Objectives Update on Plantar Fasciitis - podiatrym.com · drome. Plantar fasciitis can be divid-ed...

APRIL/MAY 2001 • PODIATRY MANAGEMENTwww.podiatrymgt.com 99

has taken the place of what used tobe referred to as heel pain syn-drome. Plantar fasciitis can be divid-ed into proximal plantar fasciitisand distal plantar fasciitis.1 Proximalplantar fasciitis refers to pain onlyin the heel at the site of the plantarmedial tubercle of the calcaneus.1

Distal plantar fasciitis is character-

ized by pain and tenderness in thearch.

Plantar fasciitis has been de-scribed as having a self-limiting nat-ural course.2 Approximately 90-95percent of patients improve withconservative management;3 how-ever, improvement may be slow,

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Plantar fasciitis is the mostcommon cause of heel pain.Other terms for plantar heel

pain include calcaneodynia, heelpain syndrome, and subcalcanealheel pain. Currently plantar fasciitis

By Ellen Sobel, D.P.M., Ph.D. andSteven J. Levitz, D.P.M.

Objectives1) To know the etiology of plan-

tar fasciitis.2) To be able to describe the

clinical presentation of plantarfasciitis.

3) To be familiar with the epi-demiology of plantar fasciitis, in-cluding the age group, gender,physical attributes, foot type, andoccupation.

4) To know the significance ofheel spurs on radiographic find-ings.

5) To be able to diagnose plan-tar fasciitis in adult patients.

6) To be familiar with the differ-ential diagnosis of plantar fasciitis.

7) To be able to manage adultpatients with plantar fasciitis andknow the results of the latest stud-ies testing heel pads, foot or-thoses, physical therapy, injectiontherapy, night splints, and belowknee casts.

Continuing

Medical Education

C L I N I C A L P O D I A T R YC L I N I C A L P O D I A T R Y

Update onPlantar FasciitisDiagnosis, management, and current treatments.

many years of walking, repetitivemicrotrauma tends to result in mi-crotears at the origin of the plantarfascia. During sleep, the foot andankle assume a relaxed 15º plan-tarflexed position because of thenormal tone in the gastrocnemiusand soleus muscles. This plan-tarflexed ankle position results in

tightness of the posterior musclegroup and shortening of the plantarfascia. Healing of the microtears inthe plantar fascia occurs at nightduring sleep in this relaxed plantarflexed ankle position. In the morn-ing the individual gets out of bedand steps down, dorsiflexing theankle, and the delicately healed mi-crotears in the plantar fascia ruptureagain. The attempted unsuccessfulrepairs of the microtears lead tochronic inflammation. This accounts

for the pain of post static dyskinesia.One of the newer treatments forplantar fasciitis, the night splint, isthought to operate by keeping thefoot in the dorsiflexed position allnight in the splint and permits theplantar fascia to heal in this extend-ed position, and then when the indi-vidual takes the first step in themorning the microtears in the plan-tar fascia will not rupture again. Thechronic microtearing and reparativeprocess may result in thickening ofthe plantar fascia when left untreat-ed.11 The thickening of all threebands of the plantar fascia in indi-viduals with painful plantar fasciitishas been demonstrated with ultra-sonography and magnetic resonanceimaging (Figures 2A/B). Microrup-tures, hemorrhage, collagen degener-ation at Sharpey’s fibers (where thefascia inserts into the calcaneus),lead to fibrosis and ossification ofthe plantar fascia.(figure).5,12

Plantar fasciitis is more frequentin females, associated with middleage (most commonly between age40 to 60,13 and occupations involv-ing long periods of standing andtight tendoachilles.14-18 Althoughplantar fasciitis most frequently oc-curs unilaterally, there is a bilateralpresentation up to 15 percent of thetime.19 Athletes involved in runningand jumping sports are likely to de-velop plantar fasciitis.20-22 Patientssometimes remember increasedwalking or sports activity prior todeveloping plantar fasciitis.

Both the flat foot and the cavusfoot are associated with plantarfasciitis. In the over pronated foot,which fails to supinate duringpropulsion, the plantar fascia abnor-mally stretches to stabilize the footduring toe-off.13 Similarly the tighttendoachilles results in a pronatedfoot type, again resulting in exces-sive stretching of the plantar fascia.In contrast the cavus foot is oftenunable to pronate and dissipateground reaction forces at heel strike,increasing the stress in both theplantar fascia and the fat pad.

Symptoms and PhysicalExamination of the Patient withPlantar Fasciitis

The diagnosis of plantar fasciitisis based upon clinical presentation

taking many months, and somepatients do not improve after longcourses of treatment.4-7 This articlewill review the diagnosis and man-agement of plantar fasciitis. A cur-rent update of treatment modalitieswill also be included as well as basicassessment of the most commondifferential diagnoses for plantarheel pain.

Mechanical Etiology of PlantarFasciitis

In older people plantar fasciitisconsists of degenerative micro-tears ofthe medial band of the plantar fascia.In younger people who are athletesand runners, plantar fasciitis is anoveruse injury. The plantar fascia origi-nates from the plantar medial cal-caneal tuberosity and inserts into thebases of the proximal phalanges (Fig-ure 1). During standing half the bodyweight is converted into tensile forcesin the plantar fascia.8 Ligament cuttingexperiments in cadavers have shownthat the plantar fascia is the primaryligamentous restraint to arch collapse9

and sectioning the plantar fascia caus-es arch sag in individuals operated onfor intractable plantar fasciitis.10

Repetitive tensile traction load-ing within the insertion of the plan-tar fascia into the calcaneus overtime strains the plantar fascia. After

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100 www.podiatrymgt.comPODIATRY MANAGEMENT • APRIL/MAY 2001

The heel spur occurs dorsal to the

plantar fascia and is located at

the insertion of the flexor digitorum brevis tendon.

