plantar fascitis_jaaos.pdf

Plantar Fasciitis: Evaluationand Treatment

AbstractPlantar fasciitis is the most common cause of plantar heel pain. Itscharacteristic features are pain and tenderness, predominately onthe medial aspect of the calcaneus near the sole of the heel.Considering a complete differential diagnosis of plantar heel pain isimportant; a comprehensive history and physical examinationguide accurate diagnosis. Many nonsurgical treatment modalitieshave been used in managing the disorder, including rest, massage,nonsteroidal anti-inflammatory drugs, night splints, heel cups/pads, custom and off-the-shelf orthoses, injections, casts, andphysical therapy measures such as shock wave therapy. Mostreported treatment outcomes rely on anecdotal experience orcombinations of multiple modalities. Nevertheless, nonsurgicalmanagement of plantar fasciitis is successful in approximately 90%of patients. Surgical treatment is considered in only a small subsetof patients with persistent, severe symptoms refractory tononsurgical intervention for at least 6 to 12 months.

Severe recalcitrant heel pain is arelatively commonly observed

phenomenon. Although this condi-tion is frequently referred to as heelspurs, currently accepted terms ofgreater accuracy are plantar fasciitis(acute inflammatory stage) and plan-tar fasciosis (chronic degenera-tion).1 Plantar fasciitis can be a pain-ful and debilitating condition thatoften frustrates not only the patientbut also the physician. Plantar fasci-itis is defined as an inflammation ofthe origin of the plantar fascia andsurrounding perifascial structures.There is no “gold standard” orbenchmark diagnostic criterion forplantar fasciitis, but the clinical pre-sentation is well recognized. The ac-cepted hallmarks are pain and palpa-ble tenderness in the area of themedial tubercle of the calcaneus,pain that is increased when takingthe first few steps in the morning,

and pain that is worse with contin-ued weight bearing. Despite exten-sive efforts taken to understand thisdisorder, foot surgeons continue todebate the source and etiology ofplantar heel pain as well as the mostappropriate modality of treatment.

Epidemiology

Plantar fasciitis is the most commoncause of plantar heel pain, account-ing for 80% of patients with symp-toms.2 It is estimated that 1 in 10persons may experience inferior heelpain at some time.3 Demographicsurveys indicate that nearly two mil-lion patients receive treatment ofplantar fasciitis each year in theUnited States,4 comprising 1% of allvisits to orthopaedists.5 The peakage of incidence in the general pop-ulation is between 40 and 60years.5,6 Risk factors include running

Steven K. Neufeld, MD

Rebecca Cerrato, MD

Dr. Neufeld is Founder and President,Orthopaedic Foot and Ankle Center ofWashington, Arlington, VA. Dr. Cerratois Foot and Ankle Fellow, Mercy MedicalCenter, Baltimore, MD.

None of the following authors or amember of their immediate families hasreceived anything of value from or ownsstock in a commercial company orinstitution related directly or indirectly tothe subject of this article: Dr. Neufeldand Dr. Cerrato.

Reprint requests: Dr. Neufeld,Orthopaedic Foot and Ankle Center,Suite 300, 2445 Army Navy Drive,Arlington, VA 22206-8316.

J Am Acad Orthop Surg 2008;16:338-346

Copyright 2008 by the AmericanAcademy of Orthopaedic Surgeons.

338 Journal of the American Academy of Orthopaedic Surgeons

athletes, occupations that involveprolonged standing, pes planus, lim-ited ankle dorsiflexion, and obesi-ty.7,8 In one third of cases, the con-dition involves both feet.7 Thedisorder is prevalent in persons withseronegative arthritis because manyof these patients have disease at thesite of attachment of tendons or lig-aments to bone.9

Anatomy

The plantar fascia originates at theanteromedial aspect of the calcaneusand spreads broadly as it extends dis-tally to divide into five digital bandsat the metatarsophalangeal joints.Each band inserts into the base ofthe proximal phalanx of each toe.Vertical fibers divide the plantar fas-cia, creating three separate compart-ments for the intrinsic plantar mus-cles. Additionally, fibers merge withthe dermis, transverse metatarsalligaments, and the flexor tendonsheaths. The plantar fascia is inelas-tic, with maximal elongation of4%.10 During the toe-off phase ofgait, the metatarsophalangeal jointsare dorsiflexed, resulting in high ten-sile forces concentrated at the calca-neal origin of the plantar fascia. Thiswas described in 1954 by Hicks,11

who named the phenomenon the“windlass effect” of the plantar fas-cia (Figure 1).

With walking, the heel absorbs aforce of 110% × body weight at heelstrike; with running, this force in-creases to 200%.2 The fat pad of thecalcaneus is a honeycomb pattern offibroelastic septa that completelyenclose fat globules. This closed-cellpattern of the fat pad allows it tofunction as a shock absorber. Afterage 40 years, the fat pad begins to at-rophy, with loss of water, collagen,and elastic tissue. The overall thick-ness and height of the fat pad de-creases, resulting in diminishedshock absorbency and reduced pro-tection of the calcaneal tuberosi-ty.10

Etiology

Plantar fasciitis was originally de-scribed in 1812 by Wood, who be-lieved it to be the result of inflamma-tion secondary to tuberculosis.12 Asinfectious theories were discredited,the role of the heel spur in plantar fas-ciitis was popularized. DuVries13 pro-moted the concept of physical im-pingement into the plantar fat pad.Cadaveric dissections demonstratedthe presence of the spur within theflexor digitorum brevis rather thanwithin the plantar fascia itself. Ap-proximately 50% of patients withheel pain will have heel spurs.14 Wil-liams et al15 found that 75% of pa-tients who had heel pain also hadspurs, compared with 63% of patientswith no heel pain. It is now widely ac-cepted that heel spurs can occur withplantar fasciitis, but they are not thecause.

