Plantar fasciitis

Introduction
Plantar fasciitis is the most common cause of heel pain in adults, resulting from inflammation and microtearing of the plantar fascia—a thick fibrous band of connective tissue running from the medial calcaneal tubercle to the proximal phalanges. It acts as a shock absorber and supports the medial longitudinal arch of the foot. Repetitive strain or overuse leads to degeneration and inflammation, resulting in characteristic heel pain, especially with first steps in the morning.

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Epidemiology

• Accounts for ~10% of running-related injuries and ~11–15% of foot symptoms requiring professional care.

• Peak incidence: Adults aged 40–60 years; also common in younger athletes.

• Risk factors include obesity, prolonged standing, high-impact sports, and biomechanical abnormalities.

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Etiology and Risk Factors

• Overuse: Running, jumping, prolonged standing or walking.

• Biomechanical factors:

  • Pes planus (flat feet) or pes cavus (high arches).

  • Excessive pronation.

  • Tight Achilles tendon or calf muscles.

• Footwear: Poor arch support or cushioning.

• Obesity: Increased mechanical load on plantar fascia.

• Occupational: Jobs requiring long hours of standing on hard surfaces.

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Pathophysiology
Chronic overloading of the plantar fascia leads to microtears near its origin at the calcaneus. This triggers a cycle of inflammation, degenerative changes (fasciosis), and thickening of the fascia. Repetitive strain perpetuates the process, and pain is most pronounced after periods of inactivity due to fascia tightening overnight.

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Clinical Presentation

• Pain location: Inferomedial heel.

• Pain pattern:

  • Sharp, stabbing pain with first steps in the morning or after prolonged sitting (“start-up pain”).

  • Improves with walking, but can worsen after prolonged activity.

• Onset: Gradual over weeks to months.

• Aggravating factors: Prolonged standing, running, walking barefoot on hard surfaces.

• Relieving factors: Rest, stretching.

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Examination

• Point tenderness at the medial calcaneal tubercle.

• Pain with passive dorsiflexion of toes (stretching plantar fascia).

• Tight Achilles tendon may be present.

• No neurological deficits (important to distinguish from tarsal tunnel syndrome or radiculopathy).

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Investigations
Diagnosis is primarily clinical. Investigations are indicated for atypical presentations or refractory cases.

• Ultrasound: Fascia thickening (>4 mm), hypoechoic areas.

• MRI: Used if diagnosis uncertain or to exclude other pathologies.

• X-ray: May show calcaneal spur (non-specific; present in many asymptomatic individuals).

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Management
Treatment is aimed at reducing pain, promoting healing, and preventing recurrence. The majority of patients improve within 6–12 months with conservative management.

1. Non-Pharmacological Measures (First-Line)

• Activity modification: Reduce high-impact activities, avoid barefoot walking on hard surfaces.

• Footwear modification: Shoes with good arch support and cushioned soles.

• Orthoses: Prefabricated or custom-made arch supports to reduce strain on plantar fascia.

• Stretching exercises:

  • Plantar fascia stretch: Pull toes toward shin while seated, holding for 30 seconds, repeat 3–5 times daily.

  • Calf stretches against a wall.

• Night splints: Maintain dorsiflexion during sleep to prevent fascia tightening.

• Ice therapy: Apply ice to heel for 15–20 minutes several times daily, especially after activity.

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2. Pharmacological Management

• Analgesics/NSAIDs:

  • Ibuprofen: 400–600 mg orally every 6–8 hours as needed.

  • Naproxen: 250–500 mg orally twice daily.

  • Used short-term for pain relief; not a cure for underlying pathology.

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3. Physical Therapy

• Manual therapy for soft tissue mobilization.

• Strengthening of intrinsic foot muscles.

• Eccentric loading exercises for calf muscles.

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4. Interventional Options (For Refractory Cases)

• Corticosteroid injections:

  • Example: Methylprednisolone acetate 20–40 mg mixed with local anesthetic, injected at maximal point of tenderness (avoid repeated injections due to risk of fascia rupture).

• Platelet-rich plasma (PRP) injections: Potential to promote healing, though evidence is mixed.

• Extracorporeal shock wave therapy (ESWT): Non-invasive therapy to stimulate healing in chronic cases.

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5. Surgical Management
Reserved for persistent, severe cases after ≥6–12 months of exhaustive conservative therapy.

• Plantar fascia release: Partial cutting of fascia to relieve tension; may be open or endoscopic.

• Risks: Arch instability, nerve injury.

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Prognosis

• ~90% improve with conservative measures within 6–12 months.

• Recurrence is possible; preventive strategies include ongoing stretching, supportive footwear, and weight management.

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Complications

• Chronic heel pain and altered gait.

• Fascia rupture (more likely after corticosteroid injection).

• Nerve entrapment or calcaneal stress fracture (if misdiagnosed).