Author(s): David Berbrayer, MD
Originally published: November 10, 2011 Last updated: May 28, 2020
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Disease/ Disorder

Definition

Plantar fasciitis is a painful condition of the foot caused by inflammation or degeneration of the plantar fascia, the thick ligamentous connective tissue that runs from the heel to the ball of the foot.

Etiology

Repetitive weight-bearing activities cause increased load on the plantar fascia, leading to microtearing, inflammation, and pain 3,6,9,10. Scar tissue forms, which both thickens and weakens the fascia. This occurrence leads to increased force on the calcaneus, which can cause plantar spurs that may or may not be painful.

Epidemiology including risk factors and primary prevention

Plantar fasciitis in the US affects 2 million people a year, with a peak incidence between 45 and 64 years and a slight gender predisposition for females. https://jaoa.org/article.aspx?articleid=2210626)34. It results in approximately 1,000,000 patient visits per year. Plantar fasciitis accounts for 10% of injuries in runners.3,5

Risk factors include obesity, sedentary lifestyle, performing occupations that require repetitive impact activities or prolonged standing, and endurance running. Biomechanical factors include tight heel cords, pes planus with hyperpronation, pes cavus, midfoot motion abnormalities, genu valgum, leg length discrepancies, and reduced dorsiflexion of the ankle.4,6,8,9,10 Primary prevention efforts include activity modification, proper footwear and arch supports, and foot and ankle flexibility exercises. https://jaoa.org/article.aspx?articleid=2210626)34.

Patho-anatomy/physiology

The plantar fascia originates on the medial tubercle of the calcaneus and fans out over the bottom of the foot to insert onto the proximal phalanges and the flexor tendon sheaths. It helps provide stability to the longitudinal arch of the foot. The plantar fascia consists of 3 bands; lateral, medial and central. The central band originates from the medial tubercle of the calcaneus and travels to the 5 toes. At the metatarsal head, the central band divides into 5 slips, each of which inserts into the proximal phalanx of each toe. When the toes are extended, the plantar fascia is functionally shortened as it wraps around each metatarsal head. This windlass effect assists the supination of the foot in the latter portion of the stance phase and also stiffens the midfoot for push off in gait.3,11 Plantar fasciitis is believed to be caused by repetitive microtrauma to the fascia; therefore, many consider it to be more degenerative than inflammatory in nature, and thus anti-inflammatory agents are only somewhat effective in treatment. Histopathologic studies show collagen degeneration, fiber disorientation and increased ground substance with an absence of inflammatory cells. In light of these features, some may feel “fasciopathy” is a more appropriate term for this condition.

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

New Onset/Acute
This phase lasts up to four weeks. The onset of pain typically follows an increase in amount or intensity of activity, or change in footwear. Patients typically complain of pain in the heel. Concomitant pain at other sites such as mid-arch, or just posterior to the metatarsal heads is also possible. This pain typically follows a diurnal pattern that is worse in the morning, improves throughout the day, and worsens again at the end of the day. Patients may also complain of worse pain upon standing after sitting for a prolonged period (such as with a desk job).

Subacute
This phase occurs from four weeks to three months. In this phase the pain increases further with activity and can even be present at rest. Individuals can still perform routine activities.

Chronic/Stable
After 3 months the condition is in the chronic phase. Adhesions, inflammation and scar tissue formation can develop and the healing process can be slow. There is intense pain with activity and at rest. Routine functional activities may be limited due to pain. An elongated plantar (calcaneal) spur may develop at the attachment of the fascia to the calcaneus, extending up to 2.5 cm. Rupture of the plantar fascia can result in cessation of symptoms after the acute pain and swelling of the rupture. Essentially the patient does a plantar release without the surgery.