As a result of cadaveric studies,entrapment of the first branch of thelateral plantar nerve (FBLPN) wasproposed as the source of plantar fas-ciitis.10 Histologic examination ofthe FBLPN in patients with chronicheel pain revealed evidence of de-myelination and perineural fibro-sis.16 Pain from FBLPN compressionhas been differentiated from that ofplantar fascial pain based on loca-

tion of maximal tenderness.17

The word fasciitis implies an in-flammatory process; however, histo-logic evidence does not support thisconcept. Findings demonstrate myx-oid degeneration, microtears in thefascia, collagen necrosis, and an-giofibroblastic hyperplasia.1 Thesechanges are more consistent with adegenerative process without inflam-mation, likely secondary to repetitivemicrotrauma at the origin of the plan-tar fascia.

Clinical Presentation

The diagnosis of plantar fasciitis isbased on the patient’s history andclinical examination. Patients reporta gradual onset of inferior heel painthat is intensely worse with the firststeps in the morning or after a peri-od of prolonged standing. The paintends to lessen with activity butworsens by the end of the day.6,18

The pain tends to be nonradiating,and associated nerve paresthesias arenot common.18 Plantar fasciitis in-volving both feet has been reportedto be as high as 30%.7 However, bi-lateral heel pain, in conjunctionwith joint pain and pain at multiplesites of tendon/ligament insertion,suggests a systemic rheumatologic

Figure 1

Note the incidental “heel spur” and plantar fascia inserting into the base of theproximal phalanges involved in the windlass mechanism.

Steven K. Neufeld, MD, and Rebecca Cerrato, MD

Volume 16, Number 6, June 2008 339

disorder. Unrelenting or nocturnalpain is a red flag that the pain may berelated to a different condition (eg,tumor, infection).

During the clinical examination,the foot and ankle should be inspect-ed during both stance and gait. A pesplanus or pes cavus foot deformitycan increase loading of the plantarfascia. An Achilles muscle/tendoncontracture is frequently associatedwith plantar fasciitis. Evaluating thespine and lower extremities can ex-pose any neurologic component tothe patient’s symptoms.

The location of the pain is impor-tant in making the correct diagnosis.The pain with plantar fasciitis is typ-ically localized to the medial tuber-cle of the calcaneus, at the origin ofthe plantar fascia. However, patientsmay have tenderness along anypoint of the plantar fascia.16 In ourexperience, passive dorsiflexion of

the toes will tighten the windlassmechanism and exacerbate thesymptoms. Any deviations from lo-cal pain isolated to the plantar heelshould raise the possibility of anoth-er diagnosis.

Differential Diagnosis

Although plantar fasciitis is themost common source of inferior orplantar foot pain, many conditionscan cause inferior heel pain.19 Acomplete history and physical exam-ination most often will direct thephysician to the appropriate diagno-sis and treatment plan7,20 (Table 1).

Neurogenic etiologies traditional-ly result from a nerve entrapment orcompression syndrome. Tarsal tun-nel syndrome and medial calcanealnerve compression produce painalong the medial and plantar areas ofthe foot. In addition, patients withthese conditions often report burn-ing and tingling and have a positiveTinel sign. Dorsiflexion of the toesdoes not exacerbate their symp-toms.

The FBLPN (Baxter nerve) inner-vates the abductor digiti quinti,quadratus plantae, and flexor digi-torum brevis muscles. It passes justsuperior to the insertion of the plan-tar fascia on the medial calcaneal tu-berosity. Compression of this nervecauses maximal pain over the plan-tar medial aspect of the foot, whichcan be confused with plantar fasci-itis.16 Because of the nerve’s closeproximity to the medial calcanealtubercle, many authors feel thatboth conditions are often present.

An L5-S1 radiculopathy canpresent with symptoms involvingplantar heel pain. A history that in-cludes radiating symptoms in the leg,combined with a thorough neurolog-ic examination (ie, reflexes, motorstrength), can facilitate diagnosis ofthis condition. Patients with periph-eral neuropathies, common in diabe-tes, frequently report foot and heelpain. Typically, these patients lack afocal area of discomfort and do not re-

port improvement with non–weightbearing.

