Plantar Fasciitis

WHAT IS PLANTAR FASCIITIS?

• Plantar fasciitis is a common cause of heel pain, characterized by pain and tenderness at the bottom of the heel or sole of the heel what the plantar fascia connects to the heel [Scher et al, 2009; Goff & Crawford, 2011].
  

• The plantar fascia is a thick, fibrous band of connective tissue that runs along the bottom of the foot. The plantar fascia originates from the medial heel bone and extends forward to insert into the bases of the toes [Stecco et al, 2013; Guo et al, 2018].
  

• The plantar fascia plays a crucial role in supporting the arch of the foot and in absorbing and distributing the forces encountered during walking and running.
  

• Plantar fasciitis is the most common cause of heel pain, and most commonly occurs between ages 40 to 60 years [Martin et al, 2014; Ahn et al, 2023].

WHAT CAUSES PLANTAR FASCIITIS?

• Plantar Fasciitis often is not related to a specific injury. It is often due to biomechanical stress on the plantar fascia, which can be exacerbated by factors such as obesity, prolonged standing, and excessive foot pronation [Trojian & Tucker, 2019; Thomas et al, 2010; Goff & Crawford, 2011].
  
• Most plantar fascia injuries are a result of gradual wear and tear. Micro-damage over time can result in degenerative tears of the fascia and pain. Histological evidence suggests that rarely is inflammation observed in chronic cases, and instead, degenerative tears in the tissue are more commonly seen [Thomas et al, 2010; Wearing et al, 2006].
  
• The plantar fascia is closely related to the Achilles tendon through the periosteum of the calcaneus, suggesting a functional link between these structures. This relationship is significant in the context of plantar fasciitis, as any condition the affects the Achilles tendon can influence the plantar fascia [Stecco et al, 2013; Singh et al, 2021].
  

WHAT ARE THE SYMPTOMS OF PLANTAR FASCIITIS?

• Symptoms of plantar fasciitis are consistent with the underlying etiology, which involves gradual wear and tear and micro-damage over time, leading to degenerative changes in the plantar fascia. These include:
  • Heel pain: The most common symptom of plantar fasciitis is a stabbing, non-radiating heel pain. The pain is typically most severe with the first few steps in the morning or after periods of prolonged sitting [Trojian & Tucker, 2019; Thomas et al, 2010; Goff & Crawford, 2011].
    
  • Pain with initial weight-bearing: Patients often experience significant pain upon initiation of weight-bearing activities, such as getting out of bed in the morning or standing up after sitting for a long time. The pain usually decreases after a few minutes of walking, but tends to return and worsen by the end of the day with prolonged activity [Trojian & Tucker, 2019; Thomas et al, 2010; Goff & Crawford, 2011].
  • Tenderness: Patients often report tenderness to palpation at the medial heel bone [Trojian & Tucker, 2019; Thomas et al, 2010; Goff & Crawford, 2011].
    
  • Pain with dorsiflexion: Sometimes discomfort can be elicited by passive flexing the ankle and first toe, which stretches the plantar fascia [Goff & Crawford, 2011].
  • Associated findings: Other associated findings may include tightness of the Achilles tendon, and inappropriate shoe wear [Schroeder, 2002; Thomas et al, 2010].

HOW IS PLANTAR FASCIITIS DIAGNOSED?

• Diagnosis is based on detailed history, physical examination, and imaging. The area will likely be tender upon palpation.
  

• Imaging
  

  • Imaging plays a secondary role in diagnosing plantar fasciitis, and is primarily reserved for recalcitrant cases or to rule out other pathologies when the clinical diagnosis is uncertain [Goff & Crawford, 2011].
    