Fig.1

Figure 1. The medial band of the plantar fascia at the main insertion on the me-dial plantar tubercle of the calcaneus.

rather than radiographs.2,23 Patientscomplain of pain upon the first stepin the morning (post static dyskine-sia). The pain may be severe enoughthat the patient limps or is actuallyunable to bear weight on the affect-ed heel. The pain lessens after tak-

Biomechanics... pearing foot with no grossdeformity. The heel is usuallynot swollen or erythematous.

ing a few steps, but tends to returnagain after walking and standing allday. Pain tends to reoccur duringthe day after periods of sitting whenthe patient gets upout of a chair.

Examination ofthe foot generallyreveals a normal ap-

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Figure 2A. Ultrasound imaging of normal medial band of theplantar fascia. The vertical line labeled “1” shows the relativelynarrow width of the normal plantar fascia.

Figure 2B. Ultrasound imaging from patient with plan-tar fasciitis with enlarged medial band. The vertical linelabeled “1” shows the relatively thickened width of theinflamed plantar fascia. The vertical line labeled “2”shows the normal width where the inflammation haddisappeared. Although this ultrasonography study onlyshows the medial band, thickness of the central bandand the lateral band has also been demonstrated.


dlevel plantar fascia is often painfulto palpation as well.24 The plantarfascia should also be palpated fornodules, indicating plantar fibromaor multiple nodules (fibromatosis)(Figure 3).

ImagingX-rays are not particularly help-

ful unless they show evidence ofanother diagnosis, such as calcanealstress fracture or bone tumor. Thebody’s response to repeated mi-crotears, inflammation and tractionof the plantar fascia is the deposi-tion of calcium, which results inthe characteristic heel spur (Figure

4). Although the lateral heel spur isnot the cause of heel pain in plan-tar fasciitis, it is associated with thedisorder.25-27 Plain lateral radio-graphs reveal a heel spur in approx-imately 50 percent19,28 to 75 per-cent29 of patients with painful plan-tar fasciitis; however, studies haveobserved that a heel spur may befound in 13 percent30to 63 percent29

of asymptomatic heels. The heelspur occurs dorsal to the plantarfascia and is located at the insertionof the flexor digitorum brevis ten-don.31 Although the typical hori-zontal heel spur is not the cause ofpain, some suggest that down-

pointing bony spursmay actually pro-duce heel pain.32 Ra-diographs do nothave to be per-formed on the firstvisit if there is nosuspicion of fractureor more serious eti-ology of heel pain,but should be per-formed prior to in-jection.33 Bone scans,although rarely nec-essary for plantarfasciitis, may show apositive delayedt e c h n e t i u m 9 9bone scan in chron-ic conditions.31

Differential Diagnosis of Plantar Heel Pain

Almost any musculoskeletal con-dition can result in heel pain. Themost common are described below.

Nerve Entrapment: Entrap-ment of the medial calcaneal nerveis a cause of heel pain. The tibialnerve divides at the level of the me-dial malleolus into superficial anddeep branches (Figure 5). The super-ficial branch runs subcutaneouslyabove the laciniate ligament and isnamed the medial calcaneal nerve.The medial calcaneal nerve inner-vates the plantar heel pad and is re-sponsible for sensation to the plan-tar heel. Numbness in the plantaraspect of the heel after surgery forplantar fasciitis is a result of the me-dial calcaneal nerve inadvertentlybeing cut.

An important cause of plantar

There is a point of maximal ten-derness at the plantar medialtuberosity of the calcaneus (Figure1). Tenderness on palpation of theplantar medial calcaneal tubercle issometimes intensified by dorsiflex-ion of the ankle and toes. The mi-

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Fig.5

Figure 3. Plantar fibromatosis. Noticethe medial bulges in the plantar fasciaprominent on the medial side of thefoot.

Figure 4. Characteristic heel spur associated with plantarfasciitis is pointy, well demarcated and parallel to theground.

Figure 5. Anatomy of the tibial nerve. Notice that the tibial nerve divides into 3major branches, the medial calcaneal nerve, the medial plantar nerve, and thelateral plantar nerve. The first branch of the lateral plantar nerve is Baxter’snerve, thought to be a major etiology of plantar heel pain.

Circle #36

ment of nerve compression is simi-lar to treatment for plantar fasciitis.

Radiculopathy in the L-5 to S-1distribution should be considered inthe patient with low back pain espe-

cially when the heel pain is bilateral.31

Heel Fat Pad Atropy: Theheel pad cushion is composed ofglobules of fat encapsulated in a fi-broelastic reticulated structure,34

which effectively absorbs 20-25percent of the contact force at heel

strike.35 Thestresses to the tis-sues beneath theheel pad are in-versely propor-

tional to the thickness of the heelfat pad.36 After the age of fortythere is loss of collagen, elastic tis-sue, water and the overall thicknessof the heel pad diminishes.33 Fatpad atrophy is demonstrated bypain directly under the bonyprominence in the central aspect ofthe heel.24,37 The heel pad no longerfeels thick and rubbery (Figure 6A).The bony calcaneal tuberostiy canbe palpated. Loss of height of thefat pad may be observed (Figure6B). In addition to normal aging,heel pad atrophy can be induced byinjection of corticosteroids into theplantar heel fat pad.

Trauma/Calcaneal Frac-ture/Stress Fracture: Calcanealfracture is an important cause ofheel pain. The calcaneus is the mostfrequently fractured bone in thefoot.38 Most calcaneal fractures healwithout major problems; however,some patients may be left with per-sistent severe heel pain. The patientpresents with painful, tenderprominences under the plantar sur-face of the calcaneus or from lateralperoneal impingement by the dis-

fasciitis is entrapment of the firstbranch of the lateral plantar nerve(Baxter’s nerve), also known as thenerve to abductor digiti quinti mus-cle, thought to account for thecause of plantar heel pain in 20 per-cent of patients (Figure 5).31 The firstbranch of the lateral plantar nervepasses right next to the plantar me-dial tubercle of the calcaneus, whereit may become entrapped and com-pressed between the abductor hallu-cis muscle and the medial belly ofthe quadratus plantae muscle.

