Conditions

Plantar Fasciitis

Plantar Fasciitis

Plantar fasciitis is localised inflammation and degeneration of the proximal plantar aponeurosis (plantar facsia) most commonly near the origin at the medial calcaneal tuberosity of the calcaneus (heal bone).

The strongest risk factor is obesity. There is evidence hamstring inflexibility (tightness) also plays a role. There is inconclusive evidence physical activity, including weight bearing endurance activity and prolonged standing; deceased ankle dorsiflexion (extension, upwards bend) due to calf tightness; and reduced toe flexion (downwards bend) strength are risk factors.

Heel spurs are not a risk factor for plantar fasciitis. They reside in the short muscles of the foot, not the plantar fascia; are common, present in 1 in 10 (10%) people; and only 1 in 20 people (20%) with heel spurs have heel pain.

Plantar fasciitis initially presents with sharp localised medial (inside) heel pain that has a ‘start-up’ quality in that it is worse on arising from bed in the morning or when going from sitting to standing. Eventually it is replaced by an ache that is worse at the end of the day or after prolonged standing.

On examination there is usually tenderness over the medial calcaneal tuberosity (inside heel) and pain on dorsiflexion (bending up) of the ankle and toes. There is usually also calf tightness.

Other possible causes of similar heel pain that need to be ruled out include Baxter’s neuropathy (entrapment of the 1st branch of the lateral plantar nerve), tarsal tunnel syndrome, heel fat pad contusion, Achilles tendinopathy, tibias posterior dysfunction, calcaneal stress injury, subtalar joint arthritis, and inflammatory arthritis.

Most cases, 80-90%, resolve within 10 months. A small proportion of cases do not resolve without treatment.

Plain radiographs (XRays) are often normal. Diagnostic ultrasound scanning may show thickening (> 4 mm thickness), hypoechogenecity (dark appearance), hyperaemia (increased blood flow), and intrasubstance tearing. MRI scanning can additionally show bone marrow oedema at the calcaneal enthesis (‘bone bruising’ in the heel bone), perifascial oedema (swelling around the plantar fascia).

Treatment should include addressing the risk factors including weight loss, relative rest from painful activity, hamstring and calf stretching, and foot muscle (short foot and high load) strengthening. Plantar fascia specific stretching can also be beneficial as well as topical ice and non-steroidal anti-inflammatory medications (NSAIDs).

Plantar Fascia Specific Stretching

High Load Strengthening

A soft off-the-shelf orthotic incorporating a heel cut-out and plantar fascia groove can be effective particularly if low-dye taping of the foot provides some pain relief.

The ultrasound guided perifascial (underneath and beneath the plantar fascia) injection of cortisone can provide patients with 6-8 weeks of relief. The costisone should not be injected into the plantar fascia itself as it can tear the plantar fascia and weaken it as the corstisone is catabolic (‘breaks’ tissues down).

Focussed extracorporeal shockwave therapy is reserved for low-grade plantar fasciitis with the absence of intra-substance tears on scanning while the ultrasound guided intra-substance (into plantar fascia tear) injection of leukocyte-rich platelet-rich plasma (LR-PRP, high concentration of white blood cells and very high concentration of platelets), which induces a healing response within the plantar fascia over 12+ weeks, is reserved for chronic high-grade plantar fasciitis with intra-substance tears on scanning and symptoms of greater than 6-12 months.

Focussed Extracorpreal Shockwave Therapy (Storz Duolith SD1 T-Top Shockwave Source)

Very rarely is surgery warranted.


Dr Will Craddock has been practicing in the field of sport and exercise medicine since 2005 and has extensive experience in the management of plantar fasciitis and other non-surgical musculoskeletal injuries having trained medically to a specialist level as a Specialist Sport and Exercise Physician with the Australasian College of Sport and Exercise Physicians.

Ultrasound

Tendinopathy

Plantar Fasciitis

Patellar Tendinoapathy

Achillles Tendinopathy and Enthesopathy

Achilles Paratenonitis

Extracorporeal Shock-Wave Therapy (ESWT)

US Guided Injection

Platelet Rich Plasma (PRP)/Preparation Rich in Growth Factors (PRGF)

Corticosteroids

Mesenchymal Stem Cells