| Plantar fasciitis | |
|---|---|
| Classification and external resources | |
| ICD-10 | M72.2 |
| ICD-9 | 728.71 |
| DiseasesDB | 10114 |
| MedlinePlus | 007021 |
| eMedicine | pmr/107 |
Plantar fasciitis is a painful inflammatory process of the plantar fascia, the connective tissue on the sole (bottom surface) of the foot.
Longstanding cases of plantar fasciitis often demonstrate more degenerative changes than inflammatory changes, in which case they are termed plantar fasciosis.[1] The suffix "osis" implies a pathology of chronic degeneration without inflammation. Since tendons and ligaments do not contain blood vessels, they do not actually become inflamed. Instead, injury to the tendon is usually the result of an accumulation over time of microscopic tears at the cellular level.
The plantar fascia is a thick fibrous band of connective tissue originating on the bottom surface of the calcaneus (heel bone) and extending along the sole of the foot towards the toes. It has been reported that plantar fasciitis occurs in two million Americans a year and in 10% of the U.S. population over a lifetime.[2] It is commonly associated with long periods of weight bearing. Among non-athletic populations, it is associated with a high body mass index.[3] The pain is usually felt on the underside of the heel and is often most intense with the first steps of the day. Another symptom is that the sufferer has difficulty bending the foot so that the toes are brought toward the shin (decreased dorsiflexion of the ankle). A symptom commonly recognized among sufferers of plantar fasciitis is an increased probability of knee pains, especially among runners.
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The diagnosis of plantar fasciitis is usually made by clinical examination alone.[4][5] The clinical examination may include checking the patient’s feet and watching the patient stand and walk. The clinical examination will take under consideration a patient's medical history, physical activity, foot pain symptoms and more. The doctor may decide to use imaging studies like radiographs (X-rays), diagnostic ultrasound and MRI.
An incidental finding associated with this condition is a heel spur, a small bony calcification on the calcaneus heel bone, in which case it is the underlying plantar fasciitis that produces the pain, and not the spur itself. The condition is responsible for the creation of the spur, the plantar fasciitis is not caused by the spur.
Sometimes ball-of-foot pain is mistakenly assumed to be derived from plantar fasciitis. A dull pain or numbness in the metatarsal region of the foot could instead be metatarsalgia, also called capsulitis. Some current studies suggest that plantar fasciitis is not actually inflamed plantar fascia, but merely an inflamed flexor digitorum brevis muscle belly. Ultrasound evidence illustrates fluid within the FDB muscle belly, not the plantar fascia.
Treatment options for plantar fasciitis include rest, massage therapy, stretching,[6] weight loss, night splints, motion control running shoes, physical therapy, cold therapy, heat therapy, orthotics, anti-inflammatory medications, injection of corticosteroids and surgery in refractory cases. Also, in some cases, massaging of the inflamed location serves as a temporary relief.
Orthotics, i.e., foot supports, are the only non-surgical therapy to have been supported by studies rated by the Center for Evidence-Based Medicine as being of high quality.[3] In a single-blind experiment in which patients were randomly assigned to receive off-the-shelf orthotics, personally customized orthotics, or sham orthotics made of a soft, thin foam, patients receiving real orthotics showed statistically significant short-term improvements in functionality compared to those receiving the sham treatment. There was no statistically significant reduction in pain, and there was no long-term effect when the patients were re-evaluated after 12 months. Off-the-shelf orthotics were found to be as effective as customized ones for acute (short term) plantar fasciitis.[7] There is some evidence that taping may supply short-term relief, but the evidence is weaker than the evidence supporting orthotics.[3]
Some evidence shows that stretching of the calf and plantar fascia may provide up to 2–4 months of benefit.[3] One study has shown improvement over a four-month period with stretching.[8] In cases of chronic plantar fasciitis, ultrasound therapy with 3 MHz for 10-15minutes/day may be beneficial. One study has shown high success rates with a stretch of the plantar fascia,[9] but has been criticized[3] because it was not blinded, and contained a bias because the analysis did not use the intention to treat method. Because it is impractical to do double-blind experiments involving stretching, such studies are vulnerable to placebo effects. The Center for Evidence-Based Medicine has not rated any study of stretching as being of high quality.[3]
Pain with the first steps of the day can be markedly reduced by stretching the plantar fascia and Achilles tendon before getting out of bed. Night splints can be used to keep the foot in a dorsi-flexed position during sleep to improve calf muscle flexibility and decrease pain on waking. These have many different designs. The type of splint has not been shown to affect outcomes.
To relieve pain and inflammation, nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen are often used but are of limited benefit.[10] Dexamethasone 0.4 % or acetic acid 5% delivered by iontophoresis combined with low Dye strapping and calf stretching has been shown to provide short term pain relief and increased function.[11][12][13]
Local injection of corticosteroids often gives temporary or permanent relief, but may be painful, especially if not combined with a local anesthetic and injected slowly with a small-diameter needle.[14] Recurrence rates may be lower if injection is performed under ultrasound guidance.[15] Repeated steroid injections may result in rupture of the plantar fascia. While this may actually improve pain initially, it has deleterious long-term consequences.
Surgery carries the risk of nerve injury, infection, rupture of the plantar fascia, and failure to improve the pain.[16] Traditional surgical procedures, such as plantar fascia release, are a last resort, and often lead to further complications such as a lowering of the arch and pain in the supero-lateral side of the foot due to compression of the cuboid bone. This will allow decompression of the nearby FDB muscle belly that is inflamed, yet does not fix the underlying problem. This basically allows more space for the inflamed muscle belly, thus, relieving pain/pressure.[17] An ultrasound-guided needle fasciotomy can be used as a minimally invasive surgical intervention for plantar fasciitis. A needle is inserted into the plantar fascia and moved back and forwards to disrupt the fibrous tissue.[18]
Coblation surgery (aka Topaz procedure) has been used successfully in the treatment of recalcitrant plantar fasciitis. This procedure utilizes radiofrequency ablation and is a minimally invasive procedure.[19]
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