Specific secondary or associated conditions and complications

Gait abnormalities may develop, which may place undue stress on other joints or the contralateral limb. For example, limping or avoiding pressure on the affected heel may ultimately cause hip or lower back pain on either side of the body. Posterior tibialis tendinopathy and dysfunction, flexor hallucis longus tendinopathy, and Achilles tendinopathy are common fellow-travelers (may predispose or be a result of plantar fasciitis). There also may be an entrapment neuropathy such as first branch of the lateral plantar (Baxter’s) neuropathy.33

Essentials of Assessment

History

Typically the patient has heel pain with the first steps in the morning, improving with activity then worsening with prolonged weight bearing. Pain may be worse walking barefoot, on hard surfaces or up the stairs. Pain may improve with a short heeled shoe of less than one inch, but care must be done to avoid shortening of the Achilles tendon and to only wear a heeled shoe if the forefoot is asymptomatic.13

Physical examination

There is typically tenderness to palpation along the plantar fascia at its origin at the anteromedial heel, mid arch or at the distal insertion near the metatarsal heads. Inspection should also include evaluation for pes cavus / pes planus and “too many toes” sign of posterior tibialis tendon dysfunction. Pain at the insertion is almost obligatory; if pain is not present at this location, the clinician should have a high index of suspicion of other clinical entities being the primary pain generator, such as posterior tibialis tendinopathy. Ankle dorsiflexion may be limited due to tightness of the Achilles tendon. Pain may be exacerbated by passive extension of the toes or by having the patient stand on his or her toes. Hyperextension of the 1st metatarsophalangeal joint during weight-bearing (Windlass test) may elicit pain. Patients may compensate for pain by walking on their toes, in supination on the lateral aspect of the foot, or with a limp.

Functional assessment

A full kinetic chain evaluation should be performed. In many cases the plantar fascia becomes over-stressed due to poor running biomechanics, tightness or weakness of calf, knee, hip or core muscles. The clinician needs to assess both the stance phase as well as the swing phase of the gait cycle. The plantar fascia and intrinsic and extrinsic muscles of the foot play an active role in guiding the foot as it transitions from initial contact to toe off. Efficient function of the plantar fascia and musculature of the foot depends on the configuration of the rear-foot and midfoot articulations during the different subphases of gait. Structural abnormalities that pose risk factors for development of plantar fasciitis need to be evaluated: ankle equinus, forefoot varus, rear-foot varus, pes plano valgus, and pes cavus.14 Flexibility and range of motion at all lower limb joints should be assessed, especially a functional assessment of posterior tibialis.  The tibialis posterior (TP) muscle has a vital role during gait; via multiple insertion points into the tarsal bones it acts as the primary dynamic stabilizer of the rear-foot and medial longitudinal arch (MLA). The significance of TP function is evident when the muscle and tendon are dysfunctional, whereby stability of the foot is compromised and is associated with a progressive flatfoot deformity. Assessing the function of the TP muscle and tendon can be determined through careful clinical examination including techniques such as manual muscle testing and the single heel raise test. Clinical examination can be supplemented with more specialist modalities including muscle function magnetic resonance imaging (MRI), ultrasound, electromyography (EMG) and gait analysis. TP activity can be recorded as bi-phasic, with activity occurring during contact and either mid-stance or propulsive phases of gait.15

Laboratory studies

None typically indicated except to rule out other conditions as needed.

Imaging

Plain radiographs can show associated heel spurs. Radiographs may be used to detect overt calcaneal stress fractures, but given the low sensitivity of this imaging modality, advanced imaging may be required if a stress reaction is suspected. Bone scan or MRI may aid in ruling out fracture, but MRI has the advantage of assessing fascial thickening, surrounding edema, and atrophy of the abductor digiti minimi quinti and quadratus plantae in the case of Baxter’s neuropathy. Soft tissue resolution in ultrasonography is superior to that of MRI, is far more cost effective, and can be used for interventional procedures. Increased fascial thickness (5-7 mm; normal 2-4 mm), hypoechogenicity, edema and cortical irregularities at the calcaneal insertion may be noted.

Supplemental assessment tools

Electrodiagnostic studies may be considered to evaluate for S1 radiculopathy, tarsal tunnel syndrome, medial calcaneal neuropathy, or Baxter’s nerve entrapment in refractory cases.

Early predictions of outcomes

Regardless of treatment, plantar fasciitis has been shown by many studies to be self-limiting, with symptoms resolving in most patients within 12 months, and 90% of patients achieving successful outcomes without surgery35.

