Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Heel Pain (Plantar Fasciitis)

Basics
Description
  • Plantar fasciitis is the most common cause of plantar heel pain.
  • Other causes include:
    • Compression of the 1st branch of the LPN
    • Fat pad atrophy of the heel
    • Pain and enthesopathy associated with seronegative spondyloarthropathies
    • Tarsal tunnel syndrome
    • Calcaneal stress fracture
Geriatric Considerations
Plantar heel pain in geriatric patients often is secondary to atrophy of the heel pad or degenerative changes of the plantar fascia origin.
  
Pediatric Considerations
  • Heel pain in pediatric patients usually is secondary to apophysitis of the calcaneus (Sever disease), a self-limited condition related to tension of the insertion area of the Achilles tendon.
  • It usually responds to rest, NSAIDs, restriction from running or sports, and short-term immobilization with a cast.
  • It virtually always resolves once skeletal maturity is achieved, resulting in fusion of the calcaneal apophysis.
Pregnancy Considerations
  • Heel pain often is secondary to plantar fasciitis or enthesopathy from hormonal changes or mechanical stress secondary to weight gain during pregnancy.
  • It also can occur from nerve compression of the tarsal tunnel or 1st branch of the LPN because of increased fluid retention.
  • It often improves once pregnancy ends.
General Prevention
The condition is not always preventable, but it may be limited by avoiding excessive weight gain, prolonged standing, and sudden increases in running or jumping stresses.
 
Epidemiology
Incidence
  • Extremely common in adults
  • Most common in the 3rd to 5th decades
Risk Factors
  • Decreased ankle dorsiflexion/tight heel cord
  • Obesity/body mass index >30
  • Prolonged standing
  • Running
  • Jumping sports
  • Lupus or inflammatory spondyloarthropathy
  • Diabetes
  • Thyroid dysfunction
Etiology
  • The term fasciitis represents a misnomer; fasciitis is a degenerative condition without histologic evidence of chronic inflammation
  • May have repetitive contracture and adhesions of the plantar fascia, with painful microscopic tearing with daily activity
Associated Conditions
  • Flatfoot
  • Achilles contracture or tight heel cord
  • Inflammatory arthropathies
  • Obesity
  • Cavus foot that results in contracture of plantar fascia and plantar soft tissues
Diagnosis
Signs and Symptoms
History
  • Plantar fasciitis commonly is diagnosed with the history and physical examination.
  • Patients commonly complain of heel pain that is worse in the morning with the 1st step or after prolonged sitting.
  • Symptoms may ease as the person walks and loosens up.
  • Symptoms may worsen as the day progresses.
  • Pain is described as sore, aching, burning, or stabbing.
Physical Exam
  • Assess alignment for planus or cavus foot deformity.
  • Assess ankle dorsiflexion with the knee flexed and extended to rule out contracture of Achilles tendon or gastrocnemius.
  • Palpate to localize tenderness to the plantar-medial heel at the origin of the plantar fascia.
  • Tenderness may worsen with the toes passively dorsiflexed by the examiner, a maneuver that stretches the plantar fascia.
  • Palpate and percuss (Tinel sign) over the tarsal tunnel and 1st branch of the LPN deep to the abductor hallucis muscle to identify nerve compression.
  • Pain central and directly plantar under the calcaneal tuberosity, along with thinning of the heel pad, may indicate fat pad atrophy.
  • Medial-lateral compression may be suggestive of calcaneal stress fracture.
Tests
Lab
  • Chronic cases may necessitate lab tests, including rheumatoid factor, antinuclear antibody screen, thyroid function, blood glucose and hemoglobin A1C levels.
  • HLA-B27 determination may be obtained if spondyloarthropathy is suspected.
Imaging
  • Radiography:
    • Standing radiographs of the foot should be obtained for patients with persistent pain.
    • The presence of a heel spur at the calcaneal tuberosity is not diagnostic; the spur is located within the flexor hallucis brevis muscle rather than the plantar fascia.
    • In addition, the literature reports a high incidence of spur in asymptomatic patients.
  • Bone scans may show increased uptake at the origin of the plantar fascia; more diffuse uptake may indicate calcaneal stress fracture.
  • MRI:
    • May show thickening and degenerative changes of the plantar fascia origin, along with bony edema adjacent to it.
    • In calcaneal stress fracture, MRI shows more extensive bony edema.
Pathological Findings
  • Chronic degeneration is noted at the plantar fascia origin.
  • Usually no evidence of inflammation is present.
Differential Diagnosis
  • Calcaneal apophysitis (Sever disease) in children
  • Calcaneal stress fracture
  • Central heel pad atrophy
  • Tarsal tunnel syndrome or entrapment of the 1st branch of LPN
  • Inflammatory enthesopathy
  • Spinal radiculopathy
Treatment
General Measures
  • Nonoperative treatment is the cornerstone for this problem, and surgery rarely is indicated.
  • Stretching exercises of the heel cord should be performed multiple times daily and before and after sports.
  • NSAIDs
  • Off-the-shelf gel heel pad or wedge may improve cushioning of the heel.
  • A dorsiflexion night splint has been shown to alleviate symptoms in chronic cases.
  • An orthotic arch support may be indicated if the patient has pes planus.
  • Deep tissue massage and ice application may help symptoms.
  • Immobilization in a walking cast or fracture boot may rest the plantar fascia.
  • Injections into the plantar fascia origin can be administered if the pain does not respond to other measures.
    • The patient should be immobilized for 1-2 weeks in a boot or cast to prevent rupture after injection.
  • After successful treatment, the patient may be allowed to resume activities gradually, taking care not to resume running or jumping sports too quickly or too strenuously.
  • Extracorporeal shock-wave treatment shows promise in the treatment of recalcitrant plantar fasciitis
    • Success rates of ~80%, with low complications
    • May prove to be an alternative or last resort before surgical treatment
  • A calcaneal stress fracture or apophysitis (Sever disease) usually responds to rest, restriction from sports, NSAIDs, and short-term immobilization for severe symptoms.
  • Heel pad atrophy is treated with a comfortable shoe with absorptive heel cushioning or off-the-shelf gel cushion.
Special Therapy
Physical Therapy
Physical therapy may be helpful in teaching patients to stretch and in supervising their return to physical activity.
 