Calcaneal stress fractures typical-ly present with diffuse swelling andwarmth of the hindfoot. Medial-lateral compression of the calcaneus(ie, the squeeze test) evokes pain inpatients with calcaneal stress frac-ture. Flexor hallucis tendinitis alsopresents with plantar heel pain; ten-derness with resisted flexion of thegreat toe can differentiate this condi-tion from plantar fasciitis. Painalong the midportion of the plantarfascia, in addition to palpable nod-ules within the fascial substance,points to plantar fibromatosis. Pa-tients with rupture of the plantarfascia typically describe acute onsetof pain. Examination may reveal asubtle collapse in the medial longi-tudinal arch and a palpable gap with-in the substance of the fascia. Mostof these ruptures heal successfullywith nonsurgical treatment involv-ing immobilization and prolongednon–weight bearing.21 Finally, pa-tients with fat pad atrophy reportcentralized heel pain. Palpation ofthe heel pad will reveal a flattened,atrophied surface.

Work-up

Imaging plays a limited role in rou-tine clinical evaluation for plantarfasciitis. Conventional radiographsare often unrewarding. Levy et al22

evaluated the cost effectiveness andclinical value of routine radiographsin patients with atraumatic plantarheel pain. Of 215 patients, no singleradiograph affected the diagnosis ortreatment. Therefore, radiographicevaluation would be appropriateonly in patients who fail to improvewith appropriate treatment in a rea-sonable amount of time or in pa-tients with an atypical history orphysical examination.

A triple-phase bone scan may re-veal increased uptake in the area ofthe medial calcaneal tubercle andcan be helpful in differentiating be-tween plantar fasciitis and a calca-

Table 1

Differential Diagnosis of Heel Pain

NeurologicTarsal tunnel syndromeFirst branch of the lateral plantar

nerve entrapmentMedial calcaneal nerve

entrapmentPeripheral neuropathyS1 radiculopathy

Soft tissuePlantar fascia ruptureEnthesopathiesFat-pad atrophyAchilles tendinitisFlexor hallucis longus tendinitisPlantar fibromatosisPosterior tibial tendinitis

SkeletalCalcaneal stress fractureBone contusionInfections (osteomyelitis/subtalar

pyoarthrosis)Subtalar arthritisInflammatory arthropathies

MiscellaneousNeoplasmVascular insufficiency

Plantar Fasciitis: Evaluation and Treatment


neal stress fracture.23 Proponents ofmagnetic resonance imaging (MRI)in the management of plantar fasci-itis argue that MRI is most helpful inexcluding other causes of heel pain.Typical MRI findings include fascialthickening and increased signal in-tensity in the substance of the plan-tar fascia.9 Ultrasonographic exami-nation of patients with plantarfasciitis has demonstrated thickened,hypoechoic fascia24 and is equally ef-fective in the diagnosis of plantar fas-ciitis, as are bone scintigraphy25 andMRI.26 Unlike these modalities, ultra-sound is quick and inexpensive, andit involves no radiation exposure.MRI or triple-phase bone scans shouldbe ordered to rule out occult pathol-ogy only when the heel pain has notresolved after 4 to 6 months of non-surgical treatment.

Less commonly ordered labora-tory testing to be considered includeblood testing and electromyographicnerve conduction velocity studies.Serum hematologic and immuno-logic testing can detect systemic dis-orders that contribute to heel pain.Human leukocyte antigen-B27, com-plete blood count, erythrocyte sedi-mentation rate, rheumatoid factor,antinuclear antibodies, and uric acidmay be considered in patients withbilateral or atypical heel pain.10 Elec-tromyography and nerve conductionvelocity studies are effective at iden-tifying spinal radiculopathy and dif-fuse peripheral neuropathy as well aslocal nerve entrapment, such as tar-sal tunnel syndrome. The most com-mon nerve entrapment confusedwith plantar fasciitis is the FBLPN.Unfortunately,electrodiagnosticstud-ies are not helpful in making this di-agnosis.16

Nonsurgical Treatment

A wide variety of management strat-egies have been developed to treatplantar fasciitis. Nonsurgical treat-ment is the mainstay of treatingplantar heel pain. A systematic re-view in 2003 evaluated 26 different

conservative treatments that havebeen recommended for the treat-ment of plantar fasciitis.3 Of these,only heel pads, orthoses, corticoster-oid injections, night splints, and ex-tracorporeal shock wave therapy(ESWT) have been evaluated in ran-domized trials. Since then, addition-al randomized controlled trials, pri-marily focusing on ESWT, have beenpublished.

NonsteroidalAnti-inflammatory Drugs

In a retrospective review, Wolginet al18 found that 39 of 51 patients(76%) recorded as having used non-steroidal anti-inflammatory drugs(NSAIDs) had “successful” out-comes. No conclusion could bedrawn, however, because any givenpatient could have used more thanone treatment. Gill and Kiebzak6 re-viewed the effectiveness of severalnonsurgical treatments and foundthat 27% of patients reported signif-icant improvement with use ofNSAIDs, whereas 28% felt that theywere ineffective. Recently, in a pro-spective, double-blind randomizedcontrolled study, Donley et al27 com-pared the pain and disability scoresbetween a group treated with anNSAID (celecoxib) and a placebogroup. Although a trend toward im-proved pain relief was seen in theNSAID group, no statistical signifi-cance was obtained between the twotreatment arms. To date, no studyhas specifically examined the effec-tiveness of this treatment alone.