The symptoms of entrapment ofthe first branch of the lateral plantarnerve include paresthesias along thecourse of the nerve, but no sensorydeficit. Theoretically, motor weak-ness in the abductor digiti quintimuscle may occur and the patient isunable to abduct the fifth toe. Elec-tromyography and nerve conduc-tion studies are not helpful. Treat-

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Fat pad atrophy is demonstrated by pain directly under

the bony prominence in the central

aspect of the heel.

Figure 6B. Loss of height of the heel pad in patient with bi-lateral fat pad atropy from Figure 6A.

Figure 7A. Posterior tuberosity fracture of the calcaneus in aneuropathic patient. This patient demonstrated weakness ofplantarflexion and calcaneal gait, characteristic of this typeof trauma.

Figure 7B. Healing of posterior tuberosity fracture in an up-wardly displaced attitude resulted in chronic pain through-out the heel.

Figure 6A. Patient with bilateral fat pad atrophy. Noticethe shiny callused plantar aspect of the feet.

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Posterior calcaneal tuberosity(avulsion) fractures are caused by aviolent contraction of the Achillestendon, with the foot in a fixed po-sition39,40 or a fall that causes the pa-tient’s heel to strike a hard surfacewith the triceps surae tensed.41 Ex-amination reveals weakness of theposterior muscle group with reducedactive plantarflexion and calcanealgait (Figure 7A/B).42

C a l c a n e a lstress fractures donot involve fallingfrom a height, butmay reveal a his-tory of mildertrauma such aslong periods ofwalking, a sportsinjury or anklesprain. With cal-caneal stress frac-ture, physical ex-amination mayshow tendernessof the entire calcaneus rather than apoint of maximal tenderness at theplantar medial tubercle as in plantarfasciitis. Edema and erythema of theheel are present, but the heel is notusually ecchymotic.33 Pain is presentat rest as well as weight bearing. Acalcaneal axial radiograph shows thefoot in the sagittal plane and mayshow some calcaneal fractures that alateral x-ray will miss (Figure 8).Bone scan shows increased third-phase uptake. Six to eight months isnecessary for full recovery.43

Infection: Infection secondaryto a puncture wound or foreignbody must be considered. Elevated

white blood cell counts and bodyfever are diagnostic.

Arthritis: Patients with heelpain, especially older patients,should be questioned as to a historyof rheumatoid arthritis, gout, orseronegative arthritis, all of whichcan be an etiology of heel pain. Pro-liferative periostitis around the cal-caneus is diagnostic of seronegativespondyloarthropathy or rheumatoid

arthritis (Figures9A/B). Seronega-tive arthropathymay occur in ayoung male withheel pain and as-sociated lowerback pain, orother nonarthriticcomplaints suchas penile dis-charge, dermato-logic or eye symp-toms. It should benoted that the

heel pain is likely to be unilateralsince seronegative spondyloarthritisis a pauciarticular asymmetricarthritis.44 In contrast bilateral heelpain can be a presenting symptomof sarcoidosis and can accompanyor precede sarcoid arthritis.45

Treatment for Plantar FasciitisConservative treatment should

resolve symptoms of plantar fasci-itis within two to twelve weeks.46

People having heel pain for morethan twelve months are least likelyto have positive outcomes afterconservative treatment.6 Therefore,

placed tuberosity fragment. Al-though 75 percent of calcaneal frac-tures involve the subtalar joint, themajor long-term complications arisenot from problems in the joint butfrom distortion of the calcanealanatomy, with the heel shorteningand widening, causing significantsoft-tissue impingement. The pa-tient with a calcaneal fracture gen-erally has a history of falling from aheight. The high fall drives thetalus down against the medial sideof the calcaneus. Calcaneal fractureswhich involve the subtalar joint re-sult in a reduction in Bohler’s angle(normally 20-40º).

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A good foot orthosis to relieve the

symptoms of plantar fasciitis should

result in a decrease in strain in

the plantar fascia.

Figure 8. This calcaneal fracture wouldhave been missed with a lateral view.A calcaneal axial x-ray as shown herewas necessary to see the fracture.

Figure 9A. Notice the exuberant fluffy periostitis surround-ing the calcaneus. This patient had ankylosing spondylitis.

Figure 9B. Large atypical heel spur, does not look pointy likeheel spur in Figure 4. This patient had psoriatic arthritis.

the earlier the treatment is initiat-ed, the better the chances of com-plete relief. Treatment for plantarfasciitis usually involves severalmodalities at once. For example ina recent study involving a four-point approach to the manage-ment of plantar fasciitis, all pa-tients received a heel cup or footorthosis, exercise regimen, nightsplint, and nonsteroidal anti-inflammatory (NSAID) medica-tion.11 However, the NSAIDtherapy was given to those withmore acute symptoms.

The most common treat-ments for plantar fasciitis in-clude: heel pads, foot orthoses,night splints, and injections.Historically, radiotherapy wasused as a treatment and is cur-rently being revived in Europe;however, this will not be dis-cussed here.47 Some of the empir-ical evidence for common treat-ments are reviewed below.

