eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Plantar Heel Pain

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

Updated: Jun 17, 2008

Introduction

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.

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.

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.

Clinical

History

A careful history and physical examination is valuable in identifying the etiology of heel pain. Taking a comprehensive medical and general history is important in order to distinguish between various causes. Seek the history on all the characteristics of the pain, such as onset, location, radiation, modifying factors, relation to time of the day, and relation to activities.

• The most common cause of plantar heel pain in both athletic and nonathletic populations is proximal plantar fasciitis. Patients usually have occupations that involve spending most of their time on their feet. The pain is often unilateral, but it can manifest bilaterally, with one side being more painful than the other.
• The discomfort commonly manifests spontaneously and insidiously without an antecedent trauma or fever. Occasionally, some patients state they might have stepped on a small object such as a pebble or they may have recently started an exercise regimen involving walking or running. Some patients may have a history of recent weight gain.
• The pain is localized to the plantar and medial aspects of the heel. It is worse typically with the first few steps in the morning. The pain causes patients to limp for approximately half an hour. It is also worse after a period of rest, such as after standing up from a chair or getting out of a car.
• The pain then improves with walking and stretching, but prolonged walking and standing aggravate the pain. The pain can be present with every step, causing a limp, and patients tend to walk bearing weight on the forefoot and the outer aspect of the foot.
• An acute onset of pain, especially after a vigorous or sudden athletic activity, can be indicative of traumatic rupture of the plantar fascia.
• Fat pad atrophy in elderly patients and in persons who have received multiple steroid injections manifests with pain under the heel that is more diffuse, involving most of the weight-bearing surface. The pain worsens when the patients walk on hard surfaces and when they wear hard-soled footwear. The initial improvement in walking observed in patients with plantar fasciitis is not observed in patients with fat pad atrophy.
• Pain radiating from the heel distally or proximally and associated with numbness, paresthesia, or a burning sensation after activity and continuing even after rest is likely to be neurologic in origin. This is usually due to a compressive neuropathy locally, as in tarsal tunnel syndrome, or proximally at the level of the nerve root, in which case low back pain may be associated.
• Bilateral heel pain and pain at the tendon insertions (or enthesopathy), especially associated with general symptoms such as malaise, recurrent fever, multiple joint pains, or bowel dysfunction, may indicate an association with inflammatory disorders such as rheumatoid arthritis, spondyloarthropathies, Reiter syndrome, or Behcet syndrome.
• Significant loss of appetite and weight or pain at night can be indicative of a neoplasm.

Physical

A general examination is necessary to rule out systemic causes of heel pain. A spine examination is required if the pain radiates.

• In the local examination, inspect the foot and the heel for any abnormalities such as swelling, lumps, scars, bruising, or foot deformities such as pes planus or pes cavus.
• Palpation is performed to elicit the site of maximum tenderness. Check the condition of the fad pad, feel for defects or lumps in the plantar fascia, and identify any bony deformity due to previous fractures.
• Percussion over the tibial nerve in the tarsal tunnel and its distal branches is performed to check for hypersensitivity or tingling. Percussion over any previous scars in the region can be performed to detect a neuroma in the scar.
• Examining the range of motion at the ankle joint and a performing a Silfverskiöld test reveals any stiffness in the gastrocnemius and/or the triceps surae complex.
• In persons with proximal plantar fasciitis, the tenderness is typically localized over the medial calcaneal tuberosity at the origin of the plantar fascia. Associated features may include a triceps surae contracture, decreased subtalar mobility, pes cavus, or pes planus. These conditions can create increased tension on the plantar fascia. However, when a clinical test is performed to stretch the plantar fascia by dorsiflexion of the toes, patients do not experience any aggravation of pain. On the other hand, pain may be aggravated by this maneuver in persons with an acute plantar fascia rupture, which may be accompanied by localized bruising or even a palpable defect.
• Tenderness upon squeezing both the medial and lateral sides of the posterior calcaneal tuberosity is highly indicative of a stress fracture in the calcaneus, and this may be associated with local edema.
• In persons with compressive neuropathy, either of the tibial nerve in the tarsal tunnel or of the first branch of the lateral plantar nerve, the point of maximal tenderness in the heel is located more medially in the posterior heel.
• Percussion over the tibial nerve branches elicits tingling, burning, or numbness. A valgus heel associated with pes planus or acquired flat foot can put increased stretch on the tibial nerve and can cause tarsal tunnel syndrome.
• In elderly patients or persons who have had multiple steroid injections in the heel, the pain and tenderness is maximal over the central weight-bearing area of the heel. Dorsiflexion of the toes does not aggravate the pain. The heel does not have the usual firmness; it feels soft and the underlying calcaneus is more readily palpable.