Orthoses/InsertsFoot orthoses are designed to op-

timize biomechanical loading of thefoot, decrease excessive pronation,off-load the plantar fascia at its ori-gin, and recreate the shape of the heelpad. Commonly used orthoses in-clude prefabricated silicone/rubberheel cups, prefabricated arch sup-ports, felt pads, and custom arch sup-ports. Pfeffer et al4 randomized 236patients into five treatment groups:one control and four with different

shoe inserts. The patients treatedwith the prefabricated inserts (ie, sil-icone heel pad, felt pad, rubber heelcup) had superior improvement inheel pain. A later participant-blinded,randomized controlled trial divided135 patients into three groups (shamorthosis, off-the-shelf orthosis, cus-tomized orthosis).28 At the 12-monthreview, there was no significant dif-ference between all groups.

Physical TherapyMany local therapy modalities

have been proposed for treatment ofplantar fasciitis. Support for thera-pies such as icing, heat, and massagehas largely been based on anecdotaldata. One prospective, double-blindrandomized controlled study did notdemonstrate any benefit from mag-netic insoles.7 Other small, random-ized controlled trials showed noevidence to support therapeutic ul-trasound, low-intensity laser thera-py, or exposure to an electron-generating device.3 Gudeman et al29

compared iontophoresis of dexa-methasone with a placebo group in aprospective, double-blind, random-ized controlled study; these authorsreported a benefit in pain relief withthe treatment group at 2 weeks butno statistically significant differenceat 1 month.29

A stretching program has tradi-tionally been the primary treatmenttherapy modality for patients withplantar fasciitis. Protocols have var-ied from Achilles tendon stretchingto plantar fascia–specific stretching.The goal of plantar fascia–specificstretching is to optimize tissue ten-sion through a controlled stretch ofthe plantar fascia by recreating thewindlass mechanism (Figure 2). AnAchilles tendon–stretching programtypically involves several stretchesthat attempt to maximize the lengthof both the gastrocnemius and soleusmuscle groups (Figure 3). One recentprospective, nonblinded, randomizedcontrolled study by DiGiovanni etal30 compared these two protocols.The authors showed that heel pain



was eliminated or improved at 8weeks in 52% of patients treatedwith the plantar fascia–specificstretching program versus only 22%of patients participating in the Achil-les tendon–stretching program. The2-year follow-up study reported nodifference between the two groups.30

InjectionsDespite the widespread practice of

treating plantar fasciitis by injectionof corticosteroids, typically com-bined with a local anesthetic, there islimited evidence of its effectivenessin providing sustained pain relief.One study found improved symp-toms at 1 month but not at 6 monthscompared with a control group.31 Re-cently, interest has developed in theuse of ultrasonography to improvethe accuracy, and therefore the out-come, of corticosteroid injection. Astudy by Tsai et al32 using this tech-nique showed a lower recurrence rateof heel pain. However, a second studyby Kane et al25 did not demonstrateultrasound-guided injection to be anymore effective than the palpation-guided technique. Complications as-sociated with corticosteroid injectionhave been reported, including rup-

ture of the plantar fascia and fat padatrophy.33

Over the past several years, botu-linum toxin A (BTX-A) has been in-creasingly used for various medicalconditions, including chronic tenniselbow (ie, lateral epicondylitis). In-terest in its possible role in the treat-ment of plantar fasciitis has led toseveral recent clinical trials studyingits efficacy.34,35 It is proposed thatbotulinum toxin may be effectivenot only secondary to paralysis ofthe injected muscles (ie, abductorhallucis, flexor digitorum brevis,quadratus plantae) but also becauseof direct analgesic and anti-inflammatory properties.35 Babcocket al34 studied the effect of BTX-Ain a double-blind, randomized con-trolled trial. The authors demon-strated statistically significant im-provement in the BTX-A group in allstudied measures, with no side ef-fects. These patients, however, werefollowed for only 8 weeks. Furtherinvestigation with larger numbersand longer follow-up are needed be-fore the role of botulinum toxin in-jections in the treatment of plantarfasciitis is established.

Night Splints and WalkingCasts

The use of night splints has beenpostulated to help alleviate morningstart-up pain by maintaining fasciastretching during long periods ofrest. Wapner and Sharkey,36 who rec-ommended 5º of dorsiflexion in thesplint, reported that 11 of their 14patients (79%) improved. Yet recentlarge, randomized controlled trialshave produced conflicting results. Acrossover prospective randomizedtrial of 37 patients with chronicplantar fasciitis found a benefit ofnight splinting worn for 1 month.37

Conversely, in a prospective ran-domized study of 116 patients, Probeet al38 found no statistically signifi-cant benefit in adding night splint-ing to a standard nonsurgical proto-col of anti-inflammatory medicationand stretching.

Tisdel and Harper39 hypothesizedthat a short period of casting wouldunload the heel and immobilize theplantar fascia, thus minimizing re-petitive microtrauma. Several retro-spective studies have supported theefficacy of casting;6,39 however, noprospective controlled trials of im-mobilization have been published.