Biomechanics... percent.49-51 Studies haveshown reduction or absence ofheel pain occurred in 73 percent to100 percent of individuals wearingthe Viscoheel Sof Spot for severalweeks.53,54 The Tuli heel cup (Medi-Dyne, Colleyville, TX) is a soft rub-ber heel cushion (Figure 11A). Thenew sports variety is thicker and hasmore of their trademark waffling(Figure 11B/C). In patients with heelpain caused by fat pad atrophy,

hard plastic heel cups (M-F Ath-letic company, Cranston, RI) theo-retically position the heel padunderneath the calcaneus, restor-ing the natural cushioning andcompressibility.28,34

Custom/PrefabricatedFoot Orthoses: The plantar fas-cia is in tension when the foot isloaded. Therefore a good foot or-thosis to relieve the symptoms ofplantar fasciitis should result in adecrease in strain in the plantarfascia.55 Kogler and associatesfound that the UCBL orthosis

Heel Pads: The SofSpot Viscoheel(Bauerfeind USA, Inc, Kennesaw,GA) (Figure 10) is a silicone polymerheel cushion which has a built-inarea of softer durometer speciallydesigned to disperse weight aroundthe plantar medial tubercle of thecalcaneus, the site of inflammationin plantar fasciitis. Viscoelastic heelpads have been reported to reducethe impact of heel strike on the legand low back by as much as fifty

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Figure 10. The SofSpot Viscoheels (Bauerfeind USA,Inc, Kennesaw, GA).

al foot orthoses and inverted footorthoses;60 or whether the function-al foot orthosis was fabricated fromrohadur or TL-61.61

The UCBL orthosis has been re-ported to be effec-tive in reducingthe symptoms ofplantar fasciitis inpatients with ex-treme pronation17,62

and was found toreduce heel paincaused by plantarfasciitis in 83 per-cent of those wear-ing this orthosis.63

The UCBL ortho-sis, however, isbulkier, more restrictive in foot mo-tion, more difficult to properly fitthan a functional foot orthosis orarch support, and consequently re-sults in less patient compliance.17

Recently, the first prospectiverandomized clinical trial onthe treatment of plantar fasci-itis was conducted on 236adult patients from fifteen or-thopedic treatment centers.64

There were five treatmentgroups. All groups engaged ina stretching program. Onegroup was treated withstretching only. The otherfour groups stretched andused one of four differentshoe inserts, including a sili-cone heel pad, a felt pad, a

rubber heel cup or a custom-madepolypropylene foot orthosis. Aftereight weeks of treatment 95 percentimproved with the Bauerfeind sili-cone heel pad (Bauerfeind, Kennesaw,

GA); 88 percentimproved withthe Tuli rubberheel cup (Medi-dyne, Colleyville,TX); 81 percentimproved withthe Hapad 3/4length felt insert(Hapad, BethelPark, PA); 72 per-cent improvedwith stretchingonly, and 68 per-

cent improved with the 3/4 lengthpolypropylene neutral custom footorthoses (Prolab, San Francisco). Theauthors concluded that a prefabri-cated shoe insert in conjunctionwith a stretching program was morelikely to cause improvement insymptomatic plantar fasciitis than acustom polypropylene foot orthosis.The authors also reasoned shock ab-sorption might have been the keyfeature in the prefabricated foot or-thoses. Shock absorption is most ef-fective in the silicone insert, fol-lowed by the Tuli rubber insert, andthe felt Hapad insert with thepolypropylene foot orthosis beingthe poorest shock absorber.

Injections: Heel injections are acommonly used office procedure for

the patient with heel pain. Inone study 24 of 26 heels in-jected with hydrocortisone re-mained asymptomatic at thetime of the 3-month follow-up.65 In contrast, another re-port found that heel injec-tions provided relief for fourto six weeks; however, at thetime of the six month follow-up the pain had returned inall cases.66 Similarly, in anoth-er study steroid injection wasfound to provide pain relieffor greater than 3 days in only35 percent of patients.6

Patients who present with ahighly symptomatic foot witha point of maximal tender-ness may get relief frombeing injected immediately.Some have concluded that

and two other foot orthoses signif-icantly decreased the strain in theplantar aponeurosis compared tothe barefoot control and were con-sidered effective arch supports. Incontrast the functional foot ortho-sis, prefabricated foot orthosis, andshoe alone did not effectively re-duce plantar fascia strain.55

Custom foot orthoses of variousvarieties have been reported to offerrelief of heel pain in: 81 percentafter wearing the orthosis for 3months,56 and in 74 percent ofsymptomatic runners with plantarfasciitis.57

A number of comparative studiesfound that functional foot orthosesrelieved heel pain better than: ure-thane heel pads;58 viscoelastic heelcups or anti-inflammatory therapy;59

however, there was no difference inrelief in heel pain between function-

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Stress relaxation is the decrease in stress

with time once amaterial under loading

has deformed to aconstant length.

Figure 11A. Classic Tuli heel cup with character-istic waffling design (MediDyne, Colleyville,TX).

Figure 11B. The new sports green Tuli heel cup(MediDyne, Colleyville, TX) is thicker and hasmore of their trademark waffling.

Figure 11C. New Tuli Heel cup (MediDyne,Colleyville, TX) shown from bottom.

tains the foot in a dorsiflexed attitude whilesleeping, thereby preventing tightness and con-tractures of the Achilles tendon and plantar fasciathat occurs as a result of the plantarflexed posture ofthe foot during sleep. The night splint should be usedfor a trial of six to eight weeks.

The tension night splint is typical-ly used in combination with othertreatments for heel pain. A nightsplint in conjunction with stretching,viscoheels and nonsteroidal antiin-flammatory medications was more ef-fective in the treatment of plantarfasciitis than the same treatmentswithout the night splint.

