Plantar Fasciopathy

Patients typically complain of an insidious onset of plantar heel pain. They have first-step heel pain that is often severe first thing in the morning or after periods of inactivity. Symptoms often improve through the day with activity but as the disease progresses, pain becomes more consistent, interfering with activities of daily living, making even short periods of ambulation difficult.Source: Plantar Fasciitis – StatPearls – NCBI Bookshelf (opens in a new tab)

Clinically, these patients often have localised pain over the medial calcaneal tuberosity. Passive dorsiflexion of the 1st MTP and foot will mechanically stretch the plantar fascia and will often reproduce symptoms in the heel, referred to as the windlass test.Source: Plantar Fasciitis and the Windlass Mechanism: A Biomechanical Link to Clinical Practice – PMC (opens in a new tab)

The diagnosis will be made from a combination of your clinical history, examination findings and, commonly, an ultrasound scan. The patients will have the signs and symptoms as discussed previously.

The diagnosis of plantar fasciopathy can often be made on clinical grounds alone. However, ultrasound provides a quick and accurate assessment of the plantar fascia as well as helps guide intervention options. It will allow confirmation of the diagnosis as well as help exclude other potential causes, including fibromas, plantar fascia tears and assessment of the heel fat pad.Source: Diagnostic Musculoskeletal Ultrasound in the Evaluation of the Plantar Fascia – PMC (opens in a new tab)

X-rays may be arranged to exclude other potential bony pathologies if there are atypical features. Plantar heel spurs are a common finding in both patients with and without heel pain. As such, they are not directly considered a cause of symptoms but a by-product of chronic traction/stress at the enthesis attachment resulting in the bony remodelling (enthesopathy). MRI is usually reserved for atypical cases or if initial imaging is unclear/negative; it is sensitive at assessing for pathology in the plantar fascia, stress reactions in the calcaneus that may have been missed on plain film X-ray and entrapment neuropathies.Sources: The plantar calcaneal spur: a review of anatomy, histology, etiology and key associations – PubMed (opens in a new tab); Plantar Heel Pain – StatPearls – NCBI Bookshelf (opens in a new tab); Stress fractures of the foot and ankle – PubMed (opens in a new tab)

Treatment options are divided into conservative and surgical.

Conservative options

• Activity modification/change in footwear: sometimes these simple measures will allow things to settle. Flip-flops, slippers or barefoot walking should be avoided where possible to reduce the mechanical compression through the plantar fascia. Shoes with a thick insole will provide more cushioning and better transfer of weight through the heel on ambulation.
• Physiotherapy +/- orthotic use. These are non-invasive treatment options that have been shown to reduce pain and improve function. Physiotherapy involves strengthening of the intrinsic foot musculature and lengthening exercises of the triceps surae complex. Customised orthotics can be helpful at reducing the symptoms over a 12-week period. They reduce the mechanical stress through the plantar fascia by allowing better transfer of weight across the calcaneus.Sources: Physiotherapeutic Interventions for Individuals Suffering From Plantar Fasciitis: A Systematic Review – PubMed (opens in a new tab); Custom foot orthoses improve first-step pain in individuals with unilateral plantar fasciopathy: a pragmatic randomised controlled trial – PubMed (opens in a new tab)
• Shockwave therapy. This can be a helpful non-invasive adjunct for the treatment of plantar fasciopathy.Source: Efficacy and tolerability of extracorporeal shock wave therapy in patients with plantar fasciopathy: a systematic review with meta-analysis and meta-regression – PubMed (opens in a new tab)
• In refractory cases a local anaesthetic and steroid injection can be helpful in the short to medium term, allowing better compliance with rehab for longer-term benefit. There are small complication risks, including plantar fascia rupture and fat pad atrophy.Source: Corticosteroid injection is the best treatment in plantar fasciitis if combined with controlled training – PubMed (opens in a new tab)
• PRP injections have been shown to have a better long-term outcome than steroid. However, its efficacy is still not fully understood and challenged with no standardised practice on platelet dose. Further considerations include a delayed therapeutic effect, which can cause a temporary increase in pain and may require additional injections.Source: The role of corticosteroid injections in treating plantar fasciitis: A systematic review and meta-analysis – PubMed (opens in a new tab)

Surgical intervention

For the majority of cases conservative options will allow things to settle. A small percentage of patients will have refractory symptoms, and surgical intervention may be discussed.

There are both open and endoscopic techniques. The procedure typically involves debridement of the diseased/thickened plantar fascia (fasciotomy) +/- resection of any heel spurs at the attachment/enthesis site. Success rates are generally good (70-80%), but residual symptoms in patients are still not uncommon.Sources: Surgical treatment options for plantar fasciitis and their effectiveness: a systematic review and network meta-analysis – PubMed (opens in a new tab); Plantar Fasciitis – StatPearls – NCBI Bookshelf (opens in a new tab)