Oral Revalida Written Report:
Karla Suzatte M. Dasargo
DDC- PT Intern 2014
November 11, 2013
It is also referred to as plantar heel pain syndrome, heel spur syndrome, or painful heel
It is a painful inflammatory process of the plantar fascia, the connective tissue or ligament on
the sole of the foot. It is often caused by overuse of the plantar fascia, increases in activities,
weight or age.
It is an overload injury usually associated with biomechanical abnormalities such as tight plantar
flexors and short flexor muscles.
Deterioration of the plantar fascia. Connective tissue deterioration is associated with
many systemic factors that alter microcirculation within tissue, such as the patient’s age,
arteriosclerosis, lipid abnormalities, tobacco abuse, and diabetes mellitus. Rheumatoid
arthritis, ankylosing spondylitis, and other seronegative arthropathies can be associated
with plantar fasciitis and other enthesopathies.
Mechanical overload of the plantar fascia has been suspected to play a significant role in
the development of plantar fasciitis. Several studies have identified associations of
plantar fasciitis with obesity and poor ankle flexibility; both of these factors would be
expected to add to the mechanical load of the forefoot.
The plantar fascia also may be damaged by direct impact on the heel through gait or
repetitive trauma to or overloading of the front of the foot through gait abnormalities,
posture, and other tendon contractures (eg, hamstring tendon contractures).
Damage to other supporting structures that assist in arch stabilization may increase the
stress on the plantar fascia; this may include injuries to the posterior tibial tendon or
intrinsic plantar ligaments, resulting in acquired flatfoot deformity, or “fallen arches,” and
instability caused by midfoot arthritis. The intrinsic musculature may be compromised in
many ways, including weakness resulting from compressive or peripheral neuropathy
and deconditioning because of the patient’s age or the use of overprotective footwear or
Plantar fasciitis, reportedly the most common cause of pain in the inferior heel
Estimated to account for 11 to 15 percent of all foot symptoms requiring professional
care among adults.
It is the most common cause of heel pain and affects 15-20% of runners and is also
common among military personnel.
The incidence reportedly peaks in people between the ages of 40 and 60 years in the
general population and in younger people among runners.
The predominance of the condition according to sex varies from one study to another.
The condition is bilateral in up to a third of cases.
The foot supports the body weight and provides leverage for walking and running. It is unique in
that it is constructed in the form of arches, which enable it to adapt its shape to uneven urfaces.
It also serves as a resilient spring to absorb shocks, such as in jumping.
The Sole of the Foot
The skin of the sole of the foot is thick and hairless. It is firmly bound down to the underlying
deep fascia by numerous fibrous bands. The skin shows a few flexure creases at the sites of
skin movement. Sweat glands are present in large numbers.
The sensory nerve supply to the skin of the sole of the foot is derived from the medial calcaneal
branch of the tibial nerve, which innervates the medial side of the heel; branches from the
medial plantar nerve, which innervate the medial two thirds of the sole; and branches from the
lateral plantar nerve, which innervate the lateral third of the sole.
The plantar aponeurosis is a triangular thickening of the deep fascia that protects the underlying
nerves, blood vessels, and muscles. Its apex is attached to the medial and lateral tubercles of
the calcaneum. The base of the aponeurosis divides into five slips that pass into the toes.
In younger people the plantar fascia is also intimately related to the Achilles tendon, with a
continuous fascial connection between the two from the distal aspect of the Achilles to the origin
of the plantar fascia at the calcaneal tubercle. However, the continuity of this connection
decreases with age to a point that in the elderly there are few, if any, connecting fibers.
There are also distinct attachments of the plantar fascia and the Achilles tendon to the
calcaneus so the two do not directly contact each other. Nevertheless, there is an indirect
relationship whereby if the toes are dorsiflexed, the plantar fascia tightens via the windlass
mechanism. If a tensile force is then generated in the Achilles tendon it will increase tensile
strain in the plantar fascia.