Extracorporeal ShockWave Therapy

Extracorporeal shock wave therapy(ESWT) is a recent and increasinglypopular therapeutic approach usedto treat recalcitrant plantar fasciitis.It has been shown to be effective in60% to 80% of cases. ESWT is basedon lithotripsy technology, in whichshock waves (ie, acoustic impulses)are targeted to the plantar fascia or-igin. Three modalities that can beused to generate the shock wave in-clude electrohydraulic, electromag-netic, and piezoelectric. Currently,the US Food and Drug Administra-tion has approved electrohydraulic(high-energy) and electromagnetic(low-energy) devices for the treat-ment of chronic plantar heel pain.2

However, the therapeutic mecha-nism involved still remains a topicof speculation. Ogden et al40 havehypothesized that the shock wavescause a controlled microdisruptionof plantar fascial tissue, which ini-tiates a healing response within thefascia. It is thought that this re-sponse promotes revascularization,releases local growth factors; re-cruits appropriate stem cells, and al-lows the fascia to adapt to biologicand biomechanical demands. Since1996, there have been many reportsof good and excellent results fromthe use of ESWT application forplantar fasciitis, both in Europe andthe United States.40-43

Currently, no consensus existsconcerning the repeated use of low-energy shock waves39 versus high-energy waves.40,44 Low-energy ESWTis defined as shock waves between0.04 and 0.12 mJ/mm2, and high-

Figure 2

Plantar fascia–specific stretch. Withthe ankle dorsiflexed, the toes aredorsiflexed using the patient’s onehand. The stretch is confirmed bypalpating the tension in the plantarfascia with the other hand.



energy ESWT is at levels >0.12 mJ/mm2. In the past few years, results ofseveral well-designed, randomizedcontrolled studies have supportedboth approaches. In their prospectiverandomized trial, Rompe et al43 con-cluded that, at 6 and 12 months,three treatments with 2,100 low-energy shocks were safe and effec-tive at reducing morning pain in thetreatment group compared with thecontrol group. Maier et al42 reportedgood or excellent results in 75% of48 heels after low-energy shockwaves were applied three times atweekly intervals. In their prospec-tive randomized trial, Ogden et al40

reported that a single application of1,500 high-energy shocks was safe,with good results in 47% of their pa-tients. Buch et al44 reported that62% of patients who received oneapplication of 3,800 high-energyshocks had good results.

In a randomized, placebo-con-trolled, double-blind clinical trial,Kudo et al45 confirmed that, at 3months, there was a statistically sig-nificant improvement in symptomsin a treatment group that received oneapplication of 3,800 high-energyshock waves. In another randomizedcontrolled trial, 83% of patients whoreceived 1,500 high-energy shocks in

a single session reported good or ex-cellent results at a follow-up of 72months.46 The authors did not reportany ill effects from the ESWT treat-ment.

The procedure is commonly per-formed with the patient under con-scious sedation along with regionalanesthesia (ankle block). It is welltolerated by patients, and no seriousside effects have been reported.43

Current indications for ESWT in-clude 6 months of plantar fasciitisheel pain that has been recalcitrantto at least three nonsurgical thera-py modalities. Contraindications toESWT include patients with hemo-philia, coagulopathies, malignancy,and open bone growth physes.

Surgical Treatment

Although plantar fasciitis is often aself-limited problem that does notcause excessive disability in most pa-tients, surgery may be indicated whensymptoms persist. Unfortunately, norandomized controlled studies haveevaluated the effectiveness of surgeryin comparison with nonsurgical treat-ment programs to manage thesecases.

Plantar fasciotomy, either partialor complete, is the common surgical

procedure chosen for treating recal-citrant cases. Although it has beenreported to have an acceptable suc-cess rate,14,47,48 several studies haveshown that <50% of patients report-ed satisfaction following surgery andthat many patients continue to havefunctional limitations.49

Release of the plantar fascia hasrisks of complications and can be as-sociated with prolonged healing andrehabilitation times. Plantar fasciarelease is thought to alter the biome-chanics of the foot and decrease footarch stability. Partial and total re-lease of the plantar fascia has beenshown to decrease tarsal arch height,lead to increased strain of the cuboidattachment areas of the plantar liga-ments, and intensify stress in themidfoot and metatarsal bones. Post-operatively, patients may experienceacute plantar fasciitis, forefoot stressfractures, calcaneal and cuboid frac-tures, and medial or lateral columnfoot pain.14,50 Biomechanical andfinite-element studies have shownthat release of >40% of the plantarfascia has detrimental effects on oth-er ligamentous and bony structuresin the foot; therefore, releases shouldbe limited.50

A large number of surgical tech-niques have been described for plan-

Figure 3

Achilles tendon stretch. A, An Achilles tendon–stretching protocol should involve gentle ankle dorsiflexion with both the kneesflexed to isolate the soleus muscle. B, The knee is extended to involve the entire gastrocnemius–soleus complex. C, Ankledorsiflexion over a stool or step will maximize the length of the Achilles tendon.



tar fasciitis, including endoscopicplantar fascia release. There is littleconsensus, however, as to the bestsurgical technique, and no studiesdirectly compare open surgery withendoscopic procedures. When thereis suspicion of entrapment of the cal-caneal branches of the tibial nerve,particularly the FBLPN, nerve de-compression can be performed.16

The patient lies supine on the op-erating room table, and an ankle orpopliteal nerve block is performed.A tourniquet is not routinely used.A 5-cm oblique incision is made onthe medial heel just above theweight-bearing skin of the heel pad.The superficial fascia of the abductorhallucis muscle is divided. The mus-cle is retracted superiorly. TheFBLPN lies between the deep fasciaof the abductor hallucis muscle andthe medial border of the quadratusplantae muscle. This taut fascia iscarefully divided, thus decompress-ing the nerve. A small portion of theplantar fascia near its insertion tothe os calcis is incised. A heel spur,if present, is carefully removed.

