ortopedia

1. Plantar Fasciitis: Evaluation
and Treatment
Abstract
Plantar fasciitis is the most common cause of plantar heel pain. Its
characteristic features are pain and tenderness, predominately on
the medial aspect of the calcaneus near the sole of the heel.
Considering a complete differential diagnosis of plantar heel pain is
important; a comprehensive history and physical examination
guide accurate diagnosis. Many nonsurgical treatment modalities
have been used in managing the disorder, including rest, massage,
nonsteroidal anti-inflammatory drugs, night splints, heel cups/
pads, custom and off-the-shelf orthoses, injections, casts, and
physical therapy measures such as shock wave therapy. Most
reported treatment outcomes rely on anecdotal experience or
combinations of multiple modalities. Nevertheless, nonsurgical
management of plantar fasciitis is successful in approximately 90%
of patients. Surgical treatment is considered in only a small subset
of patients with persistent, severe symptoms refractory to
nonsurgical intervention for at least 6 to 12 months.
Severe recalcitrant heel pain is a
relatively commonly observed
phenomenon. Although this condi-
tion is frequently referred to as heel
spurs, currently accepted terms of
greater accuracy are plantar fasciitis
(acute inflammatory stage) and plan-
tar fasciosis (chronic degenera-
tion).1 Plantar fasciitis can be a pain-
ful and debilitating condition that
often frustrates not only the patient
but also the physician. Plantar fasci-
itis is defined as an inflammation of
the origin of the plantar fascia and
surrounding perifascial structures.
There is no “gold standard” or
benchmark diagnostic criterion for
plantar fasciitis, but the clinical pre-
sentation is well recognized. The ac-
cepted hallmarks are pain and palpa-
ble tenderness in the area of the
medial tubercle of the calcaneus,
pain that is increased when taking
the first few steps in the morning,
and pain that is worse with contin-
ued weight bearing. Despite exten-
sive efforts taken to understand this
disorder, foot surgeons continue to
debate the source and etiology of
plantar heel pain as well as the most
appropriate modality of treatment.
Epidemiology
Plantar fasciitis is the most common
cause of plantar heel pain, account-
ing for 80% of patients with symp-
toms.2 It is estimated that 1 in 10
persons may experience inferior heel
pain at some time.3
Demographic
surveys indicate that nearly two mil-
lion patients receive treatment of
plantar fasciitis each year in the
United States,4
comprising 1% of all
visits to orthopaedists.5
The peak
age of incidence in the general pop-
ulation is between 40 and 60
years.5,6 Risk factors include running
Steven K. Neufeld, MD
Rebecca Cerrato, MD
Dr. Neufeld is Founder and President,
Orthopaedic Foot and Ankle Center of
Washington, Arlington, VA. Dr. Cerrato
is Foot and Ankle Fellow, Mercy Medical
Center, Baltimore, MD.
None of the following authors or a
member of their immediate families has
received anything of value from or owns
stock in a commercial company or
institution related directly or indirectly to
the subject of this article: Dr. Neufeld
and Dr. Cerrato.
Reprint requests: Dr. Neufeld,
Orthopaedic Foot and Ankle Center,
Suite 300, 2445 Army Navy Drive,
Arlington, VA 22206-8316.
J Am Acad Orthop Surg 2008;16:338-
346
Copyright 2008 by the American
Academy of Orthopaedic Surgeons.
338 Journal of the American Academy of Orthopaedic Surgeons

2. athletes, occupations that involve
prolonged standing, pes planus, lim-
ited ankle dorsiflexion, and obesi-
ty.7,8 In one third of cases, the con-
dition involves both feet.7
The
disorder is prevalent in persons with
seronegative arthritis because many
of these patients have disease at the
site of attachment of tendons or lig-
aments to bone.9
Anatomy
The plantar fascia originates at the
anteromedial aspect of the calcaneus
and spreads broadly as it extends dis-
tally to divide into five digital bands
at the metatarsophalangeal joints.
