Orthopedics Book

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Plantar Fasciitis

Aka: Plantar Fasciitis, Painful Heal Syndrome
  1. Anatomy
    1. Plantar fascia
      1. Originates at medial tubercle of Calcaneus
      2. Inserts proximal phalanges
    2. Plantar fascia forms longitudinal foot arch
      1. Important for normal gait
  2. Epidemiology
    1. Most common cause of plantar Heel Pain
    2. Peak Incidence ages 40 to 60 years old
  3. Pathophysiology
    1. Repetitive micro-tears of the plantar fascia
    2. Results in collagen degeneration at medial calcaneal tubercle (plantar fascia origin)
  4. Risk factors
    1. Functional abnormalities
      1. Athletes: Overuse Injury (especially runners)
      2. Non-athletes: Tight or weak muscles or tendons
        1. Tight Achilles tendon or heel cord
        2. Tight or weak gastrocnemius or soleus muscles
      3. Older patients
        1. Mechanism
          1. Weak foot intrinsic muscles
          2. Acquired flat foot
          3. Thinning of heel fat pad
        2. Characteristics of pain
          1. Localized pain in central heel
          2. First steps in morning not provocative
        3. Benefit from heel pads or heel cups
    2. Anatomic abnormalities
      1. Over-Pronated foot
      2. Leg Length Discrepancy
      3. Forefoot varus
      4. Lateral tibial torsion
      5. Femoral Anteversion
      6. Abnormal longitudinal foot arch
        1. Low arch: Pes Planus (flat foot)
        2. High arch: pes cavus
  5. Symptoms
    1. Characteristic: dull tooth-ache or burning pain
    2. Stiffness may also be present
    3. Pain Location: Posterior and medial aspect of heel
      1. Medial tubercle of Calcaneus
      2. Medial longitudinal arch
    4. Both heels often affected
    5. Provocative
      1. Pain worse with first few steps in morning
      2. Pain may be worse at days end in severe cases
      3. Pain worse with first steps of run
        1. Pain worse during first 5-10 minutes of run
        2. Less pain during remainder of run
        3. Pain worsens after run completed
      4. Pain worse with prolonged standing (weight bearing)
        1. Especially standing in hard shoes on hard floor
  6. Signs
    1. Focal point tenderness
      1. Calcaneus medial tubercle (anteromedial Calcaneus)
      2. Beneath longitudinal arch at proximal plantar fascia
    2. Provocative maneuvers to strain fascia and elicit pain
      1. Passive dorsiflexion toes or ankle
      2. Stand on tips of toes
  7. Differential diagnosis
    1. See Heel Pain
  8. Imaging: Foot Xray
    1. General
      1. Foot XRay is often normal
      2. Indicated for refractory course to assess for tumor and other alternative diagnosis
    2. Traction spur may be seen at Os Calcis
      1. Spur directed distally
      2. Spur is a response to muscle tension
      3. Seen in asymptomatic foot
      4. No Relationship between Heel Pain and spur formation
    3. Calcaneus Stress Fracture (Calcaneus)
      1. Assess for in chronic cases
  9. Imaging: MRI
    1. Indicated in severe refractory cases
    2. Findings
      1. Thickening of the proximal plantar fascia (to 7-8 mm)
      2. Plantar aponeurosis inflammation
      3. Reactive calcaneal marrow edema
      4. Middle or proximal fascial rupture
  10. Management: Stage 1 Acute
    1. Anticipatory guidance
      1. Prolonged recovery expected: 6-18 months
    2. NSAIDs
    3. Ice Therapy
      1. See Local Cold Therapy
    4. Relative rest with alternative activities
      1. Consider switch to non-irritating activities
    5. Avoid provocative activities
      1. Avoid prolonged weight bearing
      2. Avoid walking on hard surfaces
    6. Pre-fabricated Orthotics (e.g. Superfeet Orthotics)
      1. Pfeffer (1999) Foot Ankle Int 20:214-21 [PubMed]
    7. Properly fitting, newer Running Shoes
      1. General
        1. Thicker, cushioned mid-sole
        2. Highly dense, vinyl acetate Running Shoe
      2. Motion control shoe for Pes Planus
        1. Lasted construction
        2. External heel counter
        3. Wide flare
        4. Additional medial support
  11. Management: Stage 2 Stretching and Strengthening
    1. General
      1. Avoid Stretching the acutely painful foot
      2. Consider early initiation of Posterior Night Splints for 3 weeks (see below)
    2. Dynamic stretches and massage
      1. Roll foot arch over Tennis Ball or 15-oz metal can
      2. Cross friction massage over plantar fascia
    3. Plantar fascia stretch
      1. Sit with affected foot crossed over opposite thigh
      2. Use one hand at base of toes on plantar surface
      3. Pull toes toward shin (dorsiflex) until stretch felt
      4. More effective than achilles tendon stretches
        1. DiGiovanni (2003) J Bone Joint Surg 85-A:1270-7 [PubMed]
    4. Achilles Tendon stretches
      1. Heel Stretching with towel
        1. Maximize passive dorsiflexion
        2. Pull with towel below foot (pull and release)
      2. Calf stretches against wall
        1. Lean forward into wall onto outstretched hands
        2. Extend Stretching leg back behind you
        3. Move other leg forward in front
        4. Gastrocnemius stretch
          1. Legs slightly bent
        5. Soleus muscle stretch
          1. Legs fully extended
      3. Calf stretches using steps or boards
        1. Technique
          1. Toes on edge of step or board
          2. Heel drops down over edge of step
        2. Adjuncts
          1. Stair stretch
          2. Two-by-Four piece or wood
          3. Slant board
          4. Wobble board
        3. Pointers
          1. Consider using in places of prolonged standing
          2. Examples: By kitchen stove or sink
    5. Strengthening of intrinsic foot muscles
      1. With heel on floor, pick up marbles with toes
      2. Towel curls
        1. Sit in chair with a towel on the floor
        2. Place foot on towel, and keep heel firmly planted
        3. Use toes to pull towel toward body
      3. Toe taps
        1. Keep heel on floor
        2. Raise all toes off floor
        3. Tap floor with great toe 10 to 50 times
        4. Tap floor with 4 lateral toes 10 to 50 times
  12. Management: Stage 3 Refractory
    1. Reconsider differential diagnosis of Heel Pain
    2. Posterior Night Splints
      1. Indicated if other measures not effective in 2 weeks
      2. Most efficacious if symptoms >12 months
    3. Custom Orthotic: Semi-rigid, 3/4 to full length
      1. Modestly effective for Pes Planus, but expensive
      2. Provides longitudinal arch support
      3. Controls over-pronation
      4. Controls first Metatarsal head motion
    4. Over-the-counter arch supports
      1. Indicated for mild Pes Planus
    5. Arch Taping or strapping
      1. Transient support for under 30 minutes of activity
    6. Heel Cup
      1. Low efficacy in Plantar Fasciitis in general
      2. Indications
        1. Short term use for acute injury
        2. Older adults with thinning fat pad
        3. Fat pad syndrome
        4. Heel Bruise
    7. Local Corticosteroid Injection of Plantar Fascia
      1. Effective in short-term, but less long-term benefits
      2. Consider for 3-4 weeks of refractory symptoms
      3. Risk of plantar fascia rupture (10% in some studies)
        1. Acevedo (1998) Fook Ankle Int 19:91-7 [PubMed]
    8. Short Leg Walking Cast for 6 weeks
  13. Management: Stage 4 Referral
    1. Podiatry or Orthopedic referral Indications
      1. Failed conservative therapy as above for >6 weeks
    2. Options
      1. Extracorporeal Shock Wave Therapy
        1. Rompe (2003) Am J Sports 31:268-75 [PubMed]
      2. Plantar Fasciotomy
        1. Plantar fascia release at os calcis
        2. Risk of longitudinal arch flattening (Pes Planus)
        3. Risk of plantar fascia rupture
  14. Prognosis
    1. Good overall prognosis
    2. Slow resolution over 6 to 18 months
  15. References
    1. Barrett (1999) Am Fam Physician 59(8):2200-6 [PubMed]
    2. Young (2001) Am Fam Physician 63(3): 467-74 [PubMed]