When endoscopic plantar fasciot-omy is performed, a 1-cm incision ismade along the medial heel just an-terior to the weight-bearing plantarskin. A hemostat is used to bluntlydissect down to the plantar fascia, andthe subcutaneous layer is freed fromits inferior edge. In the pathwaycreated by the hemostat, a bluntobturator/cannula is introduced frommedial to lateral, inferior to the fas-cia. The obturator is removed, and a30°, 4.0-mm endoscope is placedwithin the cannula. The plantar fas-cia can be seen superiorly. Care istaken to transect the medial 25% to50% of the central plantar fascia us-ing a disposable cannulated knife. Astop-device is used to prevent exces-sive transection.

Because of the relative ease andincreased popularity of procedure,the American Orthopaedic Foot andAnkle Society (AOFAS) developed aposition statement regarding heelsurgery that is based on expert opin-

ion.51 Essentially, the society recom-mends nonsurgical treatment beforeundergoing surgical treatment. Non-surgical treatment should be usedfor a minimum of 6 months and,preferably, for 12 months because>90% of patients respond positivelyto nonsurgical management. TheAOFAS recommends initial treat-ments with heel padding, medica-tions, and stretching; customorthoses and extended physical ther-apy are used as a second-line option.Furthermore, a medical evaluationshould be considered before surgery,and the patient must be advised ofthe risks and complications of sur-gery. In addition, an open procedure,as opposed to an endoscopic proce-dure, should be done when nervecompression is involved. This rec-ommendation is based on sugges-tions that the risk of nerve injurymay be higher with endoscopic pro-cedures than with open procedures.

A new, less invasive surgical tech-nique using bipolar radiofrequencymicrotenotomy (TOPAZ MicroDe-brider; ArthroCare Sports Medicine,Sunnyvale, CA) has been described totreat recalcitrant plantar fasciitis.52

Radiofrequency stimulation, both inthe heart and in wound healing, hasled to increased angiogenesis. Inves-tigators have reported that this tech-nique was technically simple to per-form and was much less invasivethan conventional surgery. Patientshad a rapid and uncomplicated recov-ery and reported minimal to no pain7 to 10 days following the procedure.Pain relief persisted or improvedthrough 24 months.52 Althoughpromising, this procedure has notbeen studied in a prospective, ran-domized trial in patients with plan-tar fasciitis.

Summary

In our algorithm for the treatment ofplantar fasciitis, the patient initiallyis counseled to pursue daily activi-ties as tolerated; pain should be theguide to his or her activities. When

a patient can tolerate over-the-counter anti-inflammatory medica-tions, these are recommended. Nar-cotics are not routinely prescribed. Apair of heel pads or over-the-counterorthoses are dispensed at the time ofthe first office visit, and patients aregiven handouts describing an exer-cise program (Figures 2 and 3).Theseexercises should be done before get-ting out of bed in the morning, in theafternoon, and before bedtime, aswell as after any period of prolongedsitting. In addition, a night splint isoften fitted to keep the plantar fasciastretched during sleep. The patientis reassured that surgery is uncom-mon. Frequently, patients come intothe office with radiographs showinga heel spur and request to have it re-moved. The physician should at-tempt to minimize the role of the so-called spur, which often requirescounseling to dispel myths that thepatient was told from friends or oth-er clinicians.

According to this algorithm, thepatient is treated for approximately4 to 6 weeks. When the pain is notcontrolled, multiple treatment mo-dalities are attempted to manage thepain, assuming that the fasciitis runsits course and resolves on its own.First, a corticosteroid injection isgiven in the region of the anterome-dial calcaneal tuberosity, followedby immobilization in a cast or Camwalker. Second, physical therapy isstarted, a custom orthosis with adeep heel cup is made, and pre-scription-strength NSAIDs are giv-en. In addition, a lateral radiographof the heel is taken prior to any an-ticipated invasive procedure to ruleout a stress fracture or other patho-logic process.

Rarely, at a follow-up visit, ap-proximately 4 to 6 weeks later, thepatient still reports discomfort. Ifsome improvement has been made,the treatment plan is continued. Ifno improvement is noted, MRI maythen be ordered to help confirm thediagnosis of plantar fasciitis, partic-ularly when there are other con-



founding pathologic conditions orwhen the course is atypical.

Alternative treatment may beconsidered, such as the use of ESWT.Finally, if the patient has failed allother treatments and has significantpain that prevents him or her fromwork and recreation, surgery is of-fered. When surgery is necessary, weprefer a small plantar medial inci-sion with either release of the medi-al one-third edge of the plantar fasciaor decompression of the FBLPN,along with the subtotal plantar fas-cia release.