  • Radiographs (x-rays) play a limited but specific role in diagnosing plantar fasciitis. While the primary diagnosis is based on clinical history and physical examination, radiographs can be useful in certain scenarios and can be helpful in ruling out other potential causes of heel pain. However, the presence of calcaneal spurs, often seen on radiographs, is not a definitive diagnostic feature of plantar fasciiits as they can be present in both symptomaticand asymptomatic individuals [Martin et al, 2014; Osborne et al, 2006].

  • can be useful in showing heel spurs found in some cases of
    plantar fasciitis, but typically the spur is not the cause of pain.

  • Ultrasonography (US) is a valuable tool in the diagnosis of plantar fasciitis. Ultrasound has shown good sensitivity (80%) and specificity (88%) compared to MRI. Ultrasound can reveal increased plantar fascia thickness, hypoechoic fascia, and perifascial edema, which are indicative of plantar fasciitis. Ultrasound is also useful in detecting complete and partial tears of the plantar fascia [Tafur et al, 2020; Cardinal et al, 1996].

  • Magnetic Resonance Imaging (MRI) provides detailed characterization of the plantar fascia and adjacent soft tissues. MRI is considered the most sensitive imaging modality for diagnosing plantar fasciitis, showing increased plantar fascia thickness and abnormal tissue signal. However, some findings on MRI can be nonspecific and may also be seen in asymptomatic patients, necessitating correlation with clinical symptoms to avoid overdiagnosis [Tafur et al, 2020].
    

DO PLANTAR HEEL SPURTS NEED TO BE REMOVED?

• Plantar heel spurs do not need to be removed and are not a cause of heel pain, but rather a symptom of chronic tension on the plantar fascia. This is supported by several studies and clinical guidelines.
  • The American College of Foot and Ankle Surgeons, in their clinical practice guideline, emphasizes that the presence of a heel spur is not necessarily indicative of the cause of heel pain. Instead, heel spurs are often a result of chronic tension and biomechanical stress on the plantar fascia [Schroeder, 2002; Thomas et al, 2010].
    
  • A study published in the Journal of Foot and Ankle Surgery found that the removal of plantar heel spurs does not significantly improve outcomes in the surgical treatment of plantar heel pain, suggesting that the spurs themselves are not the primary source of pain [Cooperman et al, 2024].
  • Additionally, research published in Foot & Ankle International demonstrated that the shape and size of heel spurs do not correlate with the severity of pain or functional impairment in patients with plantar fasciitis, further supporting the notion that heel spurs are a secondary phenomenon rather than a direct cause of pain [Ahmad et al, 2016].
  • Histological studies, such as those published in Scientific Reports and The Journal of Rheumatology, have shown that heel spurs are likely the result of traction forces and degenerative changes at the plantar fascia enthesis, rather than being pathological in themselves [Zwirner et al, 2021; Kumai & Benjamin, 2002].

HOW IS PLANTAR FASCIITIS TREATED?

• Conservative Management

  • Initial treatment of plantar fasciitis consists of rest, ice, NSAIDs, calf-muscle stretching, night splints and physical therapy. In 90% of cases, patients improve with these conservative techniques [Goff & Crawford, 2011].
    

• Shockwave Therapy

  • Shockwave therapy may be used as an adjunctive therapy for plantar fasciitis. Shockwave therapy initiates the body’s natural healing process with the aim of reducing pain and inflammation and increasing function, and can be effective treatment for chronic plantar fasciitis that has not responded to conservative therapy.

