Most common cause of plantar heel pain. Some authors make a distinction between heel spur syndrome and insertional plantar fasciitis, others do not.
*osseous calcaneal spurs are present in 17% of the population and are considered of no diagnostic significance , in an anatomical study, showed that the heel spur is in the insertion of the tendon of the short flexor tendon and not the plantar aponeurosis.
Onset is usually gradual – often initially described as ‘burning’. Classic sign is ‘post-static dyskinesia’ – pain in heel upon standing after resting for prolonged period of time. Maximum tenderness/pain at insertion of plantar fascia in medial plantar tubercle of calcaneus and maybe tender along plantar fascia. Pain may be worse when ankle is dorsiflexed and/or actively establishing the windlass mechanism by dorsiflexing the hallux (positive windlass manoeuvre).
Medial-lateral compression of calcaneus generally no symptoms (if symptomatic, may indicate calcaneal stress fracture)
X-ray – presence and size of bony spurs do not correlate to symptoms – up to 20% of normal population have osseous spurs.
MRI – a number have been shown to have bone marrow oedema may be due to local inflammatory reaction increased fluid content of bone increased intraosseous pressure pain. Clinical features of heel spur syndrome/insertional plantar fasciitis are usually fairly consistent, but MRI findings may be able to identify clinical subtypes that are correlated to clinical outcomes
Pronation fatigue failure of plantar aponeurosis
Sagittal plane block
Achilles tightness pronates
tissues in common
Differential diagnosis – seronegative spondyloarthropathy or other rheumatological disease; tarsal tunnel syndrome or other nerve entrapment; pre-stage one posterior tibial dysfunction
Initial – RICE; NSAID’s; strapping; temporary orthoses; activity modification to reduce weightbearing;
Long term – stretching; physical therapy; functional foot orthoses – may need lateral forefoot post to plantarflex first ray re-establish efficient windlass mechanism; appropriate shoes for rearfoot control
lateral forefoot wedging has been shown to reduce pain scores in those with plantar fasciitis , presumable through enhancing the windlass mechanism or facilitating a functional hallux limitus.
Physical therapy - ultrasound, electrotherapeutic modalities
Soft tissue therapy - Plantar palming – patient supine, leg extended, foot dorsiflexed – use palm of hand apply frictional pressure to plantar fascia from metatarsal heads, sliding down to insertion.
Deep transverse frictions
If non-responsive to initial therapy try splints that keep foot dorsiflexed at night and maybe steroids. Then use below knee cast before considering surgery.
Extracorporeal shock wave therapy as been shown to help healing process (approved in USA by FDA for use after 6 months of conservative care) – especially if MRI show calcaneal bone marrow oedema
Acupuncture as been advocated, with treatment aimed at periosteal point on medial calcaneal tuberosity; tenderness can sometimes be found at the K1-1 point described as being located plantar to the mid shaft area of the 2nd and 3rd metatarsals.
Natural course is one of eventual resolution within 18 months for many cases, so non-surgical care for at least this long is appropriate.
needed in about 5%
fascia cut – complete or partial
Drilling holes in calcaneus have been reported as giving good relief in some patients – while this technique is not often used, it may be due to relief of intraosseous pressure from bone marrow oedema (when present) - bone marrow oedema has been reported in a number of cases of plantar fasciitis .
Plantar Fasciitis – how then do you treat it?