Causes

• Local
  • Proximal plantar fasciitis
  • Fat pad atrophy
  • Plantar fascia rupture
  • Tarsal tunnel syndrome
  • Compression of the first branch of the lateral plantar nerve
  • Plantar fasciitis coexisting with compression of the first branch of lateral plantar nerve
  • Stress fracture of the calcaneus
  • Bone tumor or bone cyst
  • Osteomyelitis
• Regional
  • Spinal stenosis
  • Prolapsed intervertebral disc
• Systemic
  • Inflammatory bowel disease –associated arthritis
  • Seronegative spondyloarthropathies
  • Inflammatory arthritis (ie, rheumatoid arthritis)

Differential Diagnoses

Achilles Tendon Pathology
Tarsal Tunnel Syndrome

Other Problems to Be Considered

Pain under the arch

• Distal plantar fasciitis: The tenderness is under the mid foot, and, as opposed to proximal plantar fasciitis, dorsiflexion of the toes aggravates pain.
• Plantar fibromatosis: Painful nodules or lumps are palpable in the plantar fascia.

Pain on the posterior aspect of the hindfoot

• Insertional Achilles tendinitis: Pain, tenderness, and a bony prominence are mainly located at the back of the heel. Plain radiographs may show calcification at the insertion of the Achilles tendon.
• Haglund syndrome: This is a term given to the prominent posterosuperior corner of the calcaneus that is thought to impinge on the Achilles tendon and give rise to pain, swelling, and tenderness in the posterior aspect of the heel. The diagnosis is made based on plain radiographic findings.
• Pump bump: This is a term used to describe a prominent posterolateral protuberance in the calcaneus near the attachment of the Achilles tendon. The pain is usually caused by friction from footwear.
• Flexor hallucis longus tenosynovitis: The pain and tenderness are posteromedial at the level of the subtalar joint and can be aggravated by dorsiflexion of the great toe with the ankle held in full plantarflexion.
• Posterior impingement of the os trigonal or Stieda process or fracture: Usually, activities that require acute plantar flexion, such as a pointe in ballet, can aggravate the pain, and the tenderness is posterolateral at the level of the subtalar joint.

Pain on the medial aspect of the ankle

• Posterior tibial tendon dysfunction: This is associated with pain on the medial side of the ankle, which radiates proximally along the leg and distally into the mid foot. Swelling and pitting edema often occur over the region of the tendon. The patient has weakness in active inversion of the hindfoot and difficulty performing a single or double raise on the toes.
• Medial ankle instability: The patient history includes an ankle sprain, followed later by the ankle giving way. The pain and tenderness are in the medial gutter of the ankle. The heel is in valgus; however, unlike posterior tibial tendon dysfunction, the heel valgus is corrected when the person raises up on the toes.

Pain on the lateral aspect of the ankle

• Peroneal tendon dysfunction: The pain is on the lateral aspect of the heel over the peroneal tendons and behind the lateral malleolus. This may be associated with swelling, tenderness, and pes cavus.
• Chronic lateral ankle sprain: Pain is on the lateral aspect of the ankle. The condition is associated with a history of repeated sprains of the ankle and symptoms of instability. The patient has swelling and tenderness at the points of attachment of the anterior talofibular and calcaneofibular ligaments. A positive drawer sign signifies ligament laxity. A pes cavus and heel varus may be contributory factors.
• Sinus tarsi syndrome: This condition often follows a lateral ligament sprain of the ankle, and patients have pain and tenderness in the sinus tarsi region and lateral aspect of the hindfoot. The diagnosis is confirmed if symptoms improve with local injection of an anesthetic or a steroid. A magnetic resonance image (MRI) shows an obliteration of the fat plane, with or without interruption of the ligaments.

Workup

Laboratory Studies

• Generally, plantar fasciitis is a clinical diagnosis; laboratory and imaging studies are rarely indicated. However, heel pain, especially bilaterally, can be a rare primary presenting sign of systemic inflammatory disorders. If a patient presents with bilateral heel pain in association with systemic symptoms, then screen the blood for inflammatory markers, such as the erythrocyte sedimentation rate (ESR), human leukocyte antigen (HLA)-B27, rheumatoid factor (RF), and antinuclear antibodies (ANA).

