Plantar fascitis
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Plantar fasciitis is inflammation of the plantar fascia - the thick band of connective tissue running from the calcaneus to the toes. It's the most common cause of heel pain, typically presenting with sharp pain on the first steps in the morning or after rest, due to re-stretching of a contracted fascia.
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"plantar fasciitis"[MeSH Terms] AND treatment
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Excellent content from multiple authoritative sources. Here is the complete overview:
Plantar Fasciitis
Definition & Anatomy
Plantar fasciitis is the most common cause of plantar heel pain in adults. The plantar fascia is a fibrous band originating at the medial calcaneal tuberosity, fanning across the plantar foot, and splitting to insert into the plantar aspects of the proximal phalanges. Despite the "-itis" name, it is now understood to be primarily a degenerative condition (fasciosis) driven by chronic microtears and repetitive loading, rather than true acute inflammation.
- Miller's Review of Orthopaedics, p. 592
- Textbook of Family Medicine 9e
Pathophysiology
Repeated microtears at the origin of the plantar fascia initiate an injury-repair cycle, leading to a traction enthesophyte (heel spur). The condition is strongly associated with gastrocnemius-soleus contracture, which increases tensile stress on the fascia during the push-off phase of gait.
Key point: heel spurs are a consequence, not the cause, of plantar fasciitis and have little independent diagnostic significance.
Risk Factors
| Factor | Notes |
|---|---|
| BMI > 30 kg/m² | Single biggest risk factor |
| Pes planus (flat foot) | Reduces arch shock absorption |
| Pes cavus (high arch) | Increases fascia tension |
| Limited ankle dorsiflexion | Tightens fascial origin on push-off |
| Prolonged standing / walking on hard surfaces | Overuse mechanism |
| Running (especially on harder surfaces) | Sudden change in training surfaces |
| Faulty footwear | Lack of arch support |
Clinical Presentation
- Sharp, stabbing heel pain worst with first steps in the morning or after prolonged inactivity ("post-static dyskinesia")
- Pain typically improves with walking but worsens again with prolonged activity
- Pain increased by walking barefoot or climbing stairs
- Bilateral in a significant subset of patients
Physical exam: Point tenderness over the medial plantar tuberosity of the calcaneus at the proximal fascia insertion. Passive dorsiflexion of the toes (windlass test) may reproduce symptoms.
A small subset has pain from entrapment of the first branch of the lateral plantar nerve (Baxter's nerve) - this should be considered if symptoms are refractory.
Diagnosis
Primarily clinical - history and exam alone are usually sufficient.
- X-rays (weight-bearing): First imaging step; may show heel spur (not diagnostic); excludes stress fracture, tumor, subtalar arthritis
- Ultrasound: Shows fascia thickening (>4 mm) and hypoechogenicity at calcaneal insertion - useful and inexpensive
- MRI: Sensitive - shows fascia thickening and surrounding edema; not routinely required but helpful in atypical or refractory cases
Treatment
Nonoperative (effective in 90-95% within 12 months)
First-line:
- Plantar fascia-specific stretching and Achilles/heel cord stretching - cornerstone of treatment
- Ice/heat, massage
- Cushioned heel inserts / medial arch orthotics
- NSAIDs - analgesic benefit (note: condition is not truly inflammatory, so benefit is likely analgesic rather than anti-inflammatory)
- Activity modification - eliminate inciting activities
Second-line:
- Night splints (keep ankle at neutral/slight dorsiflexion to prevent fascial contracture during sleep)
- Foot taping/strapping
- Physical therapy
- Walking casts (for severe cases)
- Corticosteroid injection: Provides short-term relief (~1 month), but risk of plantar fascia rupture increases significantly; risk of rupture rises after ~2.67 injections; also causes fat pad atrophy. Review risks with patients before proceeding.
Emerging/adjunct:
- Platelet-rich plasma (PRP) injection - promising in limited studies
- Extracorporeal shock wave therapy (ESWT) - mixed results in studies; used in refractory cases before surgery
- Prolotherapy, dry needling, autologous blood injection - under investigation; not consistently proven
Operative (< 5% of cases)
Indicated only after 6-12 months of failed conservative treatment.
- Limited (medial half) plantar fasciotomy - preferred approach
- Avoid complete fasciotomy - risks arch collapse, lateral column overload, dorsolateral foot pain, metatarsal stress fractures
- Concomitant release of deep fascia of abductor hallucis if lateral plantar nerve entrapment is suspected
- Gastrocnemius recession - consider if there is clear gastrocnemius contracture without ankle equinus
Prognosis
- Resolution within 12 months in >80-95% of patients regardless of specific treatment
- Condition is self-limiting in the vast majority
Sources:
- Miller's Review of Orthopaedics 9th Edition, p. 592
- Harrison's Principles of Internal Medicine 22E (2025)
- Textbook of Family Medicine 9e
- Goldman-Cecil Medicine
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