plantar fasciitis sports medicine review foot pain cover

Understanding Plantar Fasciitis: A Comprehensive Review

Plantar fasciitis is a common source of heel pain that is due to degeneration of the plantar fascia insertion on the calcaneus which can be treated with multiple treatment modalities. The plantar fascia is a thick band of connective tissue that travels from the heel to the toes (4). It is most commonly seen in patients between the ages 40-60 and is more common in runners (2). Another risk factor includes wearing shoes without good arch support (3). Inflammatory cells are not commonly seen on histologic sections after the first two weeks of symptoms (2). Chronic plantar fascia histologic sections show degeneration of the collagen fibers and fibroblast proliferation (5).

Case Vignette

A 45 year old runner comes to your clinic with heel pain. Radiographs show a large horizontal inferior calcaneal enthesophyte. The patient has pain to the inferior portion of the medial calcaneus. Which of the following regarding this finding is true?

A) Patients with large heel spurs typically have worse symptoms
B) Absent or small heel spurs help rule out plantar fasciitis
C) Having a tighter gastrocnemius muscle correlates with worse plantar fasciitis symptoms
D) Injections with corticosteroids have no adverse effects and are first line treatment options for plantar fasciitis

Diagnosis

Plantar fasciitis is a clinical diagnosis. Heel pain that is worse with the first step in the morning is characteristic of plantar fasciitis (2). Patients may also complain of pain upon resuming walking after a period of prolonged rest (2). Radiographs are done as well to help rule out other diagnoses like calcaneal stress fractures (2). Radiographs can show a plantar heel spur and the etiology of the spur is unknown (3). Most providers believe it is a traction enthesophyte from the plantar fascia (3). Heel spurs can be described as horizontal, vertical, or hooked (3). In a study done in Foot & Ankle International, they found that patients with large horizontal heel spurs had less pain than absent or smaller heel spurs (3). This helps support the theory that the size of a heel spur does not correlate with a patient’s symptoms.

plantar fascia heel spur xray

Image 1. Types of Heel Spurs (3)

Treatment

Treatment options for plantar fasciitis span from conservative options, including bracing, to more aggressive options, which include injections. Conservative options are home based physical therapy programs that focus on gastrocnemius stretching and intrinsic foot muscle strengthening. A study done in Foot & Ankle International looked at the significance of gastrocnemius tightness and the severity of heel pain in plantar fasciitis. They found a statistically significant correlation between the tightness of the gastrocnemius muscle and heel pain. As a result, patients with plantar fasciitis should be given home exercises that include gastrocnemius muscle stretching.

calf stretch example for plantar fasciitis

Image 2. Gastrocnemius stretching (2) 

Nighttime splinting with a Strassburg sock or removeable boot can also lead to slight improvement of symptoms. Orthotics are also recommended in plantar fasciitis. Orthotics are thought to provide a benefit by decreasing foot pronation with standing, preserving the longitudinal arch, and elongating the foot (4). A study in the Archives of Internal Medicine found that wearing prefabricated and custom orthotics for plantar fasciitis led to a statistically significant pain improvement (4).

Injections have also been studied in the treatment of plantar fasciitis. Studies have looked at the injection of corticosteroids, dextrose, amniotic stem cells, whole blood, and platelet rich plasma. Corticosteroids can be injected via palpation guidance or ultrasound guidance. In a study published in the British Medical Journal, they looked at improvement of plantar fasciitis pain with ultrasound guided corticosteroid injections. They found a statistically significant pain reduction and reduction of plantar fascia size in the group that received ultrasound guided cortisone injections vs. saline injection (5). The results of a cortisone injection can be enhanced with the addition of strengthening/stretching exercises compared to patients who receive just a cortisone injection (6).  

Platelet rich plasma (PRP) injections are also done for plantar fasciitis. A PRP injection delivers growth factors and cytokines to an injured area to augment healing and collagen synthesis (1). A meta-analysis in the American Journal of Sports Medicine compared PRP vs. corticosteroid injections for plantar fasciitis. They found that there were no significant differences in pain between PRP and steroid injections in the short term, but there were statistically significant improvements of pain in the long term follow up in the PRP group (7).

Another treatment option includes injection with cryopreserved amniotic membrane. The amnion contains growth factors and cytokines similar to PRP but are thought to be more specific for the regenerative stages which could be a benefit in musculoskeletal issues (8). In a study published in Foot & Ankle International, they performed a randomized control trial in which patients with plantar fasciitis were randomized to receive a cortisone injection vs. an amniotic membrane injection. They found that the amniotic membrane group performed as well as cortisone. Most significantly, there were few adverse events in the amniotic membrane injection (8).  