    • A meta-analysis published in Clinical Orthopaedics and Related Research demonstrated that shockwave therapy significantly improves pain scores and functional outcomes in patients with chronic plantar fasciitis. The study found that shockwave therapy led to a greater reduction in pain compared to placebo, with improvements maintained for up to 12 months [Aqil et al, 2013].
    • Another meta-analysis in the American Journal of Physical Medicine & Rehabilitation confirmed the effectiveness of ESWT, showing significant reductions in morning pain and overall pain with activity. Both moderate- and high-intensity shockwave therapy were effective in improving functional outcomes [Dizon et al, 2013].
    • A randomized, controlled multicenter study published in The Journal of Bone and Joint Surgery found that focused shockwave therapy significantly reduced heel pain and improved functional scores compared to placebo, with success rates between 50% and 65% [Gollwitzer et al, 2015].
    • Additionally, a study in The American Journal of Sports Medicine reported that radial shockwave therapy significantly improved pain, function, and quality of life compared to placebo, with sustained benefits observed at 12 months [Gerdesmeyer et al, 2008].
    • A retrospective study in The Journal of Foot and Ankle Surgery found that a majority of patients with chronic plantar fasciitis achieved functional gains using either form of shockwave therapy with no difference in outcomes between radial and combined groups regarding [DeLuca et al, 2021].
      
• Platelet Rich Plasma (PRP) Injections

  • PRP concentrates a patient’s blood to increase various growth factors. Platelet-rich plasma (PRP) injections have been studied as a treatment for plantar fasciitis, particularly in comparison to extracorporeal shock wave therapy. At least 21 randomized controlled studies have evaluated PRP for plantar fascitiis [Herber et. al, 2024]. The available studies demonstrate that PRP injections maybe effective for treating plantar fasciitis with significant improvements in pain and function, fewer recurrences and faster return to sports:

    • A network meta-analysis in Rheumatology (Oxford, England) indicated that autologous blood-derived products, including PRP, had the highest probability of providing significant pain relief at 3 months. At 6 months, PRP and shockwave therapy had similar probabilities of providing pain relief, and both outperformed corticosteroids injections [Hsiao et. al, 2015].
    • Another network meta-analysis in the Journal of Cellular Physiology ranked ESWT as the most effective treatment for pain relief at 1, 3, and 6 months, buy PRP was also effective [Li et al, 2018].
    • In a prospective double-blind study in the Malaysian Orthopaedic Journal, 60 patients who fulfilled the criteria were divided randomly into patients who received a PRP injection and a steroid injection. The authors found significant improvement in pain and function in the PRP group, and concluded that a local injection of platelet-rich plasma is an effective treatment option for chronic plantar fasciitis when compared with steroid injection with long lasting benefits [Soraganvi et al, 2019].
      
    • In a prospective cohort study in the Indian Journal of Orthopedics of 30 patients with chronic plantar fasciitis.and found a single PRP injection had a clinical and statistically significant improvements in pain, function and plantar fascia thickness at the 3-month follow up [Kalia et al, 2020].
    • In a prospective cohort study of 110 patients in Cureus an injection of platelet-rich plasma (PRP) was compared to a corticosteroid injection (methylprednisolone) and found better treatment outcomes with PRP injections compared to local steroid injectoins [Vellingiri et al, 2022].
    • A retrospective comparative study in The Journal of Foot and Ankle Surgery reported that both PRP and shockwave therapy led to significant improvements in pain and function. However, PRP was associated with fewer recurrences and a faster return to sporting activities among athletes when compared to shockwave therapy [Alessio-Mazzola et al, 2023].
    • In a prospective study in Cureus PRP of 25 patients showed a significantly decrease in pain and function after the procedure with sustained benefits up to 6-months post-injection. The patients also showed a single dosage of PRP injections demonstrate clinically and statistically substantial improvements in pain, function and improved plantar fascia thickness [Kothari et al, 2024].
    • A systematic review and meta-analysis published in Foot & Ankle International found that PRP injections resulted in a statistically significant improvement in pain reduction and plantar fascia thickness compared to shockwave therapy at 3-6 months [Daher et al, 2024].
    • In a systematic review and meta-analysis in Foot & Ankle Surgery comparing the effectiveness of PRP to other conservative treatment options for the management of PF, the authors found PRP was more effective than corticosteroid injections, shockwave therapy, and placebo in reducing pain and in improving function (AOFAS scores). This study provides Level I Meta-Analysis data showing benefit of PRP over other conservative treatments [Herber et. al, 2024].
      