Those who have risk factors for persistent loading (endurance runners, occupational requirements, obesity) may be at risk for poor outcomes. Van Leeuwin et al performed a systematic review and meta-analysis and found a consistent clinical association between higher BMI and plantar fasciopathy. In people with PF compared to controls, pooled imaging data demonstrated a significantly thicker, hypoechogenic plantar fascia with increased vascular signal and perifascial fluid collection. In addition, people with PF were more likely to have a thicker loaded and unloaded heel fat pat, and bone findings, including a subcalcaneal spur and increased Tc-99 uptake. No significant difference was found in the extension of the first metatarsophalangeal joint.16

Sonographic appearance of the plantar fascia is predictive of the treatment (ie, pain) response in patients receiving supportive therapy for proximal plantar fasciitis. Patients who present with biconvexity of the plantar fascia may be less responsive to tier 1 treatment regimens that center around mechanical support of the plantar fascia. The pain response was not associated with the type of foot support after 3 months.17

Patients with severe ankle equinus were nearly 4 times more likely to experience a favorable response to treatment centered on home Achilles tendon stretching and supportive therapy. Thus, earlier use of more advanced therapies may be most appropriate in those presenting without severe ankle equinus or without severe first step pain.18

Environmental

Walking or running on uneven or hard surfaces may worsen plantar fasciitis. Running more than 25% on tartan is associated with plantar heel pain in competitive long-distance male runners.19

Social role and social support system

Plantar fasciitis may limit vocational and recreational activities and athletic performance. Proper education, prevention, and appropriate return to work or play guidelines can improve outcomes and prevent patients from returning to activities that may prevent healing. The ability of the work or athletic team manager to accommodate modifications or restrictions can aid in the recovery process. The two most influential social factors influencing athletes’ injury rehabilitation are the nature of patient-practitioner interactions and the effectiveness of social support provisions. Injury is an emotionally disruptive experience for anyone, but perhaps more so for athletes, especially those for whom sport is central to lifestyle and personal identity. There is an extensive array of psychological factors, positive and negative, that play into the recovery process for better or worse.20

Professional issues

Professional athletes have contractual obligations to fulfill their team roles and physicians may feel pressure from coaches, athletic trainers, the public or the athlete to return the athlete to play prematurely. For workers with plantar fasciitis there may be pressure from the employer to return the patient or difficulty in accommodating work restrictions. Injured workers may have less incentive to improve if there is pending litigation. This condition can often affect competitive athletes and the physician will face pressures to successfully return the athlete to their prior level of play despite the often difficult and chronic nature of this condition.

Rehabilitation Management and Treatments

Available or current treatment guidelines

The Heel Pain-Plantar Fasciitis Guidelines link International Classification of Functioning, Disability, and Health (ICF) body structures (ligaments, fascia of ankle and foot, neural structures of lower leg) and ICF body functions (pain in lower limb, radiating pain in a segment or region) with World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (ICD) health condition (plantar fascia fibromatosis/plantar fasciitis). Guidelines describe evidence-based physical therapy practice and provide recommendations for (1) examination and diagnostic classification based on body functions / structures, activity limitations, and participation restrictions,2 prognosis,3 interventions4 and assessment of outcomes.

