Plantar fasciitis

1. The most common cause of heel pain is plantar fasciitis (Biomechanical/inflammatory)

   1. Nerve related: sciatica (due to compression at the L5-S1 root), tarsal tunnel syndrome (compression of the posterior tibial nerve at the medial malleolus), entrapment of the lateral plantar nerve

   2. Traumatic: plantar fascial rupture,calcaneal stress fracture, calcaneal apophysitis (Sever’s disease),

   3. Inflamatory/Systemic: certain systemic conditions including rheumatoid arthritis, Reiter’s syndrome, Bechet’s disease, etc)

2. Etiology

   1. Biomechanical fault that causes abnormal pronation causing calcaneus to evert (increases stretch on plantar fascia and inflammation which may eventually lead to tiny tears in the fascia and further inflammation, resulting in pain). Other conditions can increase stress on the calcaneus and plantar fascia- tibia vara, ankle equines, etc.

** We will focus on plantar fasciitis as it is the most common cause of heel pain in patients regardless of age or gender.

3. Typical presentation- pain limited to the inferior medial aspect of the calcaneus (over medial calcaneal tubercle), usually worse in the morning with the first few steps and better as patient walks more. Patients frequently do not report any history or trauma but may report increased use of their feet/activity level.

   1. Atypical presentations: pain along the plantar fascia at other points (abductor hallicus tendons, flexor digitorum brevis tendons, anterior foot pain at digits, posterior ankle pain

4. Evaluation:

   1. Diagnosis usually made by history of typical presentation and physical exam.

      1. Physical exam: direct palpation of medial calcaneal tubercle causes severe pain. Palpation along the plantar fascia will produce pain near that point but medial to lateral compression of the calcaneus itself should be painless.

      2. Plain radiograph can be used to support diagnosis and rule out other causes of heel pain including rheumatoid/osteoarthritis, calcaneal stress fracture, etc.

5. Treatment

   1. Conservative management- patient education, decreasing activity level if patient is engaged in strenuous activity, medial arch pad (felt, foam, gels), custom orthotics, night splints to keep Achilles tendon stretched and foot at 90degrees, icing plantar aspect of foot each night for 10-14d for 10-15mins at a time, NSAIDs 6-8wk course, corticosteroid/lidocaine injections into heel

   2. Extracorporeal shock wave therapy- questionable efficacy- a meta-analysis of 10 big studies showed that there was no significant difference between controls/placebo and patients who received ESWT in terms of morning pain

   3. Surgical management- only after several months or years of conservative management.

      1. Plantar fasciotomy without inferior calcaneal exostectomy just as effective as the surgery with exostectomy. Also is an option of having an endoscopic procedure, which studies show have patients return to work on average of 55 days sooner than those who had open surgery.

Category: Orthopedics Notes