Plantar fasciitis or plantar heel pain is a disorder of the plantar fascia, which is the connective tissue that supports the arch of the foot. It results in pain in the heel and bottom of the foot that is usually most severe with the first steps of the day or following a period of rest. Pain is also frequently brought on by bending the foot and toes up towards the shin. The pain typically comes on gradually. It affects both feet in about one-third of cases. The cause of plantar fasciitis is not clear. Risk factors include overuse, such as from long periods of standing, an increase in exercise, and obesity. It is associated with inward rolling of the foot, a tight calf muscle and Achilles tendon, and a sedentary lifestyle. Heel spurs may play a role; they are commonly present in people who have the condition. Plantar fasciitis is a disorder of the insertion site of the ligament on the bone characterized by micro tears, collagen breakdown, and scarring. Inflammation plays either a lesser or no role. A review proposed that the disorder be renamed plantar fasciosis. Presentation of symptoms is generally the basis for diagnosis. Conditions with similar symptoms include osteoarthritis, ankylosing spondylitis, heel pad syndrome, and reactive arthritis. Ultrasound can be useful in cases where the symptoms do not imply a diagnosis. Most cases resolve with time and conservative treatment. For the first few weeks, treatment involves rest, reduced activities, pain medications, and stretching. The next level involves physiotherapy, orthotics, splinting, or steroid injections. Additional measures may include extracorporeal shockwave therapy or surgery. Between 4% and 7% of people have heel pain at any given time: about 80% are due to plantar fasciitis. Approximately 10% have the disorder at some point. It becomes more common with age. It is unclear whether one sex is more affected than the other.
Signs and symptoms When plantar fasciitis occurs, pain is typically sharp and usually unilateral (70% of cases). Bearing weight on the heel after long periods of rest worsens pain. Individuals often report that symptoms are most intense during their first steps after getting out of bed or after prolonged sitting. Symptoms typically improve with walking. Rarer symptoms include numbness, tingling, swelling, and radiating pain. Typically fevers and night sweats are not present. If the plantar fascia is overused, the fascia can rupture. Typical rapture signs and symptoms include a clicking or snapping sound, significant local swelling, and acute pain on the bottom of the foot.
Risk factors Identified risk factors for plantar fasciitis include excessive running, prolonged standing on hard surfaces, high arches, leg length inequality, and flat feet. The tendency of flat feet to excessively roll inward, or supinate, during walking or running makes them more susceptible. Obesity is seen in 70% of individuals who present with plantar fasciitis and is an independent risk factor. Plantar fasciitis is commonly a result of some biomechanical imbalance that causes increased tension along the fascia. Achilles tendon tightness and inappropriate footwear are significant risk factors.
Pathophysiology
The plantar fascia is a thick fibrous band of connective tissue that originates from the medial tubercle and anterior aspect of the heel bone. From there, the fascia extends along the sole before inserting at the base of the toes and supports the arch. Plantar fasciitis is a non-inflammatory condition. Studies reported microscopic anatomical changes indicating that plantar fasciitis is due to a non-inflammatory structural breakdown of the plantar fascia, leading to calls rename the condition. Repetitive microtrauma (small tears) appears to cause a structural breakdown of the plantar fascia. Microscopic examination shows myxomatous degeneration, connective tissue calcium deposits, and disorganized collagen fibers. Disruptions in normal mechanical movement during standing and walking (known as the Windlass mechanism) place excess strain on the calcaneal tuberosity and may contribute to symptom development. Other studies have suggested that plantar fasciitis may be a tendon injury involving the flexor digitorum brevis muscle located immediately above the plantar fascia.
Diagnosis
Plantar fasciitis is usually diagnosed by a healthcare provider based on a history, risk factors, and clinical examination. Palpation along the inner aspect of the heel bone on the sole may elicit tenderness during an examination. The foot may have limited dorsiflexion due to tightness of the calf muscles or the Achilles tendon. Dorsiflexion may elicit pain. Diagnostic imaging is not usually indicated. Occasionally, a physician may decide imaging studies (such as X-rays, diagnostic ultrasound, or MRI) are warranted to rule out other diagnoses. Other possible diagnoses include fractures, tumors, or systemic disease should pain not respond to conservative medical treatments. Bilateral heel pain or heel pain in the context of a systemic illness may indicate further diagnosis. Under these circumstances, tests such as a CBC or serological markers of inflammation, infection, or autoimmune disease such as C-reactive protein, erythrocyte sedimentation rate, anti-nuclear antibodies, rheumatoid factor, HLA-B27, uric acid, or Lyme disease antibodies may be conducted. Neurological deficits may prompt an investigation with electromyography to check for nerve or muscle damage. An incidental finding associated with this condition is a heel spur, a small bony calcification on the calcaneus (heel bone), which can be found in up to 50% of patients. In such cases, the plantar fasciitis produces the heel pain, rather than the spur. The condition creates the spur, though the clinical significance of heel spurs remains unclear.
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