Plantar Fasciitis

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Plantar Fasciitis

Plantar fasciitis is one of the most common causes of foot and heel pain in adults. The peak incidence occurs between the ages of 40 and 60 in the general population but it also occurs at a younger age in physically active individuals such as runners and dancers. It is considered to be a degenerative condition, with or without inflammation, primarily affecting the plantar fascia origin at the medial aspect of the calcaneal tuberosity.

The plantar fascia is essential in foot biomechanics, providing shock absorption and support for the arch of the foot. The plantar fascia acts as a cable that attaches the calcaneus to the metatarsophalangeal joints. When weight-bearing, the plantar fascia maintains the arch of the foot by becoming tense and preventing the metatarsal heads and the calcaneus from separating. When walking, dorsiflexion of the big toe during the propulsive phase of gait winds the plantar fascia around the first metatarsal head. This shortens the plantar fascia, which in turn, elevates the medial longitudinal arch to provide additional arch support. This shortening of the plantar fascia that results from dorsiflexion of the big toe is referred to as the Windlass Mechanism. The etiology of plantar fasciitis is considered multifactorial, but overuse is a common contributing factor. It is considered that the condition begins with the development of microtears due to repetitive stress resulting from prolonged periods of weight-bearing, leading to chronic degeneration of the fascia. Plantar fasciitis is usually successfully managed conservatively. However, it may take many weeks or months and requires high patient compliance.

Causes and Risk Factors

• Obesity
• Occupations requiring prolonged standing (e.g., nurses and factory floor workers) 
• Running in faulty shoes, on hard surfaces or training excessively
• Walking barefooted or in flat shoes 
• Pes planus (flat feet or pronated ankles)
• Pes cavus (high-arched foot)
• Reduced ankle dorsiflexion (tight calf muscles or shortened Achilles tendon)
• Leg-length discrepancy
• Heel fat pad atrophy
• Spondyloarthropathies (e.g., ankylosing spondylitis)

• Localized sharp pain at the medial calcaneal tubercle (that may become dull and constant in chronic cases)
• Pain that is worse with the first few steps in the morning (or after a period of sitting) but which quickly eases with further walking
• Pain that worsens with prolonged weight-bearing
• Pain is typically unilateral (can be bilateral in one-third of cases)

• Tenderness on palpation of the plantar fascia, primarily at the medial aspect of the calcaneal tubercle
• Positive Windlass test
• Pain may be reproduced by passive dorsiflexion of the foot and toes
• Pes planus or pes cavus may be present
• Reduced ankle dorsiflexion may be present, caused by tight calf muscles or a shortened Achilles tendon
• Leg-length discrepancy may be present

Plantar Fasciitis is a clinical diagnosis and imaging is not usually required. However, plain radiography may be helpful in ruling out other causes (e.g., calcaneal stress fracture).

MRI can confirm the diagnosis of Plantar Fascitis by demonstrating thickening of the plantar fascia. It is also useful in ruling out other conditions.

Sonography of the foot may also be useful in detecting plantar fascial thickening.

It is noteworthy that the presence of heel spurs is of questionable diagnostic value as many asymptomatic individuals have heel spurs, while many patients with plantar fasciitis do not have heel spurs.

The following are examples of “red flags” for patients presenting with foot and ankle pain:

• History of a significant injury
• Severe focal pain
• Inability to bear weight because of severe pain
• Unrelenting pain
• Nocturnal pain
• Unexplained weight loss
• Fever
• Deformity
• Significant swelling
• Presence of tingling, numbness, burning or other neurological impairment
• Loss of distal leg pulses
• Significant loss of range of motion
• Severe tenderness on palpation or severe pain with any examination procedure

If any “red flags” are identified during history taking and clinical examination, referral for urgent medical evaluation and further investigation is warranted.

Plantar Fascia Morning Exercises – It is expected that the microtears in the plantar fascia undergo some healing during sleep. However, a patient with plantar fasciitis typically finds walking very painful during their first few steps in the morning. This is likely caused by a reinjuring of the plantar fascia during these initial steps. To preserve at least some of the healing that they achieved during sleep, it is essential that the patient performs their plantar fascia exercises first thing in the morning before they take their first steps (see the Patient Exercise Sheets provided further down on this web page). This allows the plantar fascia to become more flexible and less likely to be redamaged when they commence walking.

After performing the exercises, the patient typically feels much less pain when they commence walking. The same exercises can also be performed after a prolonged period of sitting before commencing to walk. The patient should be encouraged to continue their exercises every day until they achieve full recovery. If the patient complains of developing pain in the Achilles region, this is usually due to performing the exercises incorrectly or excessively.

Plantar Fascia Ice Application – Instruct the patient to fill a drink bottle with water to about two-thirds of its capacity and place it in the freezer. When the water is frozen, this can be used to apply ice to the bottom of the foot. Ask the patient to place the bottle on the floor and to slowly roll it from the ball of their foot to their heel 20 to 30 times. This exercise should be performed 3 times a day.

Supportive Footwear – Footwear should provide adequate support. Footwear that is flexible does not provide adequate support and should be avoided. The following simple tests can be performed to check the level of support provided by footwear:

• Shoe Twist: Hold the shoe at both ends and twist it. If the shoe twists too easily it will not provide adequate support.
• Shoe Bend: Hold the shoe at both ends and fold it upward. If the shoe bends too easily it will not provide adequate support.

Heel Pain Differential Diagnosis

In addition to plantar fasciitis, the differential diagnosis of heel pain in adults includes conditions such as:

• Tarsal tunnel syndrome
• Subtalar joint dysfunction
• Arthritis
• Stress fracture
• Myofascial pain syndrome (e.g., soleus, flexor digitorum accessories, and abductor hallucis muscles)