Plantar Fasciitis

Definition

 

Pain at attachment of thickened central part of plantar aponeurosis to Medial Calcaneal Tuberosity

 

Anatomy Plantar Fascia

 

Origin 

- medial calcaneal tuberosity

 

Inserts 

- 5 bands superfical & deep layers

 

Superficial

- insert transverse MT ligament & skin

 

Deep 

- flexor sheath, volar plate & periosteum of P1

 

Action

- when toes passively DF in toe off

- inelastic

- stabilises and elevates arch of foot

- windlass mechanism

 

Fat Pad 

- absorbs 20-25% of force at heel strike

- U-shaped, fat arranged in fibro-elastic septa

 

Epidemiology

 

Usually middle-aged male

- age 40-70 years

- M:F = 2:1

- usually unilateral

 

Predisposing factors

- obesity

- certain occupations i.e. Policeman's heel

- athletes and repetitive stress

 

Aetiology

 

Usually idiopathic

 

May be associated condition especially if bilateral

- Reiter's Disease

- Ankylosing Spondylitis (enesopathy)

- Gout

 

Pronated feet / cavus feet / planus feet

Obesity

Tight tendoachilles

 

Theories

 

1.  Degenerative change fat pad most common finding 

- decreased ability to cushion heel

 

2.  Injury to windlass mechanism with micro trauma

 

3.  Nerve entrapment

 

4.  Heel spur present in 50% with heel pain

- spur is in origin FDB (short flexors) not plantar fascia

 

Shmokler 1000 patients

- 13.2% incidence heel spurs

- 5.2% of which had heel pain

 

Williams

- 45 patients 52 painful heels

- 75% painful heels with spur

- 65% opposite heel had spur

 

Foot Calcaneal Spur

 

Pathogenesis

 

Degeneration 80% 

 

Repetitive stress at attachment

- leads to microscopic tears & cystic degeneration

- maybe periosteal reaction & spur formation

 

Entrapment 20%

 

Nerve Entrapment Syndrome

- lateral plantar nerve / Baxter's nerve

- mixed motor and sensory

- motor to abductor digiti minimi

- runs superior to plantar fascia

- may be compressed by spur or fascia

- difficult to diagnose

 

History

 

Pain at inferomedial aspect of heel

- worse when first rising from bed

- worse with prolonged standing or extreme exercise

 

Examination

 

Local tenderness at inferomedial aspect of Calcaneal tuberosity

 

Pain aggravated by passive dorsiflexion of toes

 

Tinel's sign

 

Cavus / Planus

 

Tight T Achilles

 

X-ray

 

Maybe calcaneal spur (50%)

- exclude tumour & infection

 

Bone Scan

 

Can be useful in atypical presentations

 

MRI

 

Plantar fasciitis MRIPlantar Fasciitis MRI

 

Inflammation of the plantar fascia at its insertion

May show compression of 1st branch of lateral plantar nerve

 

DDx

 

Inferior heel

- calcaneal stress fracture

- fat pad atrophy

- calcaneal apophysitis

- nerve compression / tarsal tunnel

 

Posterior heel

- Achilles tendonitis

- retrocalcaneal bursitis

- STJ OA

 

NHx

 

80-95% settle with non-operative management

- in 6-12/12

 

Management

 

Non-operative

 

Acute cases respond better to HCLA

Chronic better to orthoses

 

Soft Heel Cup with Instep

 

Physiotherapy

- T Achilles stretches

- Plantar fascia stretches

- can rolling

 

Orthoses

- well padded running shoes

- viscous heel cushions + longitudinal arch support

- Soft Heel Cup with Instep

 

Night splint 

- hold in 15o DF

- very effective

- maintain night-time stretch

 

NSAIDS

 

ECSW

 

Aqil et al. CORR 2013

- meta-analysis of RCTs

- safe and effective treatment

- effects evidence at 12 weeks, last up to 12 months

 

High energy ECSW v low energy ECSW

- evidence for both

 

Cast immobilisation 

- keeps plantar fascia under constant stretch and minimises microtrauma

- patient should undergo this treatment before consideration for surgery

- very effective treatment

 

Injections

 

Cortisone

- ? US guided

- max 2 (plantar fascia can rupture)

 

PRP

 

Acosta-Olivo et al. J Am Podiatr Assoc 2016

- RCT of cortisone v PRP

- equally efficacious

- no between group difference

 

Botox

 

Ahmed et al Foot Ankle Int 2016

- RCT of saline v Botox

- significant improvement in botox group

 

Operative

 

Indication

- must have minimum 12 months non-operative treatment

- 5% of patients

- results of surgery variable

 

Results

 

Contompasis

- 129 patients

- 43% complete improvement

- 38% some improvement

- none worse off

 

Open Release of Plantar Fascia

 

Set up

- tourniquet

- prone / lateral / supine

 

Incision

- medial longitudinal incision

- this is often vertical in line with posterior border medial malleolus

- protect medial calcaneal branch 

 

Dissection

- divide ABHB fascia

- reflect this superiorly

- identify plantar fascia origin from tuberosity

- FDB is above plantar fascia

- insert homan retractors above and below

- lateral plantar nerve deep to abductor, above FDB laterally

 

Resection

 

Resect medial rectangle of plantar fascia

- divide 3/4 of fascia

- don't release in full unless very old and decrepit

- take 6 deep by 2 mm thick rectangle

 

+/- neurolysis

 

+/- Resect spur

- reflect FDB

- remove with osteotome / nibbler

 

B.  Endoscopic release

 

Ogilvie-Harris Arthroscopy 2000

- 53 patients with 65 feet

- complete resolution of pain in 89%

- 71% returned to unrestricted sport

 

Results

 

Cochrane Review 2012

- no evidence for laser or ultrasound

- limited evidence for dorsiflexion night splints

- limited evidence topical corticosteroid

- some evidence for injected CS

- equivocal for ECSW