• Minimally invasive plantar fasciotomy

  • Minimally invasive plantar fasciotomy is a less invasive surgical option for treating recalcitrant plantar fasciitis, particularly in patients who do not respond to conservative treatments.

    • In Foot & Ankle International Colberg et al. reported that minimally invasive plantar fasciotomy using a microdebrider coblation wand resulted in significant pain reduction and functional improvement. In this study, 89% of patients had a successful outcome [Colberg et al, 2020].
      
    • In The Journal of Foot and Ankle Surgery Yanbin et al. demonstrated that minimally invasive plantar fasciotomy using landmark guidance and a flat-blade scalpel and significantly improved function scores in patients with chronic plantar fasciitis. At a mean follow-up of 16 months, no patients experienced symptom recurrence, and all patients had returned to regular shoe wear by three weeks postoperatively [Yanbin et al, 2015].
    • In The Journal of Foot and Ankle Surgery Benton-Weil et al. found that minimally invasive plantar fasciotomy using landmark guidance and a stab incision significantly reduced pain levels and 83% of patients reported that the procedure met or exceeded their expectations [Benton-Weil et al, 1998].
    • In International Orthopaedics Maes et al. evaluated the radiologic and clinical outcomes of minimally invasive plantar fasciotomy under fluoroscopic guidance using a scalpel and found significant improvements in function without significant changes in the medial longitudinal arch, indicating that the procedure did not adversely affect foot architecture [Maes et al, 2022].
    • In The Journal of Foot and Ankle Surgery Fallat et al. compared minimally invasive plantar fasciotomy using landmark guidance and a stab incision with a transverse incisions through 1/3 of the facia to a traditionally open fasciotomy. The authors found that the minimally invasive approach resulted in faster return to normal activity and similar pain reduction at 12 months postoperatively [Fallat et al, 2013].
      

• Plantar fascia fasciotomy using ultrasound guidance and the Tenex Device

  • In an abstract presented at the Society of Interventional Radiology (SIR) 100 patients treated with a fasciotomy using the novel Tenex device 90% of patinet sreported impovements in symptoms witha. high satisfaction rate at teh 6 month follow up [Razdan et al, 2015; Razdan et al, 2018].

  • In a retrospective matched case-controlled study in Regenerative medicine ultrasound-guided plantar fasciotomy with and without an amniotic membrane growth factor allograft injection found both groups demonstrated significant improvement in pain and a high level of patient satisfcation at the 16 and 52-week follow-up visits. In the short-term the growth factor injection did seem to show faster symptomatic improvement [Nakagawa et al, 2022].
    
  • In The Journal of Foot and Ankle Surgery Turner et al. retrospectively evaluated the outcomes of 30 patients who underwent a minimally invasive ultrasound guided plantar fasciotomy with and without PRP injections, and found that both groups had a significant decrease in pain. The patients who received PRP with the fasciotomy with Tenex showed a greater decrease in pain at the 1-month follow up with 19 month follow up. The findings suggest that the dual use of a fasciotomy with Tenex and PRP could potentially lead to a greater improvement in pain [Turner et al, 2024].
  • In the Clinical Journal of Sports Medicine 67 patients were treated with ultrasound-guided fasciotomy using the Tenex device and found that a fasciotomy with Tenex was a safe and effective treatment option for chronic plantar fasciopathy. Patients demonstrated a signficant improvement in pain at 12 and 52 weeeks after the procedure, and reported a high degree of patient satisfaction [Kruse & Volfson, 2024].
    
• Surgical Intervention

  • Surgery is indicated when the plantar fascia does not respond to any non-operative interventions.

Reference

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Other Foot/Ankle Conditions

• Achilles Tendonitis/Haglund deformity
• Ankle Sprain
• Haglund deformity
• Peroneal Nerve Entrapment
• Sever’s Disease
  
• Tendon pain (PTTD)