Skip to content

Plantar Fasciitis

BASICS

  • Definition: Degenerative change of the plantar fascia at the medial tuberosity of the calcaneus, causing plantar heel pain.
  • Synonyms: Plantar fasciopathy, plantar heel pain syndrome, plantar fasciosis, painful heel syndrome.

EPIDEMIOLOGY

  • Incidence: ~1 million U.S. visits/year.
  • Prevalence: Most common cause of plantar heel pain; lifetime risk 10–15%.
  • Peak incidence: Ages 40–60; earlier in runners.

ETIOLOGY & PATHOPHYSIOLOGY

  • Anatomy: Plantar fascia (medial, lateral, central bands) supports the longitudinal arch and absorbs force.
  • Pathology: Chronic degenerative changes (fasciosis, not -itis) at the insertion on the medial calcaneal tubercle.
  • Mechanism: Repetitive microtrauma and collagen degeneration.

RISK FACTORS

  • Intrinsic: Age (40–60), female, pregnancy, obesity (BMI >30), pes planus/cavus, overpronation, leg length discrepancy, tight hamstrings/calf/Achilles, calf/intrinsic foot muscle weakness, decreased ankle dorsiflexion, connective tissue disorders.
  • Extrinsic: Runners, dancers, court sports, prolonged standing on hard surfaces (nurses, factory workers), overuse, rapid increase in activity.

GENERAL PREVENTION

  • Maintain normal body weight.
  • Avoid rapid escalation of high-impact activities.
  • Use proper footwear with cushion and arch support.
  • Runners: replace shoes every 250–500 miles.

COMMONLY ASSOCIATED CONDITIONS

  • Heel spurs (not a marker of severity)
  • Posterior tibial neuropathy

DIAGNOSIS

History

  • Plantar heel pain, worst at medial calcaneal insertion, especially with first steps after rest ("post-static dyskinesia")
  • Pain improves after walking but may recur later in the day
  • Often unilateral; bilateral in ~⅓
  • Chronic cases: dull, constant pain; possible limp, toe walking
  • Numbness/burning → suspect nerve compression

Physical Exam

  • Point tenderness at medial tubercle of calcaneus
  • Pain with dorsiflexion of foot (Windlass test positive)
  • Decreased ankle dorsiflexion
  • Loss of heel fat pad → suspect fat pad syndrome
  • Point tenderness at posterosuperior heel → Achilles tendinopathy

Differential Diagnosis

  • Calcaneal stress fracture
  • Heel fat pad syndrome
  • Longitudinal arch strain
  • Nerve entrapment (tarsal tunnel syndrome, medial calcaneal branch)
  • Achilles tendinopathy
  • Calcaneal contusion, plantar bursitis
  • Plantar fascia tear, S1 radiculopathy
  • Adolescents: Sever disease (calcaneal apophysitis)

Diagnostic Tests

  • Usually not needed: Clinical diagnosis
  • Imaging if persistent pain (>4–6 months) or to rule out other causes
  • X-rays: Heel spur (common, not diagnostic)
  • US: Thickened, hypoechoic fascia (≥4 mm)
  • MRI: Soft tissue evaluation
  • NCS: Rule out nerve entrapment

TREATMENT

General Measures

  • Weight reduction if BMI >25
  • Intrinsic foot muscle and calf strengthening, stretching (plantar fascia stretches more effective than Achilles)
  • Activity modification; avoid aggravating activities
  • Ice (frozen water bottle roll), massage (golf/tennis ball), supportive footwear, OTC orthoses, heel cup/pad/night splint
  • Custom orthoses not superior to OTC; night splints work better with orthoses

Medication

  • NSAIDs for 2–3 weeks (naproxen, ibuprofen)
  • Acetaminophen as alternative

Additional Therapies

  • Physical Therapy: Stretching, strengthening, manual mobilization
  • Corticosteroid Injection: Short-term pain relief; risk of rupture/fat pad atrophy
  • PRP Injection: May improve pain/function; possibly superior long term
  • Extracorporeal Shock Wave Therapy (ESWT): Pain/function improvement, especially high-energy/high-session regimens
  • Dextrose Prolotherapy, RTL, taping, walking cast: Consider in refractory cases

Surgery

  • Indicated if failure of conservative therapy after 6–12 months
  • <10% require surgery; more often in severe obesity
  • Options: Open/endoscopic plantar fasciotomy (less risk with endoscopic, but less widely available)

Complementary Medicine

  • Acupuncture (short-term benefit; insufficient evidence long term)

ONGOING CARE

  • Emphasize proper technique, footwear, and stretching.
  • Reassess after 3–6 months of conservative treatment.
  • Consider PT/podiatry/surgical referral if not improved.

PATIENT EDUCATION

  • Weight loss if overweight
  • Home stretching and foot muscle strengthening
  • Proper footwear with arch support and cushioning
  • Ice after activity
  • Avoid prolonged standing, repetitive stress

PROGNOSIS

  • Self-limited: Resolves in 80–90% within 12 months
  • Complications: Chronic pain, plantar fascia rupture (more common with repeated steroid injections), gait abnormality

ICD-10

  • M72.2 Plantar fascial fibromatosis

CLINICAL PEARLS

  • Degeneration of plantar fascia at medial calcaneal tuberosity is the key pathology.
  • Morning pain with first steps is hallmark.
  • Most cases resolve with stretching, strengthening, activity modification, OTC orthoses, and weight loss.
  • Surgery rarely required.