Plantar fasciitis is the most common cause of heelpain in adults. The inflammation results from a biomechanical imbalance that causes tension along the plantar fascia and leads to collagen degeneration at the medial tubercle of the calcaneus.1
Plantar fasciitis occurs more frequently in women than in men.2 It is often seen in runners and dancers who use repetitive, maximal plantar flexion of the ankle and dorsiflexion of the metatarsophalangeal joints; in patients who experience sudden weight gain; and in overweight persons who increase their activity level.3
Here we discuss the typical presentation of plantar fasciitis and review the various treatment options.
PATHOPHYSIOLOGY
The plantar fascia originates from the medial calcaneal tuberosity, fans out across the sole of the foot, and inserts into the flexor mechanism of the toes at the metatarsal heads (Figure 1). This dense band of tissue supports the medial longitudinal arch of the foot and provides dynamic shock absorption.
At the beginning of the stance phase of the gait cycle, shortly after a heel strike, the tibia rotates internally and the foot pronates, stretching the plantar fascia as the foot flattens. Because the fascia has no elastic properties, repetitive stretching results in microtears at its origin. Repetitive microtears of the plantar fascia lead to collagen degeneration at the medial tubercle of the calcaneus, which eventually causes heel pain.
Predisposing factors that can excessively stretch a tight plantar fascia—and thus lead to repetitive microtears—may be extrinsic or intrinsic. Extrinsic factors include training errors, improper footwear, change in distance or intensity of physical activity, and change in running or walking surface.4 Intrinsic factors include pes cavus or pes planus, decreased plantar flexion strength, reduced flexibility of the plantar flexor muscles, tight Achilles tendon, excess pronation, discrepancy in leg length, torsional misalignments, and obesity or sudden weight gain (as in pregnancy).4
CLINICAL HISTORY
The classic symptom of plantar fasciitis is heel pain that occurs with the first several steps in the morning and lessens as walking continues, usually after 20 minutes. Patients often have pain at the beginning of an activity that diminishes or resolves as they warm up but generally recurs after the activity. The pain is usually insidious; a history of acute trauma is absent. Patients frequently describe the pain as a deep ache or tenderness at the anteromedial region of the calcaneus on the plantar surface of the foot. The pain may also occur with prolonged standing and can be accompanied by stiffness. In severe cases, the pain continues to worsen as activity progresses and becomes most intense at the end of the day.
EVALUATION
Physical examination. Palpation over the medial tubercle of the calcaneus usually reproduces the pain of plantar fasciitis (Figure 2). In severe cases, palpation over the proximal portion of the plantar fascia also may reproduce the pain. Other maneuvers that may replicate the pain include passive dorsiflexion of the toes with weight bearing or having the patient stand on tiptoe and toe-walk. Affected patients may also have a flat foot, high arch, or excessively pronated foot. A tight heel cord with decreased dorsiflexion of the ankle is another potential finding. A typical presentation helps distinguish plantar fasciitis from other causes of heel pain, such as fat pad atrophy (often seen in the elderly) and bone lesions (eg, fracture, tumor, and infection).
Diagnostic imaging. Radiographs are rarely useful because they are generally normal or show a bony heel spur, which is not a source of the pain. Diagnostic imaging is indicated for patients with atypical presenting signs and symptoms of plantar fasciitis, for those with heel pain from other suspected causes, and for those who do not respond to appropriate treatment.