Nonsurgical treatment of proxi-mal plantar fasciitis has a reportedsuccess rate of 85% to 90%.19,53 Theclinician needs to counsel the pa-tient that it may take as long as 6 to12 months for all pain to resolve.Surgical treatment of plantar fasci-itis should be considered only as a fi-nal resort when prolonged nonsurgi-cal treatment (>12 months) fails toprovide pain relief. When fasciotomyis necessary, partial release of <40%is recommended.50

References

Evidence-based Medicine: There area number of level I/II prospectiverandomized studies referenced (3,27, 28, 29, 30, 31, 34, 37, 38, 43, 45)along with a number of excellentcase-control retrospective studies.

Citation numbers printed in boldtype indicate references publishedwithin the past 5 years.

1. Lemont H, Ammirati KM, Usen N:Plantar fasciitis: A degenerative pro-cess (fasciosis) without inflamma-tion. J Am Podiatr Med Assoc 2003;93:234-237.

2. Tisdel CL: Heel pain, in OrthopaedicKnowledge Update: Foot and Ankle3. Rosemont, IL: American Academyof Orthopaedic Surgeons, 2003, pp113-119.

3. Crawford F, Thomson C: Interven-tions for treating plantar heel pain.Cochrane Database Syst Rev 2003;3:CD000416.

4. Pfeffer G, Bacchetti P, Deland J, et al:Comparison of custom and prefabri-

cated orthoses in the initial treatmentof proximal plantar fascitis. FootAnkle Int 1999;20:214-221.

5. Riddle DL, Schappert SM: Volume ofambulatory care visits and patterns ofcare for patients diagnosed with plan-tar fasciitis: A national study of med-ical doctors. Foot Ankle Int 2004;25:303-310.

6. Gill LH, Kiebzak GM: Outcome ofnonsurgical treatment for plantar fas-ciitis. Foot Ankle Int 1996;17:527-532.

7. Buchbinder R: Clinical practice: Plan-tar fasciitis. N Engl J Med 2004;350:2159-2166.

8. Riddle DL, Pulisic M, Pidcoe P, et al:Risk factors for plantar fasciitis: Amatched case-control study. J BoneJoint Surg Am 2003;85:872-877.

9. Berkowitz JF, Kier R, Rudicel S: Plan-tar fasciitis: MR imaging. Radiology1991;179:665-667.

10. Lee TH, Maurus PB: Plantar heel pain,in Coughlin MJ, Mann RA, SaltzmanCL (eds): Surgery of the Foot and An-kle, ed 8. Philadelphia, PA: MosbyElsevier, 2007, vol 1, pp 689-705.

11. Hicks JH: The mechanics of the foot:II. The plantar aponeurosis and thearch. J Anat 1954;88:25-30.

12. Leach RE, Seavey MS, Salter DK: Re-sults of surgery in athletes with plan-tar fasciitis. Foot Ankle 1986;7:156-161.

13. DuVries HL: Heel spur (calcanealspur). Arch Surg 1957;74:536-542.

14. Davies MS, Weiss GA, Saxby TS:Plantar fasciitis: How successful issurgical intervention? Foot Ankle Int1999;20:803-807.

15. Williams PL, Smibert JG, Cox R, et al:Imaging study of the painful heel syn-drome. Foot Ankle 1987;7:345-349.

16. Baxter DE, Pfeffer GB: Treatment ofchronic heel pain by surgical releaseof the first branch of the lateral plan-tar nerve. Clin Orthop Relat Res1992;279:229-236.

17. Baxter DE, Thigpen CM: Heel pain:Operative results. Foot Ankle 1984;5:16-25.

18. Wolgin M, Cook C, Graham C, et al:Conservative treatment of plantarheel pain: Long-term follow-up. FootAnkle Int 1994;15:97-102.

19. Gill LH: Plantar fasciitis: Diagnosisand conservative treatment. J AmAcad Orthop Surg 1997;5:109-117.

20. Cole C, Seto C, Gazewood J: Plantarfasciitis: Evidence-based review ofdiagnosis and therapy. Am FamPhysician 2005;72:2237-2242.

21. Saxena A, Fullem B: Plantar fasciaruptures in athletes. Am J Sports

Med 2004;32:662-665.22. Levy JC, Mizel MS, Clifford PD, et al:

Value of radiographs in the initialevaluation of nontraumatic adult heelpain. Foot Ankle Int 2006;27:427-430.

23. Graham CE: Painful heel syndrome:Rationale of diagnosis and treatment.Foot Ankle 1983;3:261-267.

24. Akfirat M, Sen C, Gunes T: Ultra-sonographic appearance of the plantarfasciitis. Clin Imaging 2003;27:353-357.

25. Kane D, Greaney T, Shanahan M, et al:The role of ultrasonography in thediagnosis and management of idio-pathic plantar fasciitis. Rheuma-tology 2001;40:1002-1008.

26. Sabir N, Demirlenk S, Yagci B, et al:Clinical utility of sonography in diag-nosing plantar fasciitis. J UltrasoundMed 2005;24:1041-1048.

27. Donley BG, Moore T, Sferra J, et al:The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) inthe treatment of plantar fasciitis: Arandomized, prospective, placebo-controlled study. Foot Ankle Int2007;28:20-23.

28. Landorf KB, Keenan A, Herbert RD:Effectiveness of foot orthoses to treatplantar fasciitis: A randomized trial.Arch Intern Med 2006;166:1305-1310.

