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Plantar fasciosis
is pain at the site of the attachment of the plantar fascia and
the calcaneus, with or without accompanying pain along the medial
band of the plantar fascia. Diagnosis is mainly clinical. Treatment
involves calf muscle and plantar soft-tissue foot–stretching exercises,
night splints, and orthotics.
Syndromes of pain in the plantar fascia have been called plantar fasciitis; however, because there is usually no inflammation, plantar fasciosis is more correct. Other terms used include calcaneal enthesopathy pain or calcaneal spur syndrome; however, there may be no bone spurs on the calcaneus. Plantar fasciosis may involve acute or chronic stretching, tearing, and degeneration of the fascia at its attachment site.
Etiology
Recognized causes include shortening or contracture of the calf muscles and plantar fascia. Risk factors for such shortening include a sedentary lifestyle, occupations requiring sitting, very high or low arches in the feet, and wearing high-heel shoes. The disorder is also common among runners and dancers and may occur in people whose occupations involve standing or walking on hard surfaces for prolonged periods. Disorders that may be associated with plantar fasciosis are obesity, RA, reactive arthritis, and psoriatic arthritis. Multiple injections of corticosteroids may contribute by causing degenerative changes of the fascia and possible loss of subcalcaneal protective fat pad cushioning.
Symptoms and Signs
Plantar fasciosis is characterized by pain at the bottom of the heel on weight bearing, particularly when first arising in the morning; pain usually improves within 5 to 10 min, only to return later in the day. It is often worse when pushing off of the heel (the propulsive phase of gait). Acute severe heel pain, especially with mild local puffiness, may indicate an acute tear. Some patients describe burning or sticking pain along the plantar medial border of the foot when walking.
Diagnosis
Other disorders causing heel pain can mimic plantar fasciosis:
Plantar fasciosis is confirmed if firm thumb pressure applied to the calcaneus when the foot is dorsiflexed elicits pain. Fascial pain along the plantar medial border of the fascia may also be present. If findings are equivocal, demonstration of a heel spur on x-ray may support the diagnosis; however, absence does not rule out the diagnosis, and visible spurs are not generally the cause of symptoms. Also, infrequently, calcaneal spurs appear ill defined on x-ray, exhibiting fluffy new bone formation, suggesting spondyloarthropathy (eg, ankylosing spondylitis, reactive arthritis). If an acute fascial tear is suspected, MRI is done.
Treatment
To alleviate the stress and pain on the fascia, the person can take shorter steps and avoid walking barefoot. Activities that involve foot impact, such as jogging, should be avoided. The most effective treatments include the use of in-shoe heel and arch cushioning with calf-stretching exercises and night splinting devices that stretch the calf and plantar fascia while the patient sleeps. Prefabricated or custom-made foot orthotics may also alleviate fascial tension and symptoms. Other treatments may include activity modifications, NSAIDs, weight loss in obese patients, cold and ice massage therapy, and occasional corticosteroid injections. However, because corticosteroid injections can predispose to plantar fasciosis, many clinicians limit these injections. For recalcitrant cases, physical medicine, oral corticosteroids, and cast immobilization should be used before surgical intervention is considered.
Last full review/revision March 2008 by Kendrick Alan Whitney, DPM
Content last modified March 2008
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