At different disease stages

  • new onset/acute includes
    • Potential curative interventions
      Stretch the plantar fascia and gastrocnemius/soleus complex. Massage the plantar fascia manually by running the thumb or fingers lengthwise along the fascia or by rolling the foot over a frozen water bottle or tennis ball.
    • Symptom relief
      Apply ice for 15-20 minute intervals after prolonged activity. Acetaminophen or NSAIDs may be used for pain.
    • Rehabilitation strategies intended to stabilize or optimize function or prepare for further interventions at later disease
      Taping, shoe inserts and orthotic arch supports can improve foot mechanics and relieve stress on the plantar fascia. The first line of relief for treating plantar fasciitis are heel cushions which provide extra shock absorption in the heel area. They help absorb the shock of heel strike in walking and running. Heel pads are generally constructed of polyvinyl chloride, silicone, leather, polyethylene foams like Plastizote, and thermoplastics. Soft heel cups cushion and contain the fat pad. They are effective for a plantar calcaneal bursitis or plantar heel spur syndrome. This silicone heel cushion has a built-in area of softer durometer that is especially designed to disperse weight around the plantar medial tubercle of the calcaneus. Sometimes, using a heel lift is helpful in shifting pressure to the forefoot. Keep in mind that a heel lift in the shoe should be no thicker than one-quarter inch.
    • Over the counter orthotics and custom orthotics may be equally effective in reducing pain in the heel, with both providing short-term (up to 3 months) reduction in pain and improvement in function 36
    • Calcaneal/low dye taping technique is used for injuries or pain caused by over-pronation. It reduces the foot joints’ range of motion, supports the plantar fascia and relieves the heel pain from the disorder. Low-dye taping has been used to provide short-term (7-10 days) pain relief by supporting the medial longitudinal arch of the foot, thus controlling the amount of rear foot pronation. After 1 week, it has not been shown to be more effective than no treatment in improving function.37 It also helps to reduce the pressure in the medial midfoot. It is thought that by reducing this pressure and decreasing the amount of pronation via an external support such as low-dye taping, the plantar fascia won’t be subject to the repetitive stretching and cycle of inflammation seen in plantar fasciitis. The patient is sitting with the leg extended and the foot are right angles to the leg. The foot is grasped gently and the first of three strips of one- or 1-1/2 inch tape is applied, starting proximal to the fifth metatarsal joint. After the tape is secured on the outside of the foot, grasp the end in one hand and wrap it around the heel while simultaneously inverting or turning the heel in slightly. Attach the other end of the tape just behind the big toe joint on the inside of the foot. Individuals who improve with these taping techniques are thought to have a higher likelihood of responding to foot orthoses that support the medial longitudinal arch and cushion the heel 36.
    • Therapy on strengthening the lower extremity kinetic chain, including the foot intrinsics also improves function. Atrophy of intrinsic foot muscles may be associated with symptoms of plantar fasciitis in runners.12,21
  • Subacute care includes
    • Secondary prevention and disease management strategies
      Deep tissue procedures: Graston Technique and Active Release Technique break scar tissue and restore soft tissue. 38
    • Symptom relief
      Corticosteroid injection is considered if pain is not responding to plantar stretching and/or appropriate shoe inserts or orthoses. Relief would be expected for 1 month.22
    • Rehabilitation strategies intended to optimize function
      Wear motion control shoes and change every 250-500 miles.
  • Chronic/stable care includes
    • Secondary prevention and disease management strategies
      Prefabricated splints set at 5 degrees of dorsiflexion should be worn at night.
    • Symptom relief
      Extracorporeal shockwave- (ESWT) therapy is shown to provide significant improvement in pain and walking ability at 3 and 6 months compared to sham. In ESWT, high frequency pulsed sound waves are delivered to the fascia; this therapy is shown to induce healing and even normalization of plantar fascial thickening by inducing neovascularization and through analgesic and anti-inflammatory effects. Following the procedure, patients are asked to take it easy the remainder of the day. The next day, most patients can take part in their normal, daily activities. Significant pain relief was noted by 50-65% of the patients within a week following the procedure. No immobilization is required.23 ESWT has been shown to be more effective when applied in higher energy levels without local analgesia 39 ESWT is a safe and effective treatment of chronic plantar fasciitis refractory to nonoperative treatments. Improved pain scores with the use of ESWT were evident 12 weeks after treatment. The evidence suggests this improvement is maintained for up to 12 months.24
    • Intracorporeal pneumatic shock treatment (IPST) can be used if pain is not responding to conservative management.
    • Rehabilitation strategies intended to optimize function
      Rearfoot varus, pes planus and forefoot varus foot structures may benefit from motion control sneakers.
    • Surgical outcomes

Surgery should be considered only after 12 months of aggressive nonsurgical treatment. Plantar fascia surgery involves either an open procedure (cutting part of the plantar fascia ligament) or by endoscopic procedures. The majority of patients who undergo surgery will have decreased pain and improved function. On average, most patients will be able to return to normal weight bearing two to three weeks after surgery. Continued stretching, good footwear, and avoiding activities that cause pain are important to a successful recovery.  In endoscopy, the medial slip of the plantar fascia is completely released. The lateral one half to two thirds of the fascial band is left intact.25

Coordination of care

  1. Parallel practice: Patients may be rehabilitating but still working or competing.
  2. Coordinated: Employers, coaches and family may need to be involved to promote a successful outcome.
  3. Multidisciplinary: Athletic trainers, physical therapists, orthotists may be utilized.
  4. Interdisciplinary: Foot-ankle trained orthopedic surgeons or podiatrists can be consulted in refractory cases
  5. Integrated: n/a

Patient & family education

Educate on the importance of foot and ankle stretching, appropriate training volume and intensity, appropriate shoe (and orthotic) wear and weight reduction. Different athletic shoes should be worn every 6 months and can be rotated for longer wear.

