Plantar Fasciitis

Epidemiology

• Common
• Affects adults

Aetiology

• Repetitive impact activity
• May be related to spondyloarthropathy (enthesiopathy)
• Obesity

Pathoanatomy

• Pain at plantar fascia origin on medial calcaneal tubercle
• Degenerative microtears of plantar fascia
• Reactive enthesiopathy with spur formation
• Spurs are related but not causative
  • Many people with spurs are asymptomatic

Differential Diagnosis

Entrapment of Baxter’s Nerve

• 1st branch of lateral plantar nerve, just beyond the tarsal tunnel
• Runs beneath Abductor Hallucis, supplies Quadratus Plantae
• Causes medial heel pain with rest or shooting pains

Calcaneal Stress Fracture

• Due to repetitive high-impact activity (e.g., military recruits)
• Bone scan or MRI diagnostic
• Suspect if history fits & does not settle with non-operative measures

Clinical Features

• Pain with first few steps in the morning
• Activity-related pain
• Settles at rest
• Neurologic symptoms → suspect other causes
• Tight Achilles tendon is common
• Windlass Test
  • Dorsiflexion of toes causes pain
• Often overweight patients
• Tibialis Posterior (TP) insufficiency may co-exist

Management

Non-Surgical

• Almost always effective enough to avoid surgery
• Weight loss
• Activity modification
• Shoewear modification
  • Heel pads with cut-outs, silicone insoles, etc.
• Plantar fascia stretching programme
  • Similar to Achilles stretches
• Steroid injections
  • May be useful but beware of plantar fascia rupture

Surgical Management

• Only if non-surgical methods fail
• Release of medial 1/3 plantar fascia origin + Abductor Hallucis fascia release
  • +/- Excision of prominent spurs if indicated
• Avoid complete release to prevent:
  • Arch collapse
  • Lateral column overload
• Baxter’s nerve compression is uncommon but may explain failure of non-surgical treatment
  • May as well release during surgery
• Surgical outcomes are unpredictable