eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Plantar Fasciitis

Author: Matthew D Sorensen, DPM, Foot and Ankle Surgeon, Summit Orthopedics
Coauthor(s): Christopher F Hyer, DPM, FACFAS, Foot and Ankle Surgeon, Director, Advanced Foot and Ankle Surgery Fellowship, Orthopedic Foot and Ankle Center; Gregory C Berlet, MD, FRCS(C), Clinical Assistant Professor of Orthopedics, Chief of Foot and Ankle Surgery, Department of Orthopedic Surgery, Ohio State University College of Medicine and Public Health
Contributor Information and Disclosures

Updated: Jun 9, 2009

Introduction

Background

Plantar heel pain is one of the most common maladies treated in foot and ankle practice and primary care clinics. It has been stated that approximately 10% of the United States population experiences bouts of heel pain resulting in 600,000 visits annually to medical professionals for treatment of plantar fasciitis.1  The etiology of this condition is multifactorial and generally characterized as an overuse syndrome. There are many diagnoses within the differential of heel pain; however, plantar fasciitis is the most common. 

Plantar fasciitis can be a difficult problem to treat without an available panacea. Time-intensive treatment and patient acceptance of responsibility regarding the treatment end are required for success.

Pathophysiology

The plantar fascia acts like a windlass mechanism, as described by Hicks in 1954, to provide tension and support through the arch.2 It functions as a tension bridge in the foot, providing both static support and dynamic shock absorption.3 The plantar fascia is made up of 3 distinct parts: the medial, central, and lateral bands. It extends from the heel bone (calcaneus) to the metatarsal heads distally as a thick aponeurosis in the subcutaneous tissue of the arch. As the fascia progresses to the toes, it divides into 5 digital bands at the metatarsophalangeal joints.4   Small plantar nerves are invested in and around the plantar fascia, acting to register and mediate pain.

Biomechanical dysfunction of the foot is the most common origin of plantar fasciitis; however, infectious, neoplastic, arthritic, neurologic, traumatic, and other systemic conditions can prove causative. The pathology is traditionally believed to be secondary to the development of microtears, with resulting inflammation at the calcaneal/fascia interface secondary to repetitive lowering or strain of the arch upon weight bearing.5,6,7   

Studies have introduced the etiologic concept of fasciosis as the inciting pathology. Fasciosis, similar to tendinosis, is defined as a chronic degenerative condition that is characterized histologically by fibroblastic hypertrophy, absence of inflammatory cells, disorganized collagen, and chaotic vascular hyperplasia with zones of avascularity.8,9,10,11  These changes suggest a noninflammatory condition and dysfunctional vasculature.  With reduced vascularity and a compromise in nutritional blood flow through the impaired fascia, it becomes difficult for cells to synthesize the extracellular matrix necessary for repairing and remodeling.12

Regardless of the specific etiology or combination therein, we know that, often, the associated pain can alter the patient’s quality of life and even lead to incapacitation. 

Race

Differences based on race have not been reported, but risk factors have been identified.

Sex

Differences based on sex have not been reported, but risk factors have been identified.

Clinical

History

The diagnosis of plantar fasciitis/fasciosis is generally made through a good clinical history.  Patients present with an insidious onset of heel pain that is typically consistent with post–static dyskinesia–type symptoms, such as pain with the first steps out of bed or after periods of rest. The pain tends to get better with increased activity after the foot loosens up. 

Upon physical examination, the most common pain is that elicited upon palpation of the plantar-medial calcaneal tubercle at the site of plantar fascial insertion to the heel bone.5  Less frequently, the pain will localize directly below the heel bone or even in the midsubstance of the plantar arch. A tight heel cord, termed ankle equinus, is commonly a secondary finding and usually contributes to the pathology.5,13   Other findings may include flat-foot architecture or pes planus foot type, although fasciosis is also seen in high-arched patients. 