Muscles of the Sole of the Foot
The muscles of the sole are conveniently described in four layers from the inferior layer
First layer: Abductor hallucis, flexor digitorum brevis, abductor digiti minimi
Second layer: Quadratus plantae, lumbricals, flexor digitorum longus tendon, flexor hallucis
Third layer: Flexor hallucis brevis, adductor hallucis, flexor digiti minimi brevis
Fourth layer: Interossei, peroneus longus tendon, tibialis posterior tendon
Arteries of the Sole of the Foot
Medial Plantar Artery
The medial plantar artery is the smaller of the terminal branches of the posterior tibial artery. It
arises beneath the flexor retinaculum and passes forward deep to the abductor hallucis muscle.
It ends by supplying the medial side of the big toe. During its course, it gives off numerous
muscular, cutaneous, and articular branches.
Lateral Plantar Artery
The lateral plantar artery is the larger of the terminal branches of the posterior tibial artery. It
arises beneath the flexor retinaculum and passes forward deep to the abductor hallucis and the
flexor digitorum brevis. On reaching the base of the 5th metatarsal bone, the artery curves
medially to form the plantar arch and at the proximal end of the first intermetatarsal space joins
the dorsalis pedis artery. During its course, it gives off numerous muscular, cutaneous, and
articular branches. The plantar arch gives off plantar digital arteries to the toes.
Dorsalis Pedis Artery (The Dorsal Artery of the Foot)
On entering the sole between the two heads of the first dorsal interosseous muscle, the dorsalis
pedis artery immediately joins the lateral plantar artery Branches the first plantar metatarsal
artery, which supplies the cleft between the big and second toes. Veins of the Sole of the Foot
Medial and lateral plantar veins accompany the corresponding arteries, and they unite behind
the medial malleolus to form the posterior tibial venae comitantes.
Nerves of the Sole of the Foot
Medial Plantar Nerve
The medial plantar nerve is a terminal branch of the tibial nerve. It arises beneath the flexor
retinaculum and runs forward deep to the abductor hallucis, with the medial plantar artery. It
comes to lie in the interval between the abductor halluces and the flexor digitorum brevis.
Lateral Plantar Nerve
The lateral plantar nerve is a terminal branch of the tibial nerve. It arises beneath the flexor
retinaculum and runs forward deep to the abductor hallucis and the flexor digitorum brevis, in
company with the lateral plantar artery. On reaching the base of the fifth metatarsal bone, it
divides into superficial and deep branches.
Ligaments of the sole of the foot
Spring ligament (Plantar calcaneonavicular)
The plantar calcaneonavicular ligament is strong and runs from the anterior margin of the
sustentaculum tali to the inferior surface and tuberosity of the navicular bone. The superior
surface of the ligament is covered with fibrocartilage and supports the head of the talus.
Long plantar ligament
The long plantar ligament is a strong ligament on the lower surface of the joint. It is attached to
the under surface of the calcaneum behind and to the under surface of the cuboid and the
bases of the third, fourth, and fifth metatarsal bones in front. It bridges over the groove for the
peroneus longus tendon, converting it into a tunnel.
Short plantar ligament (Calcaneocuboid)
The short plantar ligament is a wide, strong ligament that is attached to the anterior tubercle on
the under surface of the calcaneum and to the adjoining part of the cuboid bone.
The Arches of the Foot
The foot has three such arches, which are present at birth: the medial longitudinal, lateral
longitudinal, and transverse arches. In the young child, the foot appears to be flat because of
the presence of a large amount of subcutaneous fat on the sole of the foot.
The medial margin of the foot, from the heel to the 1st metatarsal head, is arched above the
ground because of the important medial longitudinal arch. The pressure exerted on the ground
by the lateral margin of the foot is greatest at the heel and the 5th metatarsal head and least
between these areas because of the presence of the low-lying lateral longitudinal arch.
The transverse arch involves the bases of the five metatarsals and the cuboid and cuneiform
bones. This is, in fact, only half an arch, with its base on the lateral border of the foot and its
summit on the foot’s medial border.