Medication
NSAIDs are useful for patients with severe pain.
 
Surgery
  • Indicated only after nonoperative methods have failed for at least 6-9 months
  • Consists of partial release of plantar fascia origin
    • Some authors recommend removal of a bone spur, although most believe doing so is not necessary in most cases.
  • For resistant tarsal tunnel syndrome or entrapment of the 1st branch of the LPN, decompression of the nerve is indicated at the time of partial plantar fascia release.
  • Contraindicated in patients with Sever disease.
Follow-up
Prognosis
>90% of cases respond to nonoperative treatments, with generally good prognosis for return to activities.
 
Complications
Rupture of the plantar fascia after a steroid injection or excessive (total) surgical release can result in arch collapse and painful mechanical overload of the lateral midfoot.
 
Miscellaneous
Codes
ICD9-CM
  • 355.5 Tarsal tunnel syndrome
  • 355.8 First branch lateral plantar nerve entrapment
  • 726.73 Heel pain
  • 728.71 Plantar fasciitis
  • 732.5 Sever’s disease/apophysitis
  • 733.95 Calcaneal stress fracture
Patient Teaching
  • Instruct the patient about the anatomy of the plantar fascia and its role in stabilizing the foot.
  • Review the pathophysiology and degenerative nature of this condition, with its tendency for recurrent episodes.
  • Remind the patient about the importance of stretching and of moderation during a return to sports.
  • Reassure patients that, in most cases, this condition is self-limited.
FAQ
Q: What is the most common cause of heel pain in children?
A: Sever disease, or apophysitis of the calcaneus at the insertion of the Achilles tendon. This self-limited condition resolves once the apophysis fuses to the remainder of the calcaneus at skeletal maturity.
 
Q: What is the pathophysiology of plantar fasciitis?
A: This condition is degenerative rather than inflammatory. Microscopic tears and adhesions of the plantar fascia result in pain with weightbearing activity.
 
Q: When is surgery indicated for plantar fasciitis?
A: Only after a trial of nonsurgical methods for 6-9 months has failed.

2 comments to Heel Pain (Plantar Fasciitis)

  • Dr. Roth

    Thanks for the article – I am a foot doctor, and plantar fasciitis can be a very painful condition, but not enough people are educated about it. Thanks again!

  • Amin karim

    I have a daughter- 21 yrs old – who through surgery to remove part of heel bone due to osteomyletis- can you transplant ne bone and repair heel pad?

    Thanks
    Amin