Plantar Fasciosis

(Plantar Fasciitis)

Plantar fasciosis is pain at the attachment of the plantar fascia to the calcaneus, with or without pain along the medial border of the plantar fascia. Diagnosis is mainly by history and physical examination. Treatment involves exercises to stretch the calf muscle and plantar soft tissue in the foot, night splints, and orthoses.

Because pain syndromes of the plantar fascia usually do not include inflammation, they are more correctly called plantar fasciosis than plantar fasciitis. They may also be called calcaneal enthesopathy pain or calcaneal spur syndrome; however, there may be no bone spurs on the calcaneus. The usual cause is shortening or contracture of the calf muscles and plantar fascia. Having a sedentary lifestyle with prolonged sitting or wearing high-heeled shoes increases risk of such shortening. Acute or chronic stretching, tearing, and degeneration of the fascia at its attachment site also increase risk of plantar fasciosis. Multiple injections of corticosteroids may contribute to fascial abnormalities.

Symptoms and Signs

Pain at the bottom of the heel occurs with walking, particularly when first arising in the morning, and usually lessens within 5 to 10 min, only to return later in the day. Some patients have burning or sticking pain along the plantar medial border of the foot.

Diagnosis

Diagnosis is confirmed if firm thumb pressure applied to the calcaneus when the foot is dorsiflexed elicits pain. Tenderness along the plantar medial border of the fascia also supports the diagnosis.

Other disorders causing heel pain can mimic plantar fasciosis. Tarsal tunnel syndrome may also cause pain and tenderness in the heel but can be distinguished if tapping or palpating along the course of the posterior tibial nerve below the medial malleolus causes tingling distally. Throbbing heel pain, particularly when shoes are removed or when mild heat and puffiness are present, suggests inferior calcaneal bursitis (see Table 56-2). Acute severe heel pain with redness and heat may indicate gout. Pain that radiates from the low back to the heel may indicate an S1 radiculopathy caused by an L5 disk herniation.

If findings are equivocal, a heel spur seen on x-ray may support the diagnosis; however, absence does not rule out the diagnosis, and visible spurs may not be the cause of symptoms.

Treatment

Immediate relief can be provided by a 1.25-cm soft, flexible heel support or injection of a local anesthetic without a corticosteroid. Calf-stretching exercises and night splinting that stretches the calf and plantar fascia (with a Royce night splint) are the most effective long-term treatments.

Patients can stretch their calves by placing their hands against a wall and standing with the affected leg behind the other leg and with both heels firmly on the floor; patients then slowly bend both knees without allowing the heels to rise from the floor. Patients can also stretch their calves by standing the same way and leaning forward slowly while bending the unaffected leg (in front) but keeping the affected leg straight. In both types of calf-stretching exercises, the stretch position is held for 15 sec, and the exercise is repeated 7 or 8 times.

The night splint consists of a foam-lined plastic shell that covers the back of the calf and the bottom of the foot and is held in place by adjustable straps. The splint keeps the foot in a neutral position during sleep. However, patient adherence is usually poor. OTC or custom-made foot orthoses may also help.

This topic was last updated May 2006.