Physical

A complete lower-extremity examination is important to pinpoint the pathology. This includes a neurovascular evaluation, including pulse assessment and the presence/absence of a Tinel sign.  The Perthes test can be employed to assess whether or not tortuous varicosities are contributing to the medial heel pain. This test employs inflation of a blood pressure cuff just proximal to the ankle at a pressure just below the patient’s systolic pressure and causes engorgement of symptomatic varicosities that may be entrapping the tibial nerve or causing claudication-type symptoms. A full musculoskeletal examination, including range of motion of hind-foot joints and medial to lateral squeeze of the calcaneus, will aid further in diagnosis. Pain with compression is more frequently seen in stress fracture.

More on Plantar Fasciitis

Overview: Plantar Fasciitis
Differential Diagnoses & Workup: Plantar Fasciitis
Treatment & Medication: Plantar Fasciitis
Follow-up: Plantar Fasciitis
References
Further Reading
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References

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Further Reading

Related eMedicine topics

Plantar Heel Pain

Achilles Tendon Pathology

Stress Fractures

Acquired Flatfoot

Pes Planus

Clinical guidelines

ACR Appropriateness Criteria® chronic foot pain. American College of Radiology - Medical Specialty Society.  1998 (revised 2005).  7 pages.  NGC:004618

Diagnosis and treatment of adult flatfoot. American College of Foot and Ankle Surgeons - Medical Specialty Society.  2005 Mar/Apr.  36 pages.  NGC:004194

Diagnosis and treatment of pediatric flatfoot. American College of Foot and Ankle Surgeons - Medical Specialty Society.  2004 Nov/Dec.  33 pages.  NGC:004086

Clinical trials

Treatment of Plantar Fasciitis With Dorsiflexion Night Splints and Medial Arch Supports

PRP to Treat Plantar Fasciitis

Plantar Fasciitis Treated With Dynamic Splinting

Change and Clinical Significance of Plantar Fascia Thickness After ESWT

A Randomized Controlled Trial of Custom Foot Orthoses for the Treatment of Plantar Heel Pain

Foot and Ankle Range of Motion (Stretching) Apparatus

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Keywords

plantar fasciitis, heel pain, plantar heel pain, inflamed fascia, foot deformity, flat-foot, pes planus, stress fracture

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Contributor Information and Disclosures

Author

Matthew D Sorensen, DPM, Foot and Ankle Surgeon, Summit Orthopedics
Matthew D Sorensen, DPM is a member of the following medical societies: American College of Foot and Ankle Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher F Hyer, DPM, FACFAS, Foot and Ankle Surgeon, Director, Advanced Foot and Ankle Surgery Fellowship, Orthopedic Foot and Ankle Center
Christopher F Hyer, DPM, FACFAS is a member of the following medical societies: American College of Foot and Ankle Surgeons and American Podiatric Medical Association
Disclosure: Nothing to disclose.

Gregory C Berlet, MD, FRCS(C), Clinical Assistant Professor of Orthopedics, Chief of Foot and Ankle Surgery, Department of Orthopedic Surgery, Ohio State University College of Medicine and Public Health
Gregory C Berlet, MD, FRCS(C) is a member of the following medical societies: American Medical Association, American Orthopaedic Foot and Ankle Society, Canadian Medical Association, Canadian Orthopaedic Association, College of Physicians and Surgeons of Ontario, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Medical Editor

James K DeOrio, MD, Director of Foot and Ankle Fellowship Program, Assistant Professor of Orthopedic Surgery, Orthopedic Surgery, St Lukes Hospital, Jacksonville, Florida
James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Florida Medical Association, and German Society of Neurology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

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, FAAOS, Chairman, J Vernon Luck Distinguished Professor, Department of Orthopedic Surgery, University of Missouri
Jason H Calhoun, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, and American Orthopaedic Foot and Ankle Society
Disclosure: Nothing to disclose.

 
 
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