Imaging Studies

• Heel spurs develops in the origin of the flexor digitorum brevis in approximately 50% of patients with proximal plantar fasciitis. The etiology is thought to be repetitive traction that leads to collagen degeneration, angiofibroblastic hyperplasia, and matrix calcification. Plain weight-bearing radiographs can show calcaneal spurs in approximately 50% of patients with plantar fasciitis, but, because spurs are frequently noted in patients without heel pain, the presence of calcaneal spurs is not considered contributory to the pain, and it does not affect the diagnosis or treatment.¹¹ Plain radiographs showing the lateral view of the calcaneus can be useful in detecting a stress fracture, which appears as a double-dense sclerotic line. However, 3-4 weeks may pass from the onset of symptoms until the injury is detectable on plain radiographs. Bony infections or tumors can also be detected on plain radiographs.
• Ultrasonographic examination of the plantar heel can identify a thickened plantar fascia, but this investigation and the interpretation of the results depend on the expertise of the person performing the procedure.^7,12
• MRI can be used to confirm a diagnosis, such as a stress fracture, especially in the early stages before it is detectable with plain radiographs. MRI is also used to investigate further for soft-tissue or bone lesions in the hindfoot. In persons with plantar fasciitis, this modality demonstrates edema and thickening of the plantar fascia, but MRI is not used to diagnose this condition. Any space-occupying lesions in the tarsal tunnel, which can cause a tarsal tunnel syndrome, is also revealed.¹³

Treatment

Medical Care

Proximal plantar fasciitis is successfully managed with conservative care in approximately 90% of cases. In general, the longer the duration of symptoms, the longer it takes for the patient to obtain complete pain relief. Various modalities of treatment are available, and patient education is important to improve the understanding of the condition and to obtain compliance with various treatment regimens. The important aims of the treatment are to limit impact stresses on the heel, to alleviate inflammation, and to stretch the triceps surae muscle.

• Reducing impact
  • Activity modification: Avoiding impact activities is especially important in athletes, who can cross-train with nonimpact sports such as cycling or swimming.
  • Reduction of body weight
  • Use of soft cushions or insoles and soft-heeled footwear (see Images 1-2)
  • Taping, arch supports, and custom-molded orthotics (see Image 3)^14,15
• Reducing inflammation
  • Application of ice and/or iontophoresis
  • Anti-inflammatory medication: Medication is useful in the early stages, especially if the patient has begun stretching exercises because, initially, these can worsen the pain (see Medication).
• Stretching and strengthening
  • Exercises: A variety of exercises can help the patient to achieve active and passive ankle dorsiflexion with the knee kept straight and the subtalar joint in inversion, which helps achieve maximum stretch of the triceps surae muscle. The foot can be rolled over a tennis ball or a can to massage and stretch the plantar fascia. The exercises can be performed at home or can be guided by a physical therapist (see Images 4-6).
  • Plantar fascia–specific stretching exercises: A randomized, prospective study with 2-year follow up compared Achilles tendon stretching with plantar fascia tissue—specific exercises.¹⁶ The authors found a plantar fascia–specific stretching exercises was better. To perform the exercise, the patient crosses the affected leg over the contralateral leg. While placing the fingers across the base of the toes, the patient pulls the toes back toward the shin until he or she feels a stretch in the arch or plantar fascia. The patient confirms that the stretch was correct by palpating tension in the plantar fascia. (see Image 10).
  • Intrinsic muscle strengthening: Exercises include toe curls or other activities, such as picking up marbles with the toes.
  • Resting splints: During the night, the relaxed posture of plantar flexion at the ankle tends to favor contracture of the triceps surae. To prevent this, night splints that hold the ankle in dorsiflexion can be worn.¹⁷ Patients who wear a posterior night splint should be warned to take it off before getting out of bed. As an anecdotal example, one patient walked to the toilet while wearing the splint, slipped, and sustained a humeral fracture. However, a dorsally applied splint, as opposed to a posterior splint, does not need to be taken off before getting out of bed (see Images 7-8).
• Treating recalcitrant pain: If the pain persists for longer than 2 months despite the above treatment, then the following modalities can be offered:
  • Cast: A short leg walking cast for 6 weeks is generally effective in relieving pain, but the pain can recur after the cast is removed.¹⁸ To prevent this, the patient should use the previously mentioned treatment modalities, such as activity modification, stretching exercises, and insoles, until recovery is complete.
  • Corticosteroids: Iontophoresis is administered by a physical therapist and uses low-voltage galvanic current stimulation to distribute topical corticosteroids. It is performed 2-3 times a week. This therapy can provide short-term relief, but it is usually reserved for patients in whom other therapies are unsuccessful or who have occupations that involve spending most of their time on their feet. Depot injections can provide good short-term relief, but multiple injections can cause plantar fascia rupture and fat pad atrophy—and, later, a flat-foot deformity — especially if the injection is not administered deep into the fascia.
  • Extracorporeal shockwave therapy (ESWT)^5,19,20 : This therapy was approved by the US Food and Drug Administration (FDA) in 2005 (see New Device Approval: Orthospec Extracorporeal Shock Wave Therapy – P040026), although the treatment has been used in Europe for more than a decade. Animal study data suggest that this modality creates microdisruption and stimulates new bone and tissue formation. Shock waves may be delivered in 3 ways: (1) electrohydraulically (high power), (2) electromagnetically, and (3) piezoelectrically. The FDA approved electrohydraulic and electromagnetic devices for the treatment of chronic plantar heel pain that has persisted for longer than 6 months despite other treatment.