The body weight on standing is distributed through a foot via the heel behind and six points of
contact with the ground in front, namely, the two sesamoid bones under the head of the first
metatarsal and the heads of the remaining four metatarsals.
The Bones of the Arches
Medial longitudinal arch
This consists of the calcaneum, the talus, the navicular bone, the three cuneiform bones, and
the first three metatarsal bones.
Lateral longitudinal arch
This consists of the calcaneum, the cuboid, and the 4th and 5th metatarsal bones
This consists of the bases of the metatarsal bones and the cuboid and the three cuneiform
Biomechanics of Plantar fascia
The plantar fascia contributes to support of arch of the foot by acting as a tie-rod, where
it undergoes tension when the foot bears weight.
One biomechanical model estimated it carries as much as 14% of the total load of the
Complete rupture or surgical release of the plantar fascia leads to a decrease in arch
stiffness and a significant collapse of the longitudinal arch of the foot.
Surgical release also significantly increases both stress in the plantar ligaments and
plantar pressures under the metatarsal heads.
The plantar fascia also has an important role in dynamic function during gait. It was
found the plantar fascia continuously elongated during the contact phase of gait. It went
through rapid elongation before and immediately after mid-stance, reaching a maximum
of 9% to 12% elongation between mid-stance and toe-off. During this phase the plantar
fascia behaves like a spring, which may assist in conserving energy.
The plantar fascia has a critical role in normal mechanical function of the foot,
contributing to the "windlass mechanism". When the toes are dorsiflexed in the
propulsive phase of gait, the plantar fascia becomes tense, resulting in elevation of the
longitudinal arch and shortening of the foot.
Therefore, the plantar fascia has a number of roles, the most important of these
including supporting the arch of the foot and contributing to the windlass mechanism.
The site of abnormality is typically near the site of origin of the plantar fascia at the
medial tuberosity of the calcaneus.
Histologic examination of biopsy specimens from patients undergoing plantar fascia–
release surgery for chronic symptoms has shown degenerative changes in the plantar
fascia, with or without fibroblastic proliferation, and chronic inflammatory changes.
It is more likely caused by degeneration or weakening of the tissue. This process
probably begins with small tears that occur during activity and that, in normal
circumstances, the body simply repairs, strengthening the tissue as it does. That is the
point of exercise training.
But sometimes, for unknown reasons, this on-going tissue damage overwhelms the
body’s capacity to respond. The small tears don’t heal. They accumulate.
Most common Signs & Symptoms
Pain (throbbing, searing, or piercing) when they take their first steps after they get out of
bed or sit for a long time, you may have less stiffness and pain after you take a few
steps. But your foot may hurt more as the day goes on. It may hurt the most when you
climb stairs or after you stand for a long time.
Tenderness to palpation is present at the volar aspect of the heel, usually slightly medial
Examination & Diagnostic procedures
Ocular inspection – checks for a high arch, area of maximum tenderness on the bottom
of your foot, just in front of your heel bone, Pain that gets worse when you flex your foot
and the doctor pushes on the plantar fascia. The pain improves when you point your
toes down, Limited "up" motion of your ankle (DF).
X-ray- rule out a stress fracture of the heel bone and to see if a bone spur is present.
Bone scans - useful for distinguishing plantar fasciitis from calcaneal stress fracture
MRI- can show thickening of the plantar fascia
Laboratory tests - rule out a systemic illness causing the heel pain, such as rheumatoid
arthritis, Reiter's syndrome, or ankylosing spondylitis
on the sole
of the foot
stress fracture swelling,
Heel pain in
leg to the
Medical and Surgical
Surgery is considered only after 12 months of aggressive nonsurgical treatment.
