Plantar Fasciitis

The plantar fascia is a thick, fibrous band of connective tissue. Its origin is the medial plantar tubercle of the calcaneum. It runs along the sole of the foot like a fan, being attached at its other end to the base of each of the toes. It is a tough, resilient structure that has a number of critical functions during running and walking:

• It stabilises the metatarsal joints during impact with the ground.
• It acts as a shock absorber for the entire leg.
• It forms the longitudinal arch of the foot and helps to lift the arch to prepare it for the 'take-off' phase of the gait cycle.

• The plantar fascia is a sturdy structure but the degree of stress that it takes makes it susceptible to injury. A force equal to almost 3 times body weight passes through the foot with each step. On running, this typically happens about 90 times a minute.
• Plantar fasciitis is thought to be a traction and overuse injury. Damage to the plantar fascia is usually in the form of micro-tears. It is a degenerative rather than an inflammatory process.¹
• Damage tends to occur near the heel, where stress on the fibres is greatest, and where the fascia is the thinnest. The fascia broadens as it extends toward the toes.
• Plantar fasciitis is often associated with calcaneal spurs. These are depositions of calcium where the fascia suffers most damage. Spurs are most commonly on the medial side at the origin of the fascia from the calcaneum. Spurs are the result of the process of plantar fasciitis and not the cause of the pain.
• It can present bilaterally.¹

• Plantar fasciitis is a common problem.
• There is no sex predilection.
• About 5 to 10% of running injuries are plantar fasciitis.

Risk factors

• Participants in sports that involve some degree of running and jumping, e.g. basketball, tennis, step-aerobics, dancing.
• Non-athletic people who spend much of each day on their feet.
• It may appear in someone who suddenly becomes more active after a period of relative inactivity.
• Running on hard ground increases the risk, as does an increase in hill training.
• Worn out trainers increase risk as they lose their shock absorption properties.
• Obesity increases risk. There is increased stress placed through the fascia.
• Other mechanical risk factors include flat feet (pes planus) and having a high arch (pes cavus).²
• Pregnancy is associated with a temporary and physiological gain in weight. Hormones also cause relaxation of ligaments, predisposing to flat feet.
• There may be an association with human leucocyte antigen (HLA) B27 associated spondyloarthropathies.³

• The principle complaint is heel/plantar pain. Most often this is 1 or 2 cm distal to the medial calcaneal tuberosity.
• Ask about the onset of the symptoms and any precipitating, aggravating or relieving factors. What brings it on? What makes it worse?
  • It is often at its most severe during the first few steps after prolonged inactivity, such as sleeping or sitting.
  • Sitting with the foot elevated usually relieves the pain.
  • For those who are on their feet all day, pain is worst at the end of the day.
  • Walking barefoot, on toes, or up stairs can precipitate pain.
• Ask about running or jogging and other sports.
• Ask about footwear and when it was last replaced.
• Ask about previous trauma to the foot.

• Look at the foot. Note any obvious deformities, skin changes, or congenital conditions. Look for pes planus or pes cavus.
• There is often tightness of the Achilles tendon and ankle dorsiflexion may be limited.¹
• Palpate the plantar surface over the medial calcaneal tuberosity and along the course of the plantar fascia, pressing quite hard. The reproduction of the pain is the most important physical sign to confirm the diagnosis.
• Pain may be reproduced by asking the patient to stand on their toes or by passive dorsiflexion of the toes.¹
• Palpate the back of the heel and ankle to exclude Achilles tendonitis.
• Subcalcaneal bursitis produces a tender swelling underneath the calcaneum. It is not aggravated by dorsiflexing the toes. There is usually little or no swelling in plantar fasciitis.³
• Referred pain from an S1/2 lesion should be excluded. Perform the straight leg raising test as for examination of the back. Check the ankle tendon reflex (S1) and calf strength. This is easily performed by asking the patient to walk on toes or stand on one leg and raise the heel off the floor. These tests should be normal.
• Exclude tarsal tunnel syndrome: the posterior tibial nerve passes under the flexor retinaculum which runs between the medial malleolus and the calcaneum. Percuss over the nerve below and posterior to the medial malleolus. This can reproduce pain, numbness and burning on the medial side of the foot, ankle or calf if there is tarsal tunnel syndrome. There is no pain in plantar fasciitis.³
• Press together the heads of the 2nd and 3rd metatarsals and then the 3rd and 4th. Reproduction of the pain suggests Morton's neuroma, with entrapment of the common digital nerve between the metatarsal heads.
• A stress fracture of the calcaneum will cause tenderness over the calcaneum rather than anterior to it.