29. Gudeman SD, Eisele SA, Heidt RS Jr,et al: Treatment of plantar fasciitisby inotophoresis of 0.4% dexametha-sone: A randomized, double-blind,placebo-controlled study. Am JSports Med 1997;25:312-316.

30. DiGiovanni BF, Nawoczenski DA,Malay DP, et al: Plantar fascia–specif-ic stretching exercise improves out-comes in patients with chronic plan-tar fasciitis: A prospective clinicaltrial with two-year follow-up. J BoneJoint Surg Am 2006;88:1775-1781.

31. Crawford F, Atkins D, Young P, et al:Steroid injections for heel pain: Evi-dence of short-term effectiveness. Arandomized controlled trial. Rheuma-tology 1999;38:974-977.

32. Tsai WC, Hsu CC, Chen CP, Chen MJ,Yu TY, Chen YJ: Plantar fasciitistreated with local steroid injection:Comparison between sonographic andpalpation guidance. J Clin Ultra-sound 2006;34:12-16.

33. Acevedo JI, Beskin JL: Complicationsof plantar fascia rupture associatedwith corticosteroid injection. FootAnkle Int 1998;19:91-97.

34. Babcock MS, Foster L, Pasquina P, etal: Treatment of pain attributed to plan-tar fasciits with botulinum toxin A:



A short-term, randomized, placebo-controlled, double-blind study. Am JPhys Med Rehabil 2005;84:649-654.

35. Placzek R, Deuretzbacher G, MeissAL, et al: Treatment of chronic plan-tar fasciitis with botulinum toxin A.Clin J Pain 2006;22:190-192.

36. Wapner KL, Sharkey PF: The use ofnight splints for treatment of recalci-trant plantar fasciitis. Foot Ankle1991;12:135-137.

37. Powell M, Post WR, Keener J, et al:Effective treatment of chronic plantarfasciitis with dorsiflexion nightsplints: A crossover prospective ran-domized outcome study. Foot AnkleInt 1998;19:10-18.

38. Probe RA, Baca M, Adams R, et al:Night splint treatment for plantarfasciitis: A prospective randomizedstudy. Clin Orthop Relat Res 1999;368:190-195.

39. Tisdel CL, Harper MC: Chronic plan-tar heel pain: Treatment with a shortleg walking cast. Foot Ankle Int1996;17:41-42.

40. Ogden JA, Alvarez R, Levitt R, et al:Shock wave therapy for chronic prox-imal plantar fasciitis. Clin OrthopRelat Res 2001;387:47-59.

41. Chen HS, Chen LM, Huang TW:Treatment of painful heel syndromewith shock waves. Clin Orthop

Relat Res 2001;387:41-46.42. Maier M, Steinborn M, Schmitz C, et

al: Extracorporeal shock wave appli-cation for chronic plantar fasciitis as-sociated with heel spurs: Prediction ofoutcome by magnetic resonance im-aging. J Rheumatol 2000;27:2455-2462.

43. Rompe JD, Decking J, Schoellner C, etal: Shock wave application for chronicplantar fasciitis in running athletes: Aprospective, randomized, placebo-controlled trial. Am J Sports Med2003;31:268-275.

44. Buch M, Knorr U, Fleming L, et al: Ex-tracorporeal shockwave therapy insymptomatic heel spurs: An over-view. Orthopade 2002;31:637-644.

45. Kudo P, Dainty K, Clarfield M, et al:Randomized, placebo-controlled, dou-ble-blind clinical trial evaluating thetreatment of plantar fasciitis with anextracorporeal shockwave therapy(ESWT) device: A North American con-firmatory study. J Orthop Res 2006;24:115-123.

46. Wang CJ, Wang FS, Yang KD, et al:Long-term results of extracorporealshockwave treatment for plantar fas-ciitis. Am J Sports Med 2006;34:592-596.

47. Woelffer KE, Figura MA, Sandberg NS,et al: Five-year follow-up results of in-

step plantar fasciotomy for chronicheel pain. J Foot Ankle Surg 2000;39:218-223.

48. Vohra PK, Giorgini RJ, Sobel E, et al:Long-term follow-up of heel spur sur-gery: A 10-year retrospective study.J Am Podiatr Med Assoc 1999;89:81-88.

49. Conflitti JM, Tarquinio TA: Operativeoutcome of partial plantar fasciecto-my and neurolysis to the nerve of theabductor digiti minimi muscle for re-calcitrant plantar fasciitis. FootAnkle Int 2004;25:482-487.

50. Cheung JT, An K, Zhang M: Conse-quences of partial and total plantarfascia release: A finite element study.Foot Ankle Int 2006;27:125-132.

51. American Orthopaedic Foot & AnkleSociety. AOFAS Position Statement:Endoscopic and Open Heel Surgery.Available at: http://www.aofas.org/i4a/pages/index.cfm?pageid=3680. Ac-cessed April 29, 2008.

52. Tasto JP: The use of bipolar radiofre-quency microtenotomy in the treat-ment of chronic tendinosis of the footand ankle. Techniques Foot AnkleSurg 2006;5:110-116.

53. Martin RL, Irrgang JJ, Conti SF: Out-come study of subjects with inser-tional plantar fasciitis. Foot AnkleInt 1998;19:803-811.



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