Eleven of 14 patients with one yearor more of heel pain had complete res-olution in less than four months witha polypropylene ankle foot orthosis setin 5-degree dorsiflexion, stretching,Tuli heel cups, and nonsteroidal anti-inflammatory medication at the timeof nine month follow-up.73 Of the 3patients who did not improve, over-weight and noncompliance were con-

sidered to be the cause of the problem.Mizel and associates69 treated 57 patients who were

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Medical Educationheel injections are most effective for the acutelysymptomatic heel and orthotics are best for chronicheel pain.7,13 However, some prefer to postpone injec-tions anywhere from ten weeks46 to four months11 afterunsuccessful conservative treatment.Up to three injections can be admin-istered in a year, spaced approximate-ly two to four weeks apart. The pa-tient can be prone, supine or seated.The ankle and great toe can be dorsi-flexed to find the point of maximaltenderness, which is at the medial as-pect of the plantar fascia origin. Thesafest, least painful approach to theorigin of the plantar fascia is fromthe medial side of the foot near theorigin of the plantar fascia (Figure12). Plantar surface injections shouldbe avoided because they might leakcorticosteroid into the fat pad. Later-al injections should also be avoided.One to two milliliters of 1 percent or2 percent lidocaine and one milliliterof .5 percent must be combined with 10 milligrams oftriamcinolone hexacetonide for a total of 2.5milliliters. A 1.5 inch length 25-27 gauge needle al-lows for a relatively smooth entry as well as infiltra-tion technique and “redirecting the needle.” Themajor risk of injecting the origin of the plantar fasciais rupture of the tissue.67 Injections may also thin thecalcaneal fat pad if inadvertently deposited into thecalcaneal fat pad. Patients should avoid heavy impactloading activities for seven to fourteen days after theinjection, such as running and jumping immediatelyafter injection, but should continue to gently stretchthe plantar fascia and continue to use heel pads andorthoses.

Posterior Splint: Recently the Posterior NightSplint has been used in the treatment of recalcitrantcases of plantar fasciitis (figure 13).32,68-73 The nightsplint should maintain the plantar fascia in a stretchedposition during sleep by passively dorsiflexing theankle five to ten degrees. As previously mentioned dur-ing sleep, the unbraced foot and ankle assumes a plan-tarflexed position due to the normal tone in the gas-trocsoleus muscles. This nonfunctional plantarflexedposition results in tightness of the posterior musclegroup and the plantar fascia and is thought to accountfor the severe pain which patients with plantar fasciitisexperience upon their first step out of bed in the morn-ing as the plantar fascia resumes its functional weight-bearing length.32 Stress relaxation is the decrease instress with time once a material under loading has de-formed to a constant length.74 This is due to the vis-coelastic nature of all biological tissues.

Similarly, when the plantar fascia is kept in a dor-siflexed, stretched position by the night splint, thebiomechanical phenomenon of stress relaxation oc-curs and the plantar fascia relaxes in the newstretched position. The tension night splint main-

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A short leg walking cast was the

most effective ofnumerous other

conservative therapieswhich included steroid

injection, rest, ice,runner’s shoe,

crepe-soled shoe, andheel cup.

months, making compliance diffi-cult, especially in obese individuals.Some night splints may also be un-comfortable to wear and sleep in allnight.

Short Leg Walking Cast: Thir-ty-two patients with heel pain formore than one year were treatedwith a short leg walking cast for anaverage of six weeks (range, 1-12weeks).75 At the time of 15-monthaverage follow-up, 25 percent hadcomplete resolution of heel pain and61 percent reported improvement.The authors concluded that castingshould be tried prior to surgical in-tervention. In another study of theoutcome of nonsurgical treatmentfor plantar fasciitis, a short leg walk-

ing cast was the most effective of nu-merous other conservative therapieswhich included steroid injection,rest, ice, runner’s shoe, crepe-soledshoe, and Tuli’s heel cup.76

Recommendations for Treatmentof Plantar Fasciitis

The authors’ preference in themanagement of plantar fasciitis re-volves around how long patientshave had heel pain.

Initial treatment in a patient withheel pain up to three months: Patientswith symptomatic heel pain for upto three months should be advisedto reduce activity and to stay offtheir feet, start a stretching pro-gram and wear a heel cushion orinsole inside the shoe. If they areoverweight, weight reduction is dis-cussed and the patient is advised tolose weight. The patient’s shoes areobserved. Many patients find ithelpful to wear an elevated heel,which transfers pressure to theforefoot. Running shoes with thickshock absorbing soles and walkingshoes with wide rubber soles aregood for reducing plantar weightbearing pressure. If the heel is veryacutely symptomatic, an injectionis administered at the first visitafter x-raying. Patients should beallowed at least four weeks of ini-tial treatment.

Heel pain three to 12 months: Pa-tients having heel pain for approxi-mately three to twelve months maycontinue with the same treatments asabove. However, one or more of thefollowing will be added: custom footorthoses, night splints, injections,physical therapy and nonsteroidalanti-inflammatory medications.

Heel pain for more than one year:Patients having heel pain for morethan a year may continue with all ofthe treatments above, but shouldalso consider surgery as an option.In extreme cases the patient may beforced to permanently change activ-ities of daily living, including jobmodification. �

References1 Pfeffer G, Baxter DE, Graves S,

Michelson JD, Sammarco GJ: Sympo-sium: The management of plantar heelpain. Contemp Orthop 32(6): 357-66,1996, June.

symptomatic for at least 10months with a combination of amolded ankle foot orthosis and arocker bottom shoe. At average fol-low-up of 16 months, symptomswere completely resolved in 59 per-cent and improved in 18 percent.

Powell and colleagues71 reported88 percent improvement in 37 pa-tients with recalcitrant plantarfasciitis treated with a dorsiflexionnight splint at the time of sixmonth follow-up.71

Although the literature on nightsplints tends to be fairly positive,patients are required to wear thenight splint for as long as four

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Figure 12. Trigger point injection into posterior medial aspect of heel at thepoint of maximal tenderness.

