockwave therapy and intralesional corticosteroid injection in the treatment of plantar fasciitis. J Am Podiatr Med Assoc. Mar-Apr 2010;100(2):105-10. [Medline].

  25. Rompe JD, Decking J, Schoellner C, Nafe B. Shock wave application for chronic plantar fasciitis in running athletes. A prospective, randomized, placebo-controlled trial. Am J Sports Med. Mar-Apr 2003;31(2):268-75. [Medline].

  26. Rompe JD, Schoellner C, Nafe B. Evaluation of low-energy extracorporeal shock-wave application for treatment of chronic plantar fasciitis. J Bone Joint Surg Am. Mar 2002;84-A(3):335-41. [Medline].

  27. Othman AM, Ragab EM. Endoscopic plantar fasciotomy versus extracorporeal shock wave therapy for treatment of chronic plantar fasciitis. Arch Orthop Trauma Surg. Dec 24 2009;[Medline].

  28. Torg JS, Pavlov H, Torg E. Overuse injuries in sport: the foot. Clin Sports Med. Apr 1987;6(2):291-320. [Medline].

  29. Acevedo JI, Beskin JL. Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int. Feb 1998;19(2):91-7. [Medline].

  30. Sellman JR. Plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int. Jul 1994;15(7):376-81. [Medline].

  31. Ahstrom JP Jr. Spontaneous rupture of the plantar fascia. Am J Sports Med. May-Jun 1988;16(3):306-7. [Medline].

  32. Hogan KA, Webb D, Shereff M. Endoscopic plantar fascia release. Foot Ankle Int. Dec 2004;25(12):875-81. [Medline].

  33. Jerosch J, Schunck J, Liebsch D, Filler T. Indication, surgical technique and results of endoscopic fascial release in plantar fasciitis (E FRPF). Knee Surg Sports Traumatol Arthrosc. Sep 2004;12(5):471-7. [Medline].

  34. Buchbinder R. Clinical practice. Plantar fasciitis. N Engl J Med. May 20 2004;350(21):2159-66. [Medline].

  35. Cheng HY, Lin CL, Wang HW, Chou SW. Finite element analysis of plantar fascia under stretch - the relative contribution of windlass mechanism and Achilles tendon force. J Biomech. May 23 2008;epub ahead of print. [Medline].

  36. De Garceau D, Dean D, Requejo SM, Thordarson DB. The association between diagnosis of plantar fasciitis and Windlass test results. Foot Ankle Int. Mar 2003;24(3):251-5. [Medline].

  37. Gefen A. Stress analysis of the standing foot following surgical plantar fascia release. J Biomech. May 2002;35(5):629-37. [Medline].

  38. Jackson DL, Haglund BL. Tarsal tunnel syndrome in runners. Sports Med. Feb 1992;13(2):146-9. [Medline].

  39. Pfeffer GB. Plantar heel pain. Instr Course Lect. 2001;50:521-31. [Medline].

  40. Sammarco GJ, Helfrey RB. Surgical treatment of recalcitrant plantar fasciitis. Foot Ankle Int. Sep 1996;17(9):520-6. [Medline].

 
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Soft heel cushion to absorb shock.
Soft heel cushion and a cup.
Custom-molded orthotic.
Stretching exercise. Lean against the wall with the knee kept straight and the heel touching the floor.
Stretching the back of the leg at the edge of a stair.
Massaging and stretching the plantar fascia using a can.
A night splint applied on back of the leg and foot.
A night splint applied on the front of the leg.
Lateral radiograph of the hindfoot showing a cyst in the anterior aspect of the calcaneus in a 19-year-old patient who presented with heel pain.
Plantar fascia tissue-specific stretching exercise
Edema localized to plantar heel on the left foot in a patient with calcaneal stress fracture compared to the normal right heel
 
 
 
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