Each band inserts into the base of
the proximal phalanx of each toe.
Vertical fibers divide the plantar fas-
cia, creating three separate compart-
ments for the intrinsic plantar mus-
cles. Additionally, fibers merge with
the dermis, transverse metatarsal
ligaments, and the flexor tendon
sheaths. The plantar fascia is inelas-
tic, with maximal elongation of
4%.10
During the toe-off phase of
gait, the metatarsophalangeal joints
are dorsiflexed, resulting in high ten-
sile forces concentrated at the calca-
neal origin of the plantar fascia. This
was described in 1954 by Hicks,11
who named the phenomenon the
“windlass effect” of the plantar fas-
cia (Figure 1).
With walking, the heel absorbs a
force of 110% × body weight at heel
strike; with running, this force in-
creases to 200%.2 The fat pad of the
calcaneus is a honeycomb pattern of
fibroelastic septa that completely
enclose fat globules. This closed-cell
pattern of the fat pad allows it to
function as a shock absorber. After
age 40 years, the fat pad begins to at-
rophy, with loss of water, collagen,
and elastic tissue. The overall thick-
ness and height of the fat pad de-
creases, resulting in diminished
shock absorbency and reduced pro-
tection of the calcaneal tuberosi-
ty.10
Etiology
Plantar fasciitis was originally de-
scribed in 1812 by Wood, who be-
lieved it to be the result of inflamma-
tion secondary to tuberculosis.12
As
infectious theories were discredited,
the role of the heel spur in plantar fas-
ciitis was popularized. DuVries13
pro-
moted the concept of physical im-
pingement into the plantar fat pad.
Cadaveric dissections demonstrated
the presence of the spur within the
flexor digitorum brevis rather than
within the plantar fascia itself. Ap-
proximately 50% of patients with
heel pain will have heel spurs.14 Wil-
liams et al15
found that 75% of pa-
tients who had heel pain also had
spurs, compared with 63% of patients
with no heel pain. It is now widely ac-
cepted that heel spurs can occur with
plantar fasciitis, but they are not the
cause.
As a result of cadaveric studies,
entrapment of the first branch of the
lateral plantar nerve (FBLPN) was
proposed as the source of plantar fas-
ciitis.10 Histologic examination of
the FBLPN in patients with chronic
heel pain revealed evidence of de-
myelination and perineural fibro-
sis.16
Pain from FBLPN compression
has been differentiated from that of
plantar fascial pain based on loca-
tion of maximal tenderness.17
The word fasciitis implies an in-
flammatory process; however, histo-
logic evidence does not support this
concept. Findings demonstrate myx-
oid degeneration, microtears in the
fascia, collagen necrosis, and an-
giofibroblastic hyperplasia.1
These
changes are more consistent with a
degenerative process without inflam-
mation, likely secondary to repetitive
microtrauma at the origin of the plan-
tar fascia.
Clinical Presentation
The diagnosis of plantar fasciitis is
based on the patient’s history and
clinical examination. Patients report
a gradual onset of inferior heel pain
that is intensely worse with the first
steps in the morning or after a peri-
od of prolonged standing. The pain
tends to lessen with activity but
worsens by the end of the day.6,18
The pain tends to be nonradiating,
and associated nerve paresthesias are
not common.18 Plantar fasciitis in-
volving both feet has been reported
to be as high as 30%.7 However, bi-
lateral heel pain, in conjunction
with joint pain and pain at multiple
sites of tendon/ligament insertion,
suggests a systemic rheumatologic
Figure 1
Note the incidental “heel spur” and plantar fascia inserting into the base of the
proximal phalanges involved in the windlass mechanism.
Steven K. Neufeld, MD, and Rebecca Cerrato, MD
Volume 16, Number 6, June 2008 339

3. disorder. Unrelenting or nocturnal
pain is a red flag that the pain may be
related to a different condition (eg,
tumor, infection).