Fat pad atrophy is managed conservatively with the use of heel cups, soft insoles, and soft-soled footwear. The heel cup helps to centralize and increase the bulk of the soft tissue under the calcaneus.
 
In patients with planovalgus deformity, if the valgus hindfoot is thought to be the cause of tarsal tunnel syndrome due to traction on the tibial nerve, the initial treatment can be placement of a medial longitudinal arch support and a medial lift.

Stress fractures of the calcaneus and traumatic rupture of the plantar fascia are managed with conservative measures. Avoiding the offending activity and a 6- to 8-week period in a cast may be required to alleviate the symptoms.

Surgical Care

The guidelines developed by the American Orthopaedic Foot and Ankle Society on the use of endoscopic and open heel surgery to treat plantar heel pain are widely accepted.

Because 90% of patients with plantar fasciitis respond favorably to conservative care, conservative methods should be tried for at least 6, or, preferably 12, months before surgery is considered. Furthermore, full counseling regarding the risks and benefits must be administered because complete satisfaction after surgery is observed in only 50% of patients.

The surgery can be performed by open or endoscopic methods. However, if plantar fasciitis is suspected to coexist with compression of the first branch of the lateral plantar nerve, then the endoscopic method is not recommended. (Electromyography and nerve conduction studies are not necessary to diagnose compressive neuropathy of the first branch of the lateral plantar nerve; rather, the diagnosis of entrapment of the first branch of the lateral plantar nerve is made on a clinical basis. Testing nerve conduction across the site of entrapment in the heel is technically demanding. Motor weakness in the abductor digiti quinti may not be detected because of the dynamic nature of the compression.)

• By either the open or endoscopic method, only 50% of the plantar fascia is released because a complete release can lead to collapse of the medial and lateral longitudinal arches.
• Excision of a plantar heel spur is performed only if it is significantly large and it is compressing the first branch of the lateral plantar nerve.
• Surgery for tarsal tunnel syndrome or for decompression of the first branch of lateral plantar nerve requires release of the tibial nerve and its branches and overlying fascia, including the deep fascia of the abductor hallucis.

Medication

Medication is useful in the early stages, especially if the patient has begun stretching exercises, because, initially, these can worsen the pain.

Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or who have sustained injuries.

Acetaminophen (Aspirin Free Anacin, Feverall, Tylenol)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking PO anticoagulants.
Effective in relieving mild to moderate acute pain; however, it has no peripheral anti-inflammatory effects. May be preferred in elderly patients because of fewer adverse GI and renal effects.

Dosing

Adult

325-650 mg PO/PR q4-6h or 1000 mg tid/qid; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d

>12 years: 325-650 mg PO q4h; not to exceed 4 g/d

Interactions

Rifampin can reduce the analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity.

Contraindications

Documented hypersensitivity; known G6PD deficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity is possible in people with long-term alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative doses that exceed the recommended maximum dose.

Nonsteroidal Anti-inflammatory Drugs

NSAIDs have analgesic and antipyretic activities. The mechanism of action of these agents is not known, but NSAIDs may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation and various cell membrane functions. Treatment of pain tends to be patient specific.