Conclusion

Plantar fasciitis is a common entity seen in sports clinics and specifically in the runner population. Diagnosis is made clinically and can be aided with radiographs. Conservative treatment options include nocturnal splinting, gastrocnemius stretching, intrinsic foot muscle strengthening, and orthotics. Second line options can be corticosteroid injections, which provide good short-term benefit, and also PRP injections, which provide better long term outcomes. Providers should take a step wise approach to therapy options and always include stretching and strengthening as part of their plan.

Case Conclusion

Correct Answer: C. Patient’s with tighter gastrocnemius muscles are found to have worse plantar fascia symptoms. This is supported in a study done in Foot & Ankle International where they measured the gastrocnemius tightness and compared it to a patient’s plantar fascia pain. Also absent and small heel spurs are typically found with worse plantar fascia pain and large horizontal spurs in patients’ with less pain. In other words, the presence or absence of heel spur does not necessarily correlate with a patient’s symptoms. Corticosteroids are not first line therapy and are associated with risk, including fat pad atrophy

Pearce, Christopher J., et al. “Correlation Between Gastrocnemius Tightness and Heel Pain Severity in Plantar Fasciitis.” Foot & Ankle International, vol. 42, no. 1, Jan. 2021, pp. 76–82. PubMed, doi:10.1177/1071100720955144.
Ahmad, Jamal, et al. “Relationship and Classification of Plantar Heel Spurs in Patients With Plantar Fasciitis.” Foot & Ankle International, vol. 37, no. 9, Sept. 2016, pp. 994–1000. PubMed, doi:10.1177/1071100716649925.
– More Foot/Toe Pain from Sports Medicine Review: https://www.sportsmedreview.com/by-joint/foot/

– Read More @ Wiki Sports Medicine: https://wikism.org/Plantar_Fasciopathy

Author

Gregory Rubin, DO @ Rubinsportsmed.com

References

  1.  Hohmann, Erik, et al. “Platelet-Rich Plasma Versus Corticosteroids for the Treatment of Plantar Fasciitis: A Systematic Review and Meta-Analysis.” The American Journal of Sports Medicine, Aug. 2020, p. 363546520937293. PubMed, doi:10.1177/0363546520937293.
  2. Pearce, Christopher J., et al. “Correlation Between Gastrocnemius Tightness and Heel Pain Severity in Plantar Fasciitis.” Foot & Ankle International, vol. 42, no. 1, Jan. 2021, pp. 76–82. PubMed, doi:10.1177/1071100720955144.
  3. Ahmad, Jamal, et al. “Relationship and Classification of Plantar Heel Spurs in Patients With Plantar Fasciitis.” Foot & Ankle International, vol. 37, no. 9, Sept. 2016, pp. 994–1000. PubMed, doi:10.1177/1071100716649925.
  4. Landorf, Karl B., et al. “Effectiveness of Foot Orthoses to Treat Plantar Fasciitis: A Randomized Trial.” Archives of Internal Medicine, vol. 166, no. 12, June 2006, pp. 1305–10. PubMed, doi:10.1001/archinte.166.12.1305.
  5. McMillan, Andrew M., et al. “Ultrasound Guided Corticosteroid Injection for Plantar Fasciitis: Randomised Controlled Trial.” BMJ (Clinical Research Ed.), vol. 344, May 2012, p. e3260. PubMed, doi:10.1136/bmj.e3260.
  6. Johannsen, Finn E., et al. “Corticosteroid Injection Is the Best Treatment in Plantar Fasciitis If Combined with Controlled Training.” Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal of the ESSKA, vol. 27, no. 1, Jan. 2019, pp. 5–12. PubMed, doi:10.1007/s00167-018-5234-6.
  7. Huang, Kai, et al. “Platelet-Rich Plasma Versus Corticosteroid Injections in the Management of Elbow Epicondylitis and Plantar Fasciitis: An Updated Systematic Review and Meta-Analysis.” The American Journal of Sports Medicine, vol. 48, no. 10, Aug. 2020, pp. 2572–85. PubMed, doi:10.1177/0363546519888450.
  8. Hanselman, Andrew E., et al. “Cryopreserved Human Amniotic Membrane Injection for Plantar Fasciitis: A Randomized, Controlled, Double-Blind Pilot Study.” Foot & Ankle International, vol. 36, no. 2, Feb. 2015, pp. 151–58. PubMed, doi:10.1177/1071100714552824.