Surgical plantar fasciotomy with or without heel spur removal. There is a
method, through an open procedure, percutaneously or most common
endoscopically that release of the plantar fascia. This is an effective treatment,
without the need for removal of a calcaneal spur, when present. There is a
professional consensus, 70-90% of heel pain patients can be managed by nonoperative measures. Surgery of plantar fasciitis should be considered only after
all other forms of treatment have failed. With endoscopic plantar fasciotomy,
using the visual analog scale, the average post-operative pain was improved
from 9.1 to 1.6. For the second group (ESWT), using the visual analog scale the
average post-operative pain was improved from 9 to 2.1. Endoscopic plantar
fasciotomy gives better results than extra-corporeal shock wave therapy, but with
liability of minor complications
Gastrocnemius recession. This is a surgical lengthening of the calf
(gastrocnemius) muscles. Because tight calf muscles place increased stress on
the plantar fascia, this procedure is useful for patients who still have difficulty
flexing their feet, despite a year of calf stretches. The procedure can be
performed with a traditional, open incision or with a smaller incision and an
endoscope. Complication rates for gastrocnemius recession are low, but can
include nerve damage.
o Nonsteroidal anti-inflammatory medication. Drugs such as ibuprofen or
naproxen reduce pain and inflammation. Using the medication for more than 1
month should be reviewed with your primary care doctor.
o Cortisone injections. Cortisone, a type of steroid, is a powerful antiinflammatory medication. It can be injected into the plantar fascia to reduce
inflammation and pain. Your doctor may limit your injections. Multiple steroid
injections can cause the plantar fascia to rupture (tear), which can lead to a flat
foot and chronic pain.
More than 90% of patients with plantar fasciitis will improve within 10 months of starting
simple treatment methods
Rest. Decreasing or even stopping the activities that make the pain worse
is the first step in reducing the pain. You may need to stop athletic
activities where your feet pound on hard surfaces (for example, running or
Ice. Rolling your foot over a cold water bottle or ice for 20 minutes is
effective. This can be done 3 to 4 times a day
No studies have adequately evaluated the effectiveness of taping or
strapping for managing plantar fasciitis.
custom orthotics and prefabricated shoe inserts (e.g., silicone heel pad,
felt pad, rubber heel cup) combined with stretching
Posterior-tension night splints maintain ankle dorsiflexion and toe
extension, creating a constant mild stretch of the plantar fascia that allows
it to heal at a functional length.
Stretching protocols often focus on the calf muscles and Achilles tendon
or on the plantar fascia. The benefits of stretching both the plantar fascia
and the Achilles tendon are unknown.
Combined with strengthening of the short foot & plantar flexors
Extracorporeal shockwave therapy (ESWT). During this procedure,
high-energy shockwave impulses stimulate the healing process in
damaged plantar fascia tissue. ESWT has not shown consistent results
and, therefore, is not commonly performed.
Deep tissue massage / MFR
Journals and articles
H. B. Kitaoka, Z. P. Luo, E. S. Growney, L. J. Berglund and K. N. An (October 1994). "Material
properties of the plantar aponeurosis". Foot & ankle international 15 (10): 557–
560. PMID 7834064
G. A. Arangio, C. Chen and W. Kim (June 1997). "Effect of cutting the plantar fascia on
mechanical properties of the foot". Clinical orthopaedics and related research (339): 227–231.
Jump up ^ Amit Gefen (March 2003). "The in vivo elastic properties of the plantar fascia during
the contact phase of walking". Foot & ankle international 24 (3): 238–244. PMID 12793487
Plantar Fasciitis, Rachelle Buchbinder, M.B., B.S., F.R.A.C.P., N Engl J Med 2004; 350:21592166May 20, 2004 http://www.nejm.org/doi/full/10.1056/NEJMcp032745
No Consensus on a Common Cause of Foot Pain,nytimes; Dr. Terrence M. Philbin, a boardcertified orthopedic surgeon at the Orthopedic Foot and Ankle Center in Westerville, Ohio;
Physical Medicine & rehabilitation 3rd edition by Randall L. Braddom
Clinical Anatomy by regions 9th edition by Richard Snell
Sports medicine Just the Facts by Francis G. O’Connor, MD, FACSM et. Al
Therapeutic exercises by Kisner