Figure 13. Posterior night splint.

2 Dreeben SM, Mann RA: Heel pain:Sorting through the differential diagnosis.J Musculoskeletal Med 21-37, June, 1992.

3 Warren BL: Plantar fasciitis in run-ners. Treatment and prevention. SportsMed 10: 338-45, 1990.

4 Davis PF, Severud E, Baxter De:Painful heel syndrome: results of nonop-erative treatment. Foot Ankle Inter 15:531-5, 1994.

5 Furey JG: Plantar fasciitis: the pain-ful heel syndrome. J Bone joint Surg. 57A:672-3, 1975.

6 Wolgin M, Cook C, graham C,Mauldin D: Conservative treatment ofplantar heel pain: Long-term follow-up.Foot Ankle Int. 15: 97-102, 1994.

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8 Wright DG, Rennels DC: A study ofthe elastic properties of the plantar fascia.J Bone Joint Surg 46A: 482, 1964.

9 Huang CK, Kitaoka HB, An KN,Chao Eys: Biomechanical evaluation oflongitudinal arch stability. Foot Ankle 14:353, 1993.

Biomechanics... gical results and review of litera-ture. Clin Orthop 266: 185-96, 1991.

19 Tanz SS: Heel pain. Clin Orthop28: 169-78, 1963.

20 Gill LH: Conservative treatment forpainful heel syndrome. Proceedings of theThird Annual Summer Meeting. FootAnkle 8: 122, 1987.

21 Hill JJ, Cutting PJ: Heel pain andbody weight. Foot Ankle 9: 254-6, 1989.

22 Lester DK, Buchanan JR: Surgicaltreatment of plantar fasciitis. Clin Orthop186: 202-4, 1984.

23 Tudor GR, Finlay D et al: The roleof bone scintigraphy and plain radiogra-phy in intractable plantar fasciitis. NuclMed Commun 18: 853-6, 1997.

24 Michelson JD: Heel pain: When isit plantar fasciitis? J Musculoskel Med 22-9, 1995, March.

25 Kibler WB, Goldberg C, ChandlerTJ: Functional biomechanical deficitis inrunning athletes with plantar fasciitis. AmJ Sport Med 19: 66-71, 1991.

26 McBride AM: Plantar fasciitis, inAmerican Academy of Orthopedic Sur-geons (eds): Instructional Course Lectures,vol 33, St. Louis, Mosby Inc, 1984, pp278-82.

10 Daly PJ, Kitaoka HB, Chao EYS:Plantar fasciotomy for intractable plantarfasciitis: Clinical results and biomechani-cal evaluation. Foot Ankle 13: 188, 1992.

11 Martin RL, Irrgang JJ, Conti SF:Outcome study of subjects with insertion-al plantar fasciitis. Foot Ankle Inter19(12): 803-11, 1998.

12 Leach RE, DiIorio E, Harney RA:Pathologic hindfoot conditions in theathlete. Clin Orthop Rel Sci 177: 116,1983.

13 Karr SD: Subcalcaneal Heel Pain.Orthop Clin NA 25: 161, 1994.

14 Barrett SI, O'Malley R: Plantar fasci-itis and other causes of heel pain. AmFam Phy 59(8): 2200-6, 1999, April

15 Bordelon RL: "Heel Pain," in Sur-gery of the Foot and Ankle, 6th Ed, Vol 1,ed by RA Mann, MJ Coughlin p 837, CVMosby, St Louis, 1993.pp837-857.

16 Gill LH: Plantar fasciitis: Diagnosisand conservative management. J am AcadOrthopaed Surg 5: 109-117, 1997.

17 Kwong PK, Kay D, voner RT, WhiteMW: Plantar fasciitis mechanics and path-omechanics of treatment. Clin Sport Med7(1): 119-26, 1988.

18 Schepsis AA, Leach RE, Gorzyca J:Plantar fasciitis. Etiology, treatment, sur-

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tion. Physician & Sportsmedicine 27(9):101-2, 1999, September.

47 Mantell BS: Radiotherapy for pain-ful heel syndrome. Br Med J 2(6130): 90-1, 1978.

48 Johnson GR: The use of spectralanalysis to assess the performance ofshock absorbing footwear. Eng Med 15:117, 1986.

49 Light LH, Maclellan GE, KlenermanL: Skeletal transients on heel strike in nor-mal walking with different footwear. JBiomech 13: 477, 1980.

50 Pratt DJ, Rees PH, Rodgers C: As-sessment of some shock absorbing in-soles. Prosthet Orthot Int 10: 43, 1986.

51 Voloshin A, Wosk J: Influence ofartificial shock absorbers on human gait.Clin Orthop 160: 52, 1981.

52 Wosk J, Voloshin AS: Low backpain. Conservative treatment and artifi-cial shock absorbers. Arch Phys Med Re-habil 66: 145, 1985.

53 Maclellan GE, Vyvyan B: Manage-ment of pain beneath the heel andachilles tendonitis with visco-elastic heelinserts. Brit J Sport Med 15: 117, 1981.

54 Levitz SJ, Dykyj D: Improvementsin the design of viscoelastic heel or-thoses—A clinical study. J Amer PodiatMed Assoc 80: 653, 1990.

55 Kogler GF, Solomonidis SE, Paul JP:Biomechanics of longitudinal arch sup-port mechanisms in foot orthoses andtheir effect on plantar aponeurosis strain.Clin Biomech 11: 243, 1996.

56 Scherer PR: Heel spur syndromePathomechanics and nonsurgical treat-ment. J Amer Podiatr Med Assoc 81: 68,1991.

57 Gross ML, Davlin LB, Evanski PM:Effectiveness of orthotic shoe inserts inthe long-distance runner. Am J Sport Med19: 409, 1991.