During the clinical examination,
the foot and ankle should be inspect-
ed during both stance and gait. A pes
planus or pes cavus foot deformity
can increase loading of the plantar
fascia. An Achilles muscle/tendon
contracture is frequently associated
with plantar fasciitis. Evaluating the
spine and lower extremities can ex-
pose any neurologic component to
the patient’s symptoms.
The location of the pain is impor-
tant in making the correct diagnosis.
The pain with plantar fasciitis is typ-
ically localized to the medial tuber-
cle of the calcaneus, at the origin of
the plantar fascia. However, patients
may have tenderness along any
point of the plantar fascia.16 In our
experience, passive dorsiflexion of
the toes will tighten the windlass
mechanism and exacerbate the
symptoms. Any deviations from lo-
cal pain isolated to the plantar heel
should raise the possibility of anoth-
er diagnosis.
Differential Diagnosis
Although plantar fasciitis is the
most common source of inferior or
plantar foot pain, many conditions
can cause inferior heel pain.19 A
complete history and physical exam-
ination most often will direct the
physician to the appropriate diagno-
sis and treatment plan7,20 (Table 1).
Neurogenic etiologies traditional-
ly result from a nerve entrapment or
compression syndrome. Tarsal tun-
nel syndrome and medial calcaneal
nerve compression produce pain
along the medial and plantar areas of
the foot. In addition, patients with
these conditions often report burn-
ing and tingling and have a positive
Tinel sign. Dorsiflexion of the toes
does not exacerbate their symp-
toms.
The FBLPN (Baxter nerve) inner-
vates the abductor digiti quinti,
quadratus plantae, and flexor digi-
torum brevis muscles. It passes just
superior to the insertion of the plan-
tar fascia on the medial calcaneal tu-
berosity. Compression of this nerve
causes maximal pain over the plan-
tar medial aspect of the foot, which
can be confused with plantar fasci-
itis.16 Because of the nerve’s close
proximity to the medial calcaneal
tubercle, many authors feel that
both conditions are often present.
An L5-S1 radiculopathy can
present with symptoms involving
plantar heel pain. A history that in-
cludes radiating symptoms in the leg,
combined with a thorough neurolog-
ic examination (ie, reflexes, motor
strength), can facilitate diagnosis of
this condition. Patients with periph-
eral neuropathies, common in diabe-
tes, frequently report foot and heel
pain. Typically, these patients lack a
focal area of discomfort and do not re-
port improvement with non–weight
bearing.
Calcaneal stress fractures typical-
ly present with diffuse swelling and
warmth of the hindfoot. Medial-
lateral compression of the calcaneus
(ie, the squeeze test) evokes pain in
patients with calcaneal stress frac-
ture. Flexor hallucis tendinitis also
presents with plantar heel pain; ten-
derness with resisted flexion of the
great toe can differentiate this condi-
tion from plantar fasciitis. Pain
along the midportion of the plantar
fascia, in addition to palpable nod-
ules within the fascial substance,
points to plantar fibromatosis. Pa-
tients with rupture of the plantar
fascia typically describe acute onset
of pain. Examination may reveal a
subtle collapse in the medial longi-
tudinal arch and a palpable gap with-
in the substance of the fascia. Most
of these ruptures heal successfully
with nonsurgical treatment involv-
ing immobilization and prolonged
non–weight bearing.21
Finally, pa-
tients with fat pad atrophy report
centralized heel pain. Palpation of
the heel pad will reveal a flattened,
atrophied surface.
Work-up
Imaging plays a limited role in rou-
tine clinical evaluation for plantar
fasciitis. Conventional radiographs
are often unrewarding. Levy et al22
evaluated the cost effectiveness and
clinical value of routine radiographs
in patients with atraumatic plantar
heel pain. Of 215 patients, no single
radiograph affected the diagnosis or
treatment. Therefore, radiographic
evaluation would be appropriate
only in patients who fail to improve
with appropriate treatment in a rea-
sonable amount of time or in pa-
tients with an atypical history or
physical examination.