Measure of Impairment and Patient Outcomes: Impairment-Based Measurement

Occasionally, plantar fasciitis can lead to work time loss if the injured worker has a job that requires running or long-distance walking.

Measurement of Patient Outcomes

The Foot Function Index (FFI) is a 0-10 scale of pain and foot function over time in standing, walking, etc. The Foot Health Status Questionnaire (FHSQ) is a 42-item questionnaire assessing quality of foot health. The American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot Scale is a 100-point scale used to assess pain, function, and alignment. The Foot and Ankle Ability Measure (FAAM) is an activities-of-daily-living scale of foot health. These measures can be used to assess pain severity and to monitor response to treatment.

Cutting Edge/ Emerging and Unique Concepts and Practice

Cutting edge concepts and practice

New diagnostic techniques include ultrasound elastography which can be useful in early diagnosis. In addition to showing typical ultrasound findings of plantar fascial thickening and perifascial fluid collection, ultrasound elastography can also show softening of the plantar fascia which has been shown to differentiate patients with plantar fasciitis from normal subjects40.

There has been extensive research, both animal and human studies, with widespread applications revealing the efficacy and safety of PRP, and the use of PRP in treating plantar fasciitis is increasingly reported in scientific literature. In plantar fasciitis, there is inadequate blood supply to the problematic area as well as an inflammatory response that happens to be painful. The basis of PRP technology is to provoke a supraphysiologic release of growth factors in an attempt to jumpstart the healing of a chronic injury. Increased concentrations of autologous platelets yield high concentrations of growth factors, subsequently leading to intensified healing of soft tissue on a cellular level. Platelets and white blood cells dominate the proliferative healing response by releasing growth factors, enhancing fibroblast migration and proliferation, increasing vascularization and collagen deposition, and recruiting stem cells and supporting tissue regeneration.26,27,28,41.When used to treat plantar fasciitis, the PRP injection is targeted at the lesion, which is generally hypovascular and hypocellular and thus otherwise relatively inaccessible to growth factors.

Other new treatment techniques include percutaneous needle tenotomy, platelet rich plasma (PRP), prolotherapy, botulinum toxin injections, and, potentially in the future, stem cell therapies to promote healing.

Emerging/unique interventions

In addition to platelet rich plamsa injections as described above, other emerging and unique interventions to treat plantar fasciitis have been trialed. Dehydrated human amniotic membrane contains growth factors such as EGF, TGF-β, FFGF that are known to stimulate epithelial cell migration and proliferation, and PDGF A and B which are known to stimulate many metabolic processes 42. Randomized controlled trials examining the efficacy of injecting dehydrated human amniotic membrane into the heel of the affected foot are mixed, and further studies are needed to demonstrate the efficacy of this technique 43. Botulinum toxin type A injection is shown to produce significant improvements in pain relief and overall foot function.1,3, (ahmad – treatment chronic plantar fasciitis) Cryosurgery can be an effective treatment after failed conservative management. Acupuncture, dry needling, and prolotherapy may be beneficial in treating chronic plantar fasciitis.26,27,28, dextrose prolotherapy 2020 Iontophoresis with dexamethasone may be helpful for reducing any inflammatory component. Minimally invasive ultrasound guided techniques such as percutaneous tenotomy (Tenex) hold promise.25 Low laser and low dose radiotherapy has also been used to treat plantar fasciitis. The FX 635 laser is a non-invasive form of regenerative medicine, which stimulates a low grade healing response as opposed to steroids, which are suppressants. One major drawback to the laser is its somewhat lengthy treatment time and poor evidence of effectiveness.29 Low-dose radiotherapy is effective in most patients with painful plantar fasciitis. Due to minimal side effects and low costs, it represents an excellent treatment option compared to conventional therapies or surgery. There are newer studies reporting positive outcomes.30

Gaps in the Evidence- Based Knowledge

Gaps in the evidence-based knowledge

More evidence is required to fully understand the potential impact of the new, emerging treatments that are becoming available — including PRP, dehydrated human amniotic membrane,  stem cells, prolotherapy, botulinum toxin, percutaneous needle tenotomy, laser therapy, and others.

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Original Version of the Topic:

David Berbrayer, MD. Plantar Fasciitis. 11/10/2011.

Previous Version of the Topic:

David Berbrayer, MD. Plantar Fasciitis. 5/5/2016.

Author Disclosure

David Berbrayer, MD
Nothing to Disclose