eMedicine Specialties > Sports Medicine > Foot and Ankle

Plantar Fasciitis

Author: Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Contributor Information and Disclosures

Updated: Jan 18, 2008

Introduction

Background

Plantar fasciitis is the pain caused by inflammation of the insertion of the plantar fascia on the medial process of the calcaneal tuberosity. Plantar fasciitis may cause significant heel pain, resulting in the alteration of a person's activities. This condition sometimes is called "heel spurs" by the general public. In actuality, many asymptomatic individuals have bony heel spurs, whereas many patients with plantar fasciitis have no bony heel spur.1

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, Arch Pain, and Ankylosing Spondylitis, Neurologic Perspective.

Related eMedicine topics:
Plantar Fasciitis [in the Physical Medicine and Rehabilitation section]
Plantar Fasciitis [in the Emergency Medicine section]
Plantar Fasciitis [in the Orthopedic Surgery section]

Frequency

United States

A survey of professional football, baseball, and basketball team physicians and trainers found that plantar fasciitis was among the 5 most common foot and ankle injuries observed in professional athletes.2  It is estimated that approximately 1 million patient visits per year are due to plantar fasciitis.3

Functional Anatomy

The plantar fascia is a thickened fibrous aponeurosis that originates from the medial tubercle of the calcaneus, runs forward to insert into the deep, short transverse ligaments of the metatarsal heads, and continues forward to form the fibrous flexor sheathes on the plantar aspect of the toes. The central plantar fascia is the thickest and strongest section, and this segment is also the most likely to be involved with plantar fasciitis. The function of the plantar fascia is to provide static support for the longitudinal arch of the foot and to assist with shock absorption during foot strike.

Sport-Specific Biomechanics

During running, the vertical forces in the foot at foot strike may reach 2-3 times an individual's body weight.4 The plantar fascia and longitudinal arch are also part of the foot's shock absorption mechanism.

The plantar fascia acts as a windlass mechanism during running (see Clinical, Physical, below). During the heel-off phase of gait, tension increases on the plantar fascia, which acts as a storage of potential energy. During toe-off, the plantar fascia passively contracts, converting the potential energy into kinetic energy and imparting greater foot acceleration.

Clinical

History

  • Pain
    • The sine qua non of plantar fasciitis is a history of intense sharp heel pain with the first couple of steps in the morning.5 Pain is experienced primarily at the anterior aspect of the calcaneus, but it may radiate proximally in more severe cases. The athlete may complain of a dull ache in the heel at the end of the day, especially after extensive walking or standing.
    • During activity, the pain usually decreases as the athlete warms up, but it generally returns after activity. The pain is aggravated particularly by sprinting. In more severe cases, the athlete complains of heel pain after periods of prolonged sitting.
  • Associated symptoms: In addition to pain, athletes may complain of stiffness in the foot and of localized swelling in the heel.

Physical

Palpation over the medial tubercle of the calcaneus usually reproduces the pain of plantar fasciitis. In more severe cases, pain may also be reproduced by palpation over the proximal portion of the plantar fascia. Other maneuvers that may reproduce the pain of plantar fasciitis include passive dorsiflexion of the toes, which is sometimes called a "windlass" test, or having the athlete stand on the tiptoes and toe-walk. In a study by De Garceau et al, having the patient bear weight during the windlass test (see Image 1) increased the sensitivity of the test from 13.6% to 31.8%.6

Related eMedicine topics:
Calcaneus, Fractures
Fractures, Foot 

Causes

  • Extrinsic risk factors
    • Training errors
      • Training errors are among the major causes of plantar fasciitis.
      • Athletes usually have a history of an increase in distance, intensity, or duration of activity.
      • The addition of speed workouts, plyometrics, and hill workouts are particularly high-risk behaviors for the development of plantar fasciitis.
      • Running indoors on poorly cushioned surfaces is also a risk factor.
    • Equipment
      • Athletes should wear an appropriate shoe type for their foot type and activity (see Treatment, Acute Phase, Other Treatment, below).
      • Athletic shoes rapidly lose cushioning properties.7 Athletes who use shoe-sole repair materials are especially at risk if they do not change shoes often.
      • Athletes who train in lightweight and minimally cushioned shoes (instead of heavier training flats) are also at higher risk of developing plantar fasciitis.
  • Intrinsic risk factors
    • Structural risk factors
      • Structural risk factors include pes planus, overpronation, pes cavus, leg-length discrepancy, excessive lateral tibial torsion, and excessive femoral anteversion.
      • Athletes with pes planus (low-arched) or pes cavus (high-arched) feet have increased stress placed on the plantar fascia with foot strike.7
      • Pronation is a normal motion during walking and running, providing foot-to-ground surface accommodation and impact absorption by allowing the foot to unlock and become a flexible structure. Overpronation, on the other hand, can lead to increased tension on the plantar fascia.
      • Leg-length discrepancy, excessive lateral tibial torsion, and excessive femoral anteversion can lead to an alteration of running biomechanics, which may increase plantar fascia stress.
    • Functional risk factors
      • Tightness in the gastrocnemius and soleus muscles and the Achilles tendon is considered a risk factor for plantar fasciitis. Reduced dorsiflexion has been shown to be an important risk factor for this condition.3
      • Weakness of the gastrocnemius, soleus, and intrinsic foot muscles is also considered a risk factor for plantar fasciitis.
    • Degenerative risk factors
      • Aging and heel fat pad atrophy are 2 degenerative risk factors for plantar fasciitis.

Related eMedicine topics:
Pes Cavus
Pes Planus
Tibial Bowing

More on Plantar Fasciitis

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

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Keywords

heel spurs, heel pain, inflammation of the plantar fascia, calcaneal pain

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Contributor Information and Disclosures

Author

Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Joseph P Garry, MD, Director of Sports Medicine and Sports Medicine Fellowship, Associate Professor of Family Medicine and Exercise and Sport Science, Department of Family Medicine, East Carolina University Brody School of Medicine
Joseph P Garry, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Heart Association, American Medical Society for Sports Medicine, North American Primary Care Research Group, and North Carolina Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa, and Wilderness Medical Society
Disclosure: Nothing to disclose.

 
 
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