Fasciitis, Plantar (C0149756)

Definition (CHV) an inflammation of the plantar fascia, the tissue along the bottom of your foot that connects the heel bone to the toes
Definition (CHV) an inflammation of the plantar fascia, the tissue along the bottom of your foot that connects the heel bone to the toes
Definition (MSH) Inflammation of the thick tissue on the bottom of the foot (plantar fascia) causing HEEL pain. The plantar fascia (also called plantar aponeurosis) are bands of fibrous tissue extending from the calcaneal tuberosity to the TOES. The etiology of plantar fasciitis remains controversial but is likely to involve a biomechanical imbalance. Though often presenting along with HEEL SPUR, they do not appear to be causally related.
Concepts Disease or Syndrome (T047)
MSH D036981
ICD10 M72.2
SnomedCT 203056001, 156725003, 202882003, 2482001
English Fasciitis plantar, FASCITIS PLANTAR, plantar fasciitis (diagnosis), plantar fasciitis, Fascitis plantar, Fasciitis, Plantar [Disease/Finding], Fasciitis;plantar, policeman's heel, Plantar Fasciitis, Fasciitis, Plantar, Plantar fasciitis, Policeman's heel, Plantar fasciitis (disorder), fasciitis; plantar, plantar; fasciitis
Dutch fasciïtis plantaris, fasciitis; plantair, plantair; fasciitis, plantaire fasciïtis, Calcaneusspoor, Fasciitis, plantaire, Fasciitis plantaris, Hielsporen, Plantaire fasciitis
German Fasciitis plantar, FASCIITIS PLANTAR, plantare Fasciitis, Fasciitis plantaris, Plantarfasziitis
Italian Fascite della pinata dei piedi, Fascite plantare
Portuguese Fascite plantar, FASCEITE PLANTAR, Síndrome do Esporão Calcâneo, Fasceíte plantar, Fascite Plantar, Fasciíte Plantar
Spanish Fascitis plantar, Síndrome del Espolón del Talón, fascitis plantar (trastorno), fascitis plantar, Fasciitis plantar, Fasciitis Plantar, Fascitis Plantar
Swedish Fascit, plantar
Japanese ソクテイキンマクエン, 筋膜炎-足底部, 足底筋膜炎, 慢性足底筋膜炎, 踵骨棘症候群
Czech fasciitida plantární, Plantární fasciitida, Fasciitis plantar
Finnish Plantaarifaskiitti
Russian FASTSIT PODOSHVENNYI, FASTSIT PODOSHVENNYI KHRONICHESKII, PIATOCHNOI SHPORY SINDROM, PODOSHVENNYI FASTSIT, ПОДОШВЕННЫЙ ФАСЦИТ, ПЯТОЧНОЙ ШПОРЫ СИНДРОМ, ФАСЦИТ ПОДОШВЕННЫЙ, ФАСЦИТ ПОДОШВЕННЫЙ ХРОНИЧЕСКИЙ
French FASCIITE APONEVROSE PLANTAIRE, Aponévrosite plantaire, Fasciite plantaire
Polish Zapalenie powięzi podeszwy
Hungarian Fasciitis plantaris, Plantaris fascitis, Fascitis plantaris
Norwegian Betennelse i fotens bindeveshinne, Plantar fasceitt
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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