58 Turlik MA, Donatelli TJ, VeremisMG: A comparison of shoe inserts in re-lieving mechanical heel pain. The Foot 9:84-7, 1999.

59 Lynch DM, Goforth WP, Martin JE,et al.: Conservative Treatment of PlantarFasciitis—A prospective Study J Amer Po-diatr Med Assoc 88: 375, 1998.

60 Blake RL, Denton JA: Functionalfoot orthoses for athletic injuries. A retro-spective study. J Amer Podiatr Med Assoc75: 359, 1985.

61 Ferguson H, Raskowsky M, BlakeRL, Denton JA: TL-61 versus Rohadur Or-thoses in heel spur syndrome. J Amer Po-diatr Med Assoc 81: 439, 1991.

62 Campbell JW, Inman VT: Treat-ment of plantar fasciitis and calcanealspurs with the UC-BL shoe insert. OrthotPros 31: 23, 1977.

63 Bowman GD: New concepts in Or-thotic Management of the Adult. Hyper-pronated foot: Preliminary findings. J ProsOrtho 9: 77, 1997.

27 Tisdel C, Donley BG, Sferra JJ: Diag-nosing and treating plantar fasciitis: Aconservative approach to plantar heelpain. Cleveland Clinic Journal of Medi-cine 66(4): 231-5, April 1999.

28 Snook GA, Chrisman OD: Themanagement of subcalcaneal pain. ClinOrthop 82: 163, 1972.

29 Williams PL, Smibert JG, Cox R, etal: Imaging study of the painful heel syn-drome. Foot Ankle 7: 345-9, 1987.

30 Shmokler RL, Bravo AA, Lynch FRet al: A new use of instrumentation in flu-oroscopy controlled heel spur surgery. 78:194-7, 1988.

31 Baxter DE, Pfeffer GB, Thigpen M:Chronic heel pain treatment rationale.Orth Clin NA 20(4): 563-9, 1989.

32 Batt ME, Tanji JL: ManagementOptions for Plantar Fasciitis. Phys SportMed 23: 77, 1995.

33 Jaivin JS: The athletic heel. FootAnkle Clin 4(4): 865-79, 1999, December.

34 Jorgensen U: Achillodynia and lossof heel pad shock absorbency. Am J SportsMed 13: 128, 1985.

35 Paul IL, Munro MB, Abernathy PJ,et al: Musculoskeletal shock absorption:Relative contribution of bone and soft tis-sues at various frequencies. J Biomech 11:237, 1978.

36 Jahss MH, Michelson JD, Desai P, etal: Investigations into the fat pads of thesole of the foot: Heel pressure studies.Foot Ankle 13: 227, 1992.

37 Shapiro SL: Heel pain managementstarts with correct differential diagnosis.Biomechanics 25-6,77, 1997.September.

38 Connolly JF: Foot Fractures catch-ing the common troublemakers. Emer-gency Medicine 21-38, 1991, November30.

39 Parkes JC II: Injuries of the hind-foot. Clin Orthop 122: 28, 1977.

40 O'Connell F, Mital MA, Rowe CR:Evaluation of modern management offractures of the os calcis. Clin Orthop 83:214, 1972.

41 Lyngstadaas S: Treatment of avul-sion fractures of the tuber calcanei. ActaChir Scand 137: 579, 1971.

42 Sobel E, Glockenberg A: CalcanealGait Etiology and Clinical presentation. JAmer Podiatric Med Assoc 89(1): 39-49,1999, January.

43 Baxter DE: The heel in sport. ClinSport Med 13(4): 683-93, 1994, October.

44 Sobel E., Kosinski M. Nineteen YearOld Girl with Unilateral ankle Pain Whatis Your Diagnosis? American PodiatricMedical Association, Volume 87, 74-79,February, 1997.

45 Shaw RA, Holt PA, Steven MB: Heelpain sarcoidosis. Ann Intern Med 109:675-77, 1988.

46 Roberts WO: Plantar fascia injec-

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Drs. Levitz and Sobel are professors inthe Department of Orthopedics,NYCPM.

64 Pfeffer G, Bacchetti P, Deland J, etal: Comparison of custom and prefabri-cated orthoses in the initial treatment ofproximal plantar fasciitis. Foot Ankle In-tern 20(4): 214-21, 1999.

65 Lapidus PW, Guidotti FP: Local in-jections of hydrocortisone in 495 ortho-pedic patients. Indust. Med Surg 26: 234-44, 1957.

66 Miller RA, Torres J, McGuire M: Ef-ficacy of first-time steroid injection forpainful heel syndrome. Foot Ankle Inter16(10): 610-12, 1995.

67 Sellman JR: Plantar fascia ruptureassociated with corticosteroid injection.Foot Ankle int 15(7): 376-81, 1994.

68 Jimenez AL, Goecker RM: Nightsplints: conservative management ofplantar fasciitis. Biomechanics 4: 29,1997.

69 Mizel MS, Marymoont JV, TrepmanE: Treatment of Plantar Fasciitis with aNight Splint and Shoe Modification con-sisting of a Steel Shank and anterior rock-er bottom. Foot Ankle 17: 732, 1996.

70 Pezzullo DJ: Using night splints inthe treatment of plantar fasciitis in theathlete. J Sport Rehab 2: 287, 1993.

71 Powell M, Post WR, Keener J, Wear-den S: Effective treatment of chronicplantar fasciitis with dorsiflexion nightsplints: A crossover prospective random-ized outcome study. Foot Ankle 19: 10,1998.

72 Ryan J: Use of posterior nightsplints in the treatment of plantar fasci-itis. Am Fam Phys 52: 891, 1995.

73 Wapner KL, Sharkey PF: The use ofnight splints for treatment of recalcitrantplantar fasciitis. Foot Ankle 12: 135, 1991.

