Plantar fasciitis

• Plantar fasciitis:

  • Inflammation of plantar fascia
  • Plantar fascia = thick connective tissue attaching to calcaneus, travels along sole of foot and branches out connecting to flexor tendons of toes
  • Common condition
  • Exact cause unknown, likely multifactorial
• Risk factors:

  • Age (most common 40-60 years)
  • Pes planus (flat feet) or high arches (pes cavus)
  • Overweight
  • Running
  • Prolonged standing or walking
  • Poor fitting shoes
  • Improper gait
  • Tight muscles in calf or feet
• in a patient with suspicious enthesitis e.g. no mechanical cause, in multiple sites (plantar fascia, Achilles tendon, patellar and quadriceps tendon etc), think about spondylarthritis
• Symptoms:

  • Initial insidious onset of heel pain
  • Intense heel pain during first steps after walking or after a period of inactivity - with relief upon initiation of movement
  • Pain that reduces with moderate activity but worsens later during the day or after long periods of standing or walking
• Examination:

  • Tenderness on palpation of the plantar heel area
  • Positive windlass test - pain reproduced by extending first MTP joint
  • Limited ankle dorsiflexion range with knee in extension (straight)
  • Antalgic gait
• Initial management:

  • Ice packs and rest
  • Wear shoes with good arch support and cushioned heels - consider insoles that correct pronation and avoid walking barefoot
  • Weight loss if appropriate
  • Exercises to stretch plantar fascia e.g. stair stretches, wall push up stretches)
  • Analgesia - NSAIDs, paracetamol (with or without short term codeine)
  • A
• If significant symptoms:

  • Consider corticosteroid injection but be aware very painful, symptoms commonly return within a month, rarely can cause atrophy or plantar fascia rupture
  • Ideally refer for ultrasound guided injection
• If initial management unsuccessful after a few months:

  • Consider referral to podiatrist or physiotherapist
• If symptoms persist despite conservative treatment:

  • Consider referral to surgeons
  • Extracorporeal shockwave therapy - increases circulation and aids recovery
  • Surgical division of plantar fascia
• Prognosis:

  • Good long term prognosis
  • Most people achieve complete resolution within a year