Last updated: November 4, 2014
Synonyms: plantar fasciopathy, subcalcaneal heel pain
ICD-9 Code: 728.71.
ICD-10 Code: M72.2
Definition: Plantar fasciitis is a condition characterized by pain on the plantar surface of the foot corresponding to the anatomic course of the plantar fascia. Pain often arises acutely and abates, but the condition may be recurrent or chronic. Pain is often worsened by weight bearing, classically the most severe pain occurring when patients first arise from sleeping. Local manual pressure can also elicit pain. There may be associated bony spurs at the insertion of the plantar fascia into the calcaneous (an enthesis, hence there may be enthesitis).
Etiology: Plantar fasciitis may be idiopathic or posttraumatic with resultant inflammatory change owing to overuse or reinjury. It may result from obesity, reduced dorsiflexion, work-related weight-bearing, athletic activity, prolonged walking, improper shoes, structural instability, or direct trauma to the heel. The particular onset in the morning upon arising has been attributed to shortening of the plantar fascia during relative plantar flexion of the foot during sleep, with the acute pain on arising due to stretching. Plantar fasciitis and enthesitis may be associated with the various forms of spondyloarthrthitis (SpA; e.g., ankylosing spondylitis, psoriatic arthritis, etc.).
Pathology: There is local degenerative change in the origin of the plantar fascia with traction periostitis of the medical calcaneal tubercle. With repetitive stress, microtears develop, resulting in inflammation involving the bursa, plantar fascia, and enthesis (attachment site of the plantar fascia into the calcaneus).
Demographics: Plantar fasciitis is most common between 40 and 60 years of age. Most patients have calcaneal spurs or some history of trauma/overuse. In younger patients, suspect trauma/overuse or consider SpA as a possibilioty.
Associations: It may be associated with inflammatory conditions (SpA, RA, others), structural abnormalities (pes valgus, flexible flat foot), overuse (long distance running, prolonged standing, aerobic dance), obesity, poor footwear, diabetes, calcaneal spurs, Dupuytren’s contracture, Achilles tendinitis, or metabolic bone disease.
Cardinal Findings: Intense, sharp, aching, or burning heel pain tends to be unilateral and worse in the morning; it may improve with time and ambulation. However, pain may be exacerbated by prolonged standing or walking. Tenderness can be elicited by palpation over the inferior calcaneus near the insertion of the plantar fascia. Pronation (eversion) may worsen pain.
Diagnostic Tests: HLA-B27 may be positive in suspected SpA.
Imaging: Radiographic calcaneal spurs may not be present. Sharp, demarcated spurs tend to be degenerative. Soft, fluffy, cloudy, ill-defined spurs are typically inflammatory and may indicate a SpA. Periostitis is sometimes seen.
Keys to Diagnosis: Diagnosis is based on history, tenderness on palpation, or radiographic spurs.
Differential Diagnosis: SpA, fat atrophy of the heel pad, calcaneal stress fracture, tarsal tunnel syndrome, plantar fascia rupture (from local steroid injections), or nerve entrapment of the abductor digiti quinti should be considered.
Therapy: Rest, weight loss, reduction of activity/ambulation, heel pads or heel cup orthoses, arch supports, analgesics, and NSAIDs are advised and useful. Examine shoes for appropriate heel and arch support, wear, or instability. A therapist can teach proper stretching exercises for Achilles tendon (dorsiflexion of ankle) and plantar fascia (dorsiflexion of great toe) to be done regularly. Simple home measures (e.g. rolling the plantar surface of the foot over a tennis ball) can be effective. A number of devices that keep the foot from plantar flexing at night are availebl. Local injection (may be painful) of corticosteroids (10–20 mg prednisolone) should be tried when conservative measures fail. Surgery (partial plantar fascia release) is rarely necessary.
Williams SK, Brage M. Heel pain-plantar fasciitis and Achilles enthesopathy. Clin Sports Med 2004;23:123. PMID:15062587
Young CC, Rutherford DS, Niedfeldt MW. Treatment of plantar fasciitis. Am Fam Physician 2001;63:467–474, 477–478. PMID:11272297
Beeson P.Plantar fasciopathy: Revisiting the risk factors. Foot Ankle Surg. 2014;20:160-165. doi: 10.1016/j.fas.2014.03.003. PMID:25103701