74 Carlstedt CA, Nordin M: "Biome-chanics of tendons and Ligaments," : inBasic Biomechanics of the Musculoskele-tal System. Second Edition. Ed by MNordin, VH Frankel, Lea & Febiger,Philadelphia, 1989. Chapter 3. Pp. 59-74.

75 Tisdel CL & Harper MC: Chronicplantar heel pain: Treatment with a shortleg walking cast. Foot Ankle Intern 17: 41,1996.

76 Gill LH, Kiebzak GM: Outcome ofnonsurgical treatment for plantar fasciitis.Foot Ankle Inter 17: 527, 1996.

treatment of plantar fasciitisconducted on 236 adult patientsfrom fifteen orthopedictreatment centers, the mosteffective treatment for initialplantar fasciitis after 8 weeks oftreatment was:

A) Stretching aloneB) Stretching and Tuli heelcupsC) Stretching and Bauerfeindsilicone heel padsD) Stretching and custompolypropylene foot orthosis

7) According to the researchliterature, which foot orthoseshave been found to reduce heelpain from plantar fasciitis?

A) Bauerfeind silicone heelpadsB) Root Functional footorthosisC) UCBL foot orthosisD) All of these

8) The initial treatment forplantar fasciitis consists of:

A) Endoscopic plantarfasciotomyB) Custom foot orthosesC) Reduction in weightbearing activity and heelcushion or insole.D) Reduction in weightbearing activity, stretchingprogram and heel cushion orinsole.

9) The most important purposeof taking an x-ray in patients withplantar fasciitis is:

A) To diagnosis a heel spurB) To diagnosis a calcanealstress fracture or bone tumorC) To determine whether apatient requires surgeryD) To rule out posterior heelinvolvement

10) The main causes of fat padatrophy include:

A) Steroid injections into theheel padB) Normal aging

1) In most cases conservativetreatment should resolve thesymptoms of plantar fasciitiswithin:

A) one weekB) two to twelve weeksC) three monthsD) Impossible to determine

2) The tibial nerve divides at thelevel of the medial malleolus intosuperficial and deep branches.The superficial branch, which runssubcutaneously above thelaciniate ligament, is named the:

A) Lateral plantar nerveB) Medial plantar nerveC) Medial calcaneal nerveD) Lateral calcaneal nerve

3) Which one of the followingnerves supplies sensoryinnervation to the medial andplantar heel pad?

A) medial calcaneal nerveB) lateral calcaneal nerveC) Lateral plantar nerveD) Medial plantar nerve

4) Which of the following nerveswould be most susceptible tocompression beneath the heel?

A) the first branch of themedial plantar nerveB) The first branch of thelateral dorsal cutaneous nerveC) The medial calcaneal nerveD) The first branch of thelateral plantar nerve

5) Baxter’s nerve is foundbetween what two muscles?

A) Medial belly of quadratusplante and abductor digitiquintiB) Abductor hallucis and flexordigitorum brevisC) Abductor hallucis andmedial belly of quadratusplantaeD) Abductor hallucis andmedial band of plantar fascia

6) In the first prospectiverandomized clinical trial on the

C) Traction on the plantarfasciaD) Both normal aging andsteroid injections

11) How long a trial should nightsplints be used for?

A) 2 weeksB) 6-8 weeksC) 6 monthsD) 1 year

12) The night splint stretches theplantar fascia by thebiomechanical phenomena of:

A) Creep deformationB) ViscoelasticityC) Stress relaxationD) Rate dependent properties

13) Which one of the following isNOT helpful in distinguishingcalcaneal stress fracture fromplantar fasciitis?

A) Pain is present off weightas well on weight bearing withcalcaneal stress fractureB) The entire heel may beswollen and tender withcalcaneal stress fractureC) X-rays will show a calcanealstress fractureD) The patient generally willdescribe a history of fallingfrom a height with calcanealstress fracture

14) Generally speaking, theearlier the treatment of plantarfasciitis, the better the outcome.

A) TrueB) False

15) What is the relationshipbetween plantar fasciitis and heelspur on radiograph?

A) 1/2 to 3/4 of patients withplantar fasciitis have heel spur,but up to almost 2/3 of heelspurs are present inasymptomatic heels.B) The heel spur is the causeof the heel pain.C) There is no relationship be-

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tween plantar fasciitis and heel spur.D) Approximately 50 percent of patients withplantar fasciitis have a heel spur, but patientswith asymptomatic heels generally do not haveheel spur.

16) The effectiveness of injection therapy formanagement of plantar fasciitis shows:

A) There is usually a partial reduction in heelpain after 1 or 2 injections.B) There is usually short acting relief of heelpain, but after a while the heel pain usuallyreturns.C) Two injections are usually necessary, but ifdone properly, should alleviate heel pain inpatients having pain for under one year.D) Injections should be administered plantarlyfor the best effect

17) Generally the maximum amount of heelinjections should not exceed:

A) 1 per yearB) 1 per monthC) 3 per yearD) Any amount as long as administeredproperly

18) The major problem with the night splint in thetreatment of plantar fasciitis is:

A) complianceB) Requires long periods of time to workC) Especially poorly tolerated by obeseindividualsD) All of these

19) Surgery for plantar fasciitis should beconsidered:

A) After a short trial of conservative therapy.B) Even without conservative therapy inpatients who have had heel pain for more than3 years.C) After conservative therapy fails in patientswho have had plantar fasciitis for more thanone year.D) Surgery should never be considered becauseconservative treatment always works.

20) The prognosis for plantar fasciitis may bedescribed as:

A) May resolve without any treatmentB) Usually resolves with conservative treatmentC) May require long periods of time to resolveeven with conservative treatmentD) Any of the above

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EXAM #4/2001Update on Plantar Fasciitis

(Sobel and Levitz)

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