• Achilles tendonitis
• Subcalcaneal bursitis
• S1 radiculopathy or referred pain
• Tarsal tunnel syndrome
• Morton's neuroma
• Sever's disease (children and adolescents)
• Stress fracture of calcaneum

Very rarely:³

• Fibrosarcoma
• Metastases
• Foreign body
• Paget's disease of bone
• Osteomyelitis
• Tuberculosis
• Gout

• Blood tests are not helpful.
• Weighing and measuring the patient may reinforce that the BMI needs attention if obesity is a contributory factor.
• X-ray: should not be performed as a matter of routine but may be indicated if you suspect another diagnosis. A lateral view may show soft tissue calcifications or a calcified spur on the anterior aspect of the calcaneus. X-ray may also help to exclude stress fracture, although stress fractures may not always be evident.
• Ultrasound: this may show a thicker heel aponeurosis in plantar fasciitis.^4,1
• Bone scans and MRI: these have also been used in diagnosis.

There is no consensus as to the best way to manage plantar fasciitis. Remember that just because evidence for a treatment is limited, it does not mean that this treatment is necessarily ineffective. Shoe inserts and stretching exercises are simple first-line treatment that can easily be initiated in primary care.

General advice

• Rest the foot as much as possible.
• Loss of weight if obese.
• Correction of pes planus if present.
• Advice to run on a softer surface.
• A laced sports shoe gives good support. Update shoes regularly.
• If the patient is an athlete, discuss training schedules. Cardiovascular fitness may be built by a shift, even temporarily, to swimming, cycling, a step machine in a gym or other low-impact exercise.
• Non-steroidal anti-inflammatory drugs and ice may be useful.

Physiotherapy and stretching exercises

• Stretching exercises are often advised for the plantar fascia, calf muscles and the Achilles tendon. Again, hard evidence for their use is lacking⁵ but benefit has been shown in some studies.⁶ The patient may be taught to do these exercises independently. An exercise schedule can be found in the patient information leaflet listed below.
• Deep massage of the sole of the foot also stretches the plantar fascia.
• A physiotherapist may also recommend ultrasound, laser treatment, or iontophoresis with dexamethasone to assist pain relief and reduce inflammation. Again, evidence for these treatments is limited.^7,8,9

Orthotics, splinting and casting

• A heel and arch support may help. However, a review showed that even though there is some evidence to support the use of foot orthoses in the prevention of lower limb overuse injuries, there is limited evidence for their use in the treatment.¹⁰ Another study showed that they had short-term but not long-term treatment benefits.¹¹ A Cochrane review suggested that there was silver level evidence for their use.¹² Various pads and shoe inserts can be bought to cushion and raise the heel and give good arch support. Inserts should be worn in both shoes, even if pain is only in one foot.
• Night splints to keep the ankle dorsiflexed and the toes extended can help to stretch the plantar fascia and may induce faster healing. However, a Cochrane review found limited evidence to support their use in people who have had pain for >6 months.¹³
• A case series showed that fibreglass walking casts with the ankle in neutral/slight dorsiflexion and the toes in extension provided some pain relief.¹⁴

Corticosteroid injection

• The evidence for steroid injection shows that it may provide some short-term benefit but the evidence for its effectiveness in the long-term is lacking.^13,15 Counsel the patient accordingly.
• The technique:
  A mixture of steroid and local anaesthetic is usually used. A volume of around 5 ml is usually injected using a 21-gauge (green hub) needle, as a smaller one may fail to penetrate the tough skin.
  • Palpate the most anterior aspect of the medial plantar calcaneal tubercle and insert the needle at this site.
  • Advance the needle until it reaches the most anterior (distal) aspect of the plantar medial calcaneal tuberosity.
  • When the proximal (anterior) edge of the heel spur has been identified, advance the needle immediately anterior to this spot.
  • Avoid injecting into the superficial layers of the subcutaneous tissue, as steroid injection can cause fat necrosis and atrophy, resulting in a loss in the shock absorption of the plantar heel.
• A posterior tibial nerve block before injection has been suggested to reduce pain of the injection.
• Ultrasound guidance has been used to facilitate accurate injection.^16,17
• Plantar fascia rupture may also be a complication of steroid injection.
• Use a maximum of 3 injections in 6 months.³

Other modalities

• Extracorporeal shockwave therapy: a meta-analysis has shown this to be a safe and effective treatment that may be preferable to steroid injection.¹⁸ However, NICE states that, although the evidence on extracorporeal shockwave therapy for refractory plantar fasciitis raises no major safety concerns, current evidence on its efficacy is inconsistent.¹⁹
• Botulinum toxin A injections: may produce some benefit in the short-term.²⁰
• Autologous blood injection: the idea is that this promotes healing of the plantar fascia by stimulating fibroblast activity and vascular growth. In one study it has been shown to reduce pain and tenderness to a similar degree as corticosteroid injection.²¹
• Radiotherapy: this has been used as a treatment in some countries.^22,23
• Surgery: this has also been used in patients with refractory symptoms. The procedure releases the plantar fascia from the bone. It may also include calcaneal spur excision.² Open or endoscopic approaches may be used. Complications include increased pain, nerve injury, fascial rupture and infection.³

• Pain may be longstanding and can last for some years.
• 80% show spontaneous response within 12 months.¹ The majority resolve within 3-6 months.³

• Regularly changing footwear used for running and walking.
• Wearing shoes with good cushioning in the heels and good arch support.
• Losing weight if overweight.
• Avoiding exercising on a hard surface.
• Regular stretching exercises for the plantar fascia and Achilles tendon.

