summary Plantar Fasciitis is a painful heel condition caused by inflammation of the plantar fascia aponeurosis at its origin on the calcaneus. Diagnosis is made clinically with tenderness to palpation at the medial tuberosity of the calcaneus that worsens with dorsiflexion of the toes and foot. Treatment is a prolonged course of pain control, achilles/plantar fascia stretching, and orthotics. Rarely, surgical management is indicated in the case of progressive symptoms that fail nonoperative management. Epidemiology Demographics affects men and women equally Anatomic location affects the posteromedial heel Risk factors obesity (high BMI) decreased ankle dorsiflexion in a non-athletic population (tightness of the foot and calf musculature) weight bearing endurance activity (dancing, running) Etiology Pathophysiology pathoanatomy chronic overuse leads to microtears in the origin of the plantar fascia repetitive trauma leads to recurrent inflammation and periostitis abductor hallucis, flexor digitorum brevis, and quadratus plantae share the origin on medial calcaneal tubercle and may be inflamed as well Associated conditions calcaneal apophysitis gastrocnemius-soleus contracture heel pain triad plantar fasciitis posterior tibial tendon dysfunction tarsal tunnel syndrome anatomic variations femoral anteversion pes cavus pes planus Anatomy The plantar fascia is a thin layer of connective tissue supporting the arch of the foot Presentation Symptoms sharp heel pain insidious onset of heel pain, often when first getting out of bed may prefer to walk on toes initially worse at the end of the day after prolonged standing relieved by ambulation common to have symptoms bilaterally Physical exam inspection tender to palpation at medial tuberosity of calcaneus dorsiflexion of the toes and foot increases tenderness with palpation limited ankle dorsiflexion due to a tight Achilles tendon tenderness at origin of abductor hallucis small subset of patients indicative of entrapment or irritation of the first branch of the lateral plantar nerve (Baxter's nerve) Imaging Radiographs not necessary on initial visit often normal may show plantar heel spur optional films weight bearing axial and lateral films of hindfoot may show structural changes MRI indications may be useful for surgical planning Bone Scan can quantify inflammation and guide management useful to rule out stress fracture Studies Labs not routinely indicated useful if other causes of heel pain are suspected inflammatory arthritis infection EMG useful to rule out entrapment Treatment Nonoperative pain control, splinting & therapy (stretching) programs indications first line of treatment modalities plantar fascia-specific stretching and Achilles tendon stretching anti-inflammatories or cortisone injections corticosteroid injections can lead to fat pad atrophy or plantar fascia rupture foot orthosis examples include cushioned heel inserts, pre-fabricated shoe inserts, night splints, walking casts short leg casts can be used for 8-10 weeks outcomes pre-fabricated shoe inserts shown to be more effective than custom orthotics in relieving symptoms when used in conjunction with achilles and plantar fascia stretching dorsiflexion night splint most appropriate for chronic plantar fasciitis a non-weight bearing, plantar fascia specific stretching program is more effective than weight bearing Achilles tendon stretching programs stretching programs have equally successful satisfaction outcomes at 2 years shock wave treatment indications second line of treatment chronic heel pain lasting longer than 6 months when other treatments have failed FDA approved for this purpose technique painful for patients outcomes efficacious at 6 month followup Operative gastrocnemius recession indications no clear indications established surgical release with plantar fasciotomy indications perisistent pain after 9 months of failed conservative measures outcomes complications common and recovery can be protracted surgical release with plantar fasciotomy and distal tarsal tunnel decompression indications concomitant compression neuropathy (tibial nerve in tarsal tunnel) technique open procedure must be completed outcomes success rates are 70-90% for dual plantar fascial release and distal tarsal tunnel decompression Technique Surgical release with plantar fasciotomy approach can be done open or arthroscopically open procedure is indicated if tarsal tunnel syndrome is present as well release release medial one-third to two-thirds avoid complete release as it may lead to destabilization of the longitudinal arch overload of the lateral column dorsolateral foot pain consider simultaneous release of Baxter's nerve release the deep fascia of abductor hallucis may improve outcomes Complications Lateral plantar nerve injury Complete release of the plantar fascia with destabilization of medial longitudinal arch Increased stress on the dorsolateral midfoot Chronic pain Heel pad atrophy Plantar fascia rupture risk factors athletes minimalist runners corticosteriod injections treat with cast immobilization