Plantar Heel Pain/Plantar Fasciopathy

• Plantar Heel Pain/ Plantar Fasciopathy

  • Plantar fascia:
  • fibrous tissue that runs from anteromedial calcaneal to heads of metatarsal
  • provides structure and support to foot
  • does this in toe off phase of gait

  
• Plantar Heel Pain/Plantar Fasciopathy - why does it become painful?

  1. overloading of the plantar fascia ->
  2. degenerative fasciosis ->
  3. pain
• Who develops plantar heel pain?

  • people who are overweight - greater loading of the plantar fascia
  • people who are on their feet a lot (or have a sudden increase in use of feet) e.g. hikers, nurses, suddenly signing up for marathon
  • affects females more than males
  • higher impact sports e.g. running and jumping
• Clinical Features - Subjective Assessment:

  • sharp pain
  • unilateral
  • area of pain plantar-medial heel
  • insidious onset
  • worse on first few steps following rest
  • prolonged walking on hard surfaces

  
• Clinical Features - Objective Assessment:

  • point tenderness medial process calcaneal tuberosity
  • tenderness on palpation of medial border of plantar fascia
  • stretching plantar fascia may aggravate pain
  • decrease in calf length
  • decrease in extension range of 1st metatarsalphalangeal joint / Windlass mechanism

  
• Differential Diagnoses:

  • Calcaneum fat pad inflammation - most common - usually caused by a one off situation, usually high impact, sudden increase in activity, fat pad thins as we age evidence suggests
  • Nerve entrapment - more shooting pain
  • Calcaneal stress fracture - people with lower bone density, sudden increase in activity/high activity, tenderness when squeezing calcaneum
  • ??Relevance of calcaneal spur
• Neural Involvement/Nerve entrapment - possible causes of plantar fasciopathy pain replication:

  • Peripheral nerves:
  • Tibial nerve - tarsal tunnel
  • Sural nerve - lateral side of achilles - injured post surgery (entrapment in scar tissue)
  • Radiculopathy:
  • S1 nerve root irritation

  
• Management:

  • Self-limiting
  • 90% full resolution in 12 months
  • 10% report persisting symptoms, not responsive to conservative management:
  • ECSWT (Nice guideline,2009), surgery, steroid injection
  • Is there another cause for the patients pain? - reassess diagnosis
  • Several conservative management options with moderate levels of evidence of symptom control and building capacity
• Conservative Management to control symptoms:

  • self massage of plantar surface of foot
  • gel heel cups - takes pressure off
  • taping - takes load off
  • plantar fascia sock - keeps foot in dorsiflexion during sleep
  • stretching of calf muscles complex
  • maybe look at other factors e.g. calf, knee or hip muscles