1. Singh D, Silverberg MA, Milne L; Plantar Fasciitis. eMedicine, Oct 2008.
2. Cosca DD, Navazio F; Common problems in endurance athletes. Am Fam Physician. 2007 Jul 15;76(2):237-44. [abstract]
3. Duff R; Plantar Fasciitis and Heel Pain. Arthritis Research Campaign. February 2004.
4. Cole C, Seto C, Gazewood J; Plantar fasciitis: evidence-based review of diagnosis and therapy. Am Fam Physician. 2005 Dec 1;72(11):2237-42. [abstract]
5. Radford JA, Landorf KB, Buchbinder R, et al; Effectiveness of calf muscle stretching for the short-term treatment of plantar heel pain: a randomised trial. BMC Musculoskelet Disord. 2007 Apr 19;8:36. [abstract]
6. Digiovanni BF, Nawoczenski DA, Malay DP, et al; Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. J Bone Joint Surg Am. 2006 Aug;88(8):1775-81. [abstract]
7. Crawford F, Snaith M; How effective is therapeutic ultrasound in the treatment of heel pain? Ann Rheum Dis. 1996 Apr;55(4):265-7. [abstract]
8. Basford JR, Malanga GA, Krause DA, et al; A randomized controlled evaluation of low-intensity laser therapy: plantar fasciitis. Arch Phys Med Rehabil. 1998 Mar;79(3):249-54. [abstract]
9. Gudeman SD, Eisele SA, Heidt RS Jr, et al; Treatment of plantar fasciitis by iontophoresis of 0.4% dexamethasone. A randomized, double-blind, placebo-controlled study. Am J Sports Med. 1997 May-Jun;25(3):312-6. [abstract]
10. Collins N, Bisset L, McPoil T, et al; Foot orthoses in lower limb overuse conditions: a systematic review and meta-analysis. Foot Ankle Int. 2007 Mar;28(3):396-412.
11. Landorf KB, Keenan AM, Herbert RD; Effectiveness of foot orthoses to treat plantar fasciitis: a randomized trial. Arch Intern Med. 2006 Jun 26;166(12):1305-10. [abstract]
12. Hawke F, Burns J, Radford JA, et al; Custom-made foot orthoses for the treatment of foot pain. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006801. [abstract]
13. Crawford F, Thomson C; Interventions for treating plantar heel pain. Cochrane Database Syst Rev. 2003;(3):CD000416. [abstract]
14. Tisdel CL, Harper MC; Chronic plantar heel pain: treatment with a short leg walking cast. Foot Ankle Int. 1996 Jan;17(1):41-2. [abstract]
15. Porter MD, Shadbolt B; Intralesional corticosteroid injection versus extracorporeal shock wave therapy for plantar fasciopathy. Clin J Sport Med. 2005 May;15(3):119-24. [abstract]
16. Tsai WC, Wang CL, Tang FT, et al; Treatment of proximal plantar fasciitis with ultrasound-guided steroid injection. Arch Phys Med Rehabil. 2000 Oct;81(10):1416-21. [abstract]
17. Tsai WC, Hsu CC, Chen CP, et al; Plantar fasciitis treated with local steroid injection: comparison between sonographic and palpation guidance. J Clin Ultrasound. 2006 Jan;34(1):12-6. [abstract]
18. Ogden JA, Alvarez RG, Marlow M; Shockwave therapy for chronic proximal plantar fasciitis: a meta-analysis. Foot Ankle Int. 2002 Apr;23(4):301-8. [abstract]
19. Extracorporeal shockwave therapy for refractory plantar fasciitis, NICE Interventional Procedure Guideline (August 2009)
20. Babcock MS, Foster L, Pasquina P, et al; Treatment of pain attributed to plantar fasciitis with botulinum toxin a: a short-term, randomized, placebo-controlled, double-blind study. Am J Phys Med Rehabil. 2005 Sep;84(9):649-54. [abstract]
21. Lee TG, Ahmad TS; Intralesional autologous blood injection compared to corticosteroid injection for treatment of chronic plantar fasciitis. A prospective, randomized, controlled trial. Foot Ankle Int. 2007 Sep;28(9):984-90. [abstract]
22. Schwarz F, Christie DR, Irving M; Are single fractions of radiotherapy suitable for plantar fasciitis? Australas Radiol. 2004 Jun;48(2):162-9. [abstract]
23. Miszczyk L, Jochymek B, Wozniak G; Retrospective evaluation of radiotherapy in plantar fasciitis. Br J Radiol. 2007 Oct;80(958):829-34. Epub 2007 Sep 17. [abstract]