What is plantar fasciitis?

Plantar Fasciitis: Definition and Management

Plantar fasciitis is an inflammatory condition of the plantar fascia characterized by pain at the medial plantar calcaneal region that is typically most severe with the first few steps in the morning or after prolonged sitting. 1

Pathophysiology and Clinical Features

Plantar fasciitis affects the thick band of tissue (plantar fascia) that connects the heel bone to the toes and creates the arch of the foot. The condition involves:

• Inflammation and microtears in the plantar fascia, particularly at its insertion on the calcaneus
• Pain localized to the medial plantar calcaneal region
• Characteristic "first-step pain" in the morning or after prolonged sitting
• Pain that may worsen at the end of the day with prolonged standing or activity 2

Risk Factors

Several factors increase the risk of developing plantar fasciitis:

• Obesity and increased body mass index
• Excessive foot pronation
• Limited ankle dorsiflexion
• Prolonged standing or walking, especially on hard surfaces
• Excessive running or sudden increases in training intensity
• Sedentary lifestyle
• Improper footwear with inadequate arch support 2, 1

Diagnosis

Diagnosis is primarily clinical and includes:

• History: Sharp, stabbing, non-radiating pain in the proximal medioplantar surface of the foot, worst with first steps in the morning
• Physical examination: Tenderness to palpation at the anteromedial calcaneus (plantar fascia insertion)
• Special tests: Pain elicited by passive ankle/first toe dorsiflexion 2

Diagnostic Imaging

• Imaging is rarely needed for initial diagnosis
• Ultrasonography shows good sensitivity (80%) and specificity (88%) compared to MRI and can be used for recalcitrant cases 3
• MRI is considered the most sensitive imaging study but should be reserved for cases where the diagnosis is uncertain or to rule out other heel pathologies 3
• Findings on imaging include increased plantar fascia thickness and abnormal tissue signal 2

Treatment Algorithm

First-Line Treatment (0-6 weeks)

1. Plantar fascia-specific stretching exercises - Most important initial intervention
2. Calf stretching exercises - Complement to plantar fascia stretching
3. Ice massage to the plantar fascia (20 minutes, 3-4 times daily)
4. NSAIDs for pain relief
5. Activity modification to decrease repetitive loading 4, 2

Second-Line Treatment (6-12 weeks if no improvement)

1. Appropriate orthotic devices or arch supports
2. Night splints to maintain dorsiflexion during sleep
3. Physical therapy modalities including ultrasound therapy
4. Corticosteroid injections - Consider for significant pain, but weigh against risks of fat pad atrophy and plantar fascia rupture 3, 4

Third-Line Treatment (>12 weeks of persistent symptoms)

1. Ultrasonography-guided extracorporeal shock wave therapy (ESWT) for chronic cases
2. Referral to podiatric foot and ankle surgeon if no improvement after conservative measures 3

Surgical Options (rarely needed)

1. Plantar fasciotomy - Reserved for cases lasting longer than 6-12 months that have failed all conservative treatments
2. Endoscopic fasciotomy - Less invasive surgical option 1

Treatment Efficacy and Prognosis

• With proper treatment, approximately 80% of patients improve within 12 months 1
• Conservative treatments are effective in about 90% of cases 2
• Early intervention leads to faster resolution of symptoms 5

Common Pitfalls and Caveats

1. Delayed treatment - Earlier intervention correlates with faster resolution
2. Overuse of corticosteroid injections - Risk of plantar fascia rupture and fat pad atrophy
3. Inadequate stretching protocol - Proper technique and consistency are essential
4. Failure to address contributing factors - Weight management and appropriate footwear are important
5. Misdiagnosis - Other causes of heel pain include calcaneal stress fractures, nerve entrapment, and tarsal tunnel syndrome 3, 2

Plantar fasciitis is generally self-limiting but can significantly impact quality of life and mobility if not properly managed. A systematic approach to treatment focusing on stretching, activity modification, and appropriate supportive devices will resolve symptoms in most patients without the need for invasive interventions.