Makindo Medical Notes

Bilateral plantar fasciitis may suggest underlying systemic conditions such as spondyloarthropathies.

About Plantar Fasciitis

Plantar Fasciitis is a common musculoskeletal condition characterized by inflammation of the plantar fascia, a thick band of tissue that runs along the bottom of the foot connecting the heel bone to the toes. It affects up to 10% of the population and is a leading cause of heel pain. While generally benign, plantar fasciitis can significantly impact daily activities and quality of life. Plantar fasciitis is a prevalent cause of lower heel pain, particularly among athletes and individuals with occupations that require prolonged standing. There may be a small increase in the risk of developing chronic foot issues if plantar fasciitis is not appropriately managed.

Aetiology

Plantar fasciitis arises from repetitive strain and overuse, leading to microtears and inflammation at the fascial enthesis (the attachment point of the plantar fascia to the heel bone). Various factors contribute to its development:

• Inflamed Fascial Enthesis: Chronic inflammation and degeneration of the plantar fascia due to excessive mechanical stress.
• Heel Spurs: Bony projections on the heel bone that may develop in response to plantar fascia tension, although their presence does not necessarily correlate with pain.

Clinical Presentation

• Lower Heel Pain: Described as throbbing or searing, especially noticeable during walking or standing.
• Initial Steps Pain: Pain is most intense with the first steps in the morning or after periods of rest and tends to decrease with continued activity.
• Aggravating Factors: Pain worsens when barefoot or walking upstairs due to increased strain on the plantar fascia.
• Tenderness: Palpable tenderness over the medial aspect of the calcaneum (heel bone).
• Bilateral Symptoms: While unilateral pain is more common, bilateral plantar fasciitis may suggest underlying systemic conditions such as spondyloarthropathies.

Risks

• Age: More common in individuals aged 40-60 years.
• Obesity: Excess body weight increases the strain on the plantar fascia.
• Prolonged Standing: Occupations or activities that require long periods of standing or walking.
• Foot Mechanics: Flat feet, high arches, or abnormal walking patterns can contribute to plantar fascia stress.
• Improper Footwear: Shoes lacking proper support or cushioning can exacerbate plantar fascia strain.
• Athletic Activities: High-impact sports or activities that involve repetitive foot movements.

Differential Diagnosis

• Achilles Tendinitis: Inflammation of the Achilles tendon causing pain at the back of the heel.
• Bursitis: Inflammation of the bursae around the heel bone, leading to similar heel pain.
• Stress Fracture: Small cracks in the heel bone can mimic plantar fasciitis pain.
• Sever's Disease: Inflammatory process affecting the growth plate of the heel in children and adolescents.
• Peripheral Neuropathy: Nerve damage causing pain and discomfort in the foot.

Investigations

• Clinical Examination: Physical assessment to evaluate pain location, tenderness, and foot mechanics.
• Imaging Studies:
  • Lateral X-Ray: May reveal the presence of heel spurs, although their absence does not rule out plantar fasciitis.
  • Ultrasound: Useful for assessing the plantar fascia thickness and detecting tears or inflammation.
  • Magnetic Resonance Imaging (MRI): Employed in atypical cases to visualize soft tissue structures and rule out other pathologies.
• Other Tests:
  • Gait Analysis: Evaluates walking patterns and identifies biomechanical issues contributing to plantar fascia strain.

Management focuses on relieving pain, reducing inflammation

• Conservative Treatments:
  • Rest: Reducing activities that exacerbate heel pain to allow the plantar fascia to heal.
  • Heel Pads/Insolles: Providing cushioning and arch support to alleviate stress on the plantar fascia.
  • Plantar Fascia Stretching: Regular stretching exercises to improve flexibility and reduce tension.
  • Customized Night Splints: Wearing splints overnight to maintain plantar fascia stretching and prevent morning pain.
  • Physical Therapy: Includes manual therapy, strengthening exercises, and modalities such as ultrasound or ice therapy.
• Pharmacological Treatments:
  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): To reduce pain and inflammation.
  • Steroid Injections: Can provide acute pain relief but carry a risk of plantar fascia rupture if overused.
• Minimally Invasive Procedures:
  • Extracorporeal Shock Wave Therapy (ESWT): Uses sound waves to stimulate healing of the plantar fascia.
• Surgical Intervention:
  • Endoscopic Plantar Fasciotomy: Minimally invasive surgery to release tension in the plantar fascia.
  • Open Plantar Fasciotomy: Reserved for severe cases where conservative treatments have failed.
• Lifestyle Modifications:
  • Maintaining a healthy weight to reduce stress on the plantar fascia.
  • Wearing appropriate footwear with adequate support and cushioning.
  • Avoiding walking barefoot, especially on hard surfaces.
• Self-Limiting Nature:
  • Most cases of plantar fasciitis resolve over 3-5 years with appropriate management.

Prognosis

The prognosis for plantar fasciitis is generally favorable with timely and appropriate treatment. Most individuals experience significant pain relief and functional improvement within months. However, chronic cases may require more intensive interventions:

• Early Intervention: Leads to quicker resolution of symptoms and reduces the risk of chronic pain.
• Chronic Cases: May require surgical intervention and comprehensive rehabilitation to restore normal function.
• Recurrence: Preventive measures, such as maintaining a healthy weight and wearing supportive footwear, are essential to minimize the risk of recurrence.

Conclusion

Plantar fasciitis is a prevalent and often debilitating condition that significantly affects quality of life. Early recognition and comprehensive management, including conservative treatments and lifestyle modifications, are crucial for effective pain relief and functional recovery. In refractory cases, minimally invasive procedures or surgery may be necessary. Preventive strategies and patient education play a vital role in reducing the incidence and recurrence of plantar fasciitis.

References

• American Orthopaedic Foot & Ankle Society. Plantar Fasciitis. Available at: https://www.aofas.org
• Mayo Clinic. Plantar Fasciitis. Available at: https://www.mayoclinic.org
• Keene JS, et al. Plantar Fasciitis. J Am Acad Orthop Surg. 2004;12(7):468-476.
• Rees J, et al. Plantar Fasciitis: A Review of Current Treatments. Foot Ankle Clin. 2016;21(3):425-438.
• Langevin HM, et al. Plantar Fasciitis: Pathophysiology and Current Management. Foot Ankle Int. 2013;34(7):914-918.
• National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Plantar Fasciitis. Available at: https://www.niams.nih.gov