Ibuprofen (Advil, Excedrin IB, Motrin, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Dosing

Adult

200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d

Pediatric

<6 months: Not established

6 months to 12 years: 4-10 mg/kg/dose PO tid/qid

>12 years: Administer as in adults

Interactions

Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of coagulation abnormalities or during anticoagulant therapy

Ketoprofen (Actron, Orudis, Oruvail)

For the relief of mild to moderate pain and inflammation. Small initial dosages are indicated in small and elderly patients and in those with renal or liver disease.

Doses >75 mg do not increase therapeutic effects.

Administer high doses with caution and closely observe patient for response.

Dosing

Adult

25-50 mg PO q6-8h prn; not to exceed 300 mg/d

Pediatric

<3 months: Not established

3 months to 12 years: 0.1-1 mg/kg PO q6-8h

>12 years: Administer as in adults

Interactions

Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of coagulation abnormalities or during anticoagulant therapy

Naproxen (Aleve, Anaprox, Naprelan, Naprosyn)

For the relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which is responsible for prostaglandin synthesis. NSAIDs decrease intraglomerular pressure and decrease proteinuria.

Dosing

Adult

250-500 mg PO bid; may increase to 1.5 g/d for limited periods

Pediatric

<2 years: Not established

>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d

Interactions

Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug.

Follow-up

Deterrence/Prevention

• Because overuse is the most common cause of plantar fasciitis in athletes, avoiding overuse can help prevent this problem.²¹

Complications

• Of patients with plantar fasciitis, 90% respond favorably to conservative care. Conservative methods should be tried for at least 6 months (preferably 12 mo) before surgery is considered. Furthermore, patients should be fully counseled regarding the risks and benefits, because complete satisfaction after surgery is observed in only 50% of patients.
• For nonsurgical treatment, depot steroid injections can provide good short-term relief of symptoms; however, multiple injections can cause the plantar fascia to rupture and the fat pad to atrophy, especially if the injection is not administered deep into the fascia.^22,23,24
• Regardless of whether an open or endoscopic method is used for surgical correction, only 50% of the plantar fascia should be released, because a complete release can lead to collapse of the medial and lateral longitudinal arches.
• Endoscopic plantar fascia release can be associated with a higher incidence of nerve damage and painful and hypersensitive neuroma.^25,26

Prognosis

• Proximal plantar fasciitis is successfully managed with conservative care in approximately 90% of cases. In general, the longer the duration of symptoms, the longer it takes for the patient to obtain complete pain relief.

Miscellaneous

Medicolegal Pitfalls

• Surgical treatment for heel pain should only be considered after thorough counseling regarding the risks and benefits. Endoscopic plantar fascia release can be associated with a higher incidence of nerve damage and painful and hypersensitive neuroma.
• A complete division of the plantar fascia is no longer recommended. Inadvertent complete division of the plantar fascia can lead to lateral column syndrome, which is pain in the calcaneocuboid region and lateral aspect of the hindfoot.
• Heel pain in elderly patients or patients with atypical presentations should be investigated for deficiency fractures or for tumors (see Image 9).

Multimedia

Media file 1: Soft heel cushion to absorb shock.

Media file 2: Soft heel cushion and a cup.

Media file 3: Custom-molded orthotic.

Media file 4: Stretching exercise. Lean against the wall with the knee kept straight and the heel touching the floor.

Media file 5: Stretching the back of the leg at the edge of a stair.

Media file 6: Massaging and stretching the plantar fascia using a can.

Media file 7: A night splint applied on back of the leg and foot.

Media file 8: A night splint applied on the front of the leg.

Media file 9: 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.

Media file 10: Plantar fascia tissue-specific stretching exercise

References

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Keywords

heel pain syndrome, plantar fasciitis, proximal plantar fasciitis, heel spur, plantar heel pain, tarsal tunnel syndrome, fat pad atrophy, heel pain, foot pain, plantar fascia rupture, lateral plantar nerve compression, calcaneal stress fracture, stress fracture of the calcaneus, bone tumor, bone cyst, osteomyelitis, spinal stenosis, prolapsed intervertebral disk, prolapsed intervertebral disc, arthritic inflammatory bowel disease, seronegative spondyloarthropathy, inflammatory arthritis, rheumatoid arthritis

Contributor Information and Disclosures

Author

Vinod K Panchbhavi, MD, FRCS, FACS, Associate Professor, 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 Edinburgh, Royal College of Surgeons of England, and Texas Orthopaedic Association
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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.

CME Editor

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, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of 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.

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