A triple-phase bone scan may re-
veal increased uptake in the area of
the medial calcaneal tubercle and
can be helpful in differentiating be-
tween plantar fasciitis and a calca-
Table 1
Differential Diagnosis of Heel Pain
Neurologic
Tarsal tunnel syndrome
First branch of the lateral plantar
nerve entrapment
Medial calcaneal nerve
entrapment
Peripheral neuropathy
S1 radiculopathy
Soft tissue
Plantar fascia rupture
Enthesopathies
Fat-pad atrophy
Achilles tendinitis
Flexor hallucis longus tendinitis
Plantar fibromatosis
Posterior tibial tendinitis
Skeletal
Calcaneal stress fracture
Bone contusion
Infections (osteomyelitis/subtalar
pyoarthrosis)
Subtalar arthritis
Inflammatory arthropathies
Miscellaneous
Neoplasm
Vascular insufficiency
Plantar Fasciitis: Evaluation and Treatment
340 Journal of the American Academy of Orthopaedic Surgeons

4. neal stress fracture.23 Proponents of
magnetic resonance imaging (MRI)
in the management of plantar fasci-
itis argue that MRI is most helpful in
excluding other causes of heel pain.
Typical MRI findings include fascial
thickening and increased signal in-
tensity in the substance of the plan-
tar fascia.9 Ultrasonographic exami-
nation of patients with plantar
fasciitis has demonstrated thickened,
hypoechoic fascia24 and is equally ef-
fective in the diagnosis of plantar fas-
ciitis, as are bone scintigraphy25
and
MRI.26
Unlike these modalities, ultra-
sound is quick and inexpensive, and
it involves no radiation exposure.
MRI or triple-phase bone scans should
be ordered to rule out occult pathol-
ogy only when the heel pain has not
resolved after 4 to 6 months of non-
surgical treatment.
Less commonly ordered labora-
tory testing to be considered include
blood testing and electromyographic
nerve conduction velocity studies.
Serum hematologic and immuno-
logic testing can detect systemic dis-
orders that contribute to heel pain.
Human leukocyte antigen-B27, com-
plete blood count, erythrocyte sedi-
mentation rate, rheumatoid factor,
antinuclear antibodies, and uric acid
may be considered in patients with
bilateral or atypical heel pain.10
Elec-
tromyography and nerve conduction
velocity studies are effective at iden-
tifying spinal radiculopathy and dif-
fuse peripheral neuropathy as well as
local nerve entrapment, such as tar-
sal tunnel syndrome. The most com-
mon nerve entrapment confused
with plantar fasciitis is the FBLPN.
Unfortunately,electrodiagnosticstud-
ies are not helpful in making this di-
agnosis.16
Nonsurgical Treatment
A wide variety of management strat-
egies have been developed to treat
plantar fasciitis. Nonsurgical treat-
ment is the mainstay of treating
plantar heel pain. A systematic re-
view in 2003 evaluated 26 different
conservative treatments that have
been recommended for the treat-
ment of plantar fasciitis.3 Of these,
only heel pads, orthoses, corticoster-
oid injections, night splints, and ex-
tracorporeal shock wave therapy
(ESWT) have been evaluated in ran-
domized trials. Since then, addition-
al randomized controlled trials, pri-
marily focusing on ESWT, have been
published.
Nonsteroidal
Anti-inflammatory Drugs
In a retrospective review, Wolgin
et al18 found that 39 of 51 patients
(76%) recorded as having used non-
steroidal anti-inflammatory drugs
(NSAIDs) had “successful” out-
comes. No conclusion could be
drawn, however, because any given
patient could have used more than
one treatment. Gill and Kiebzak6
re-
viewed the effectiveness of several
nonsurgical treatments and found
that 27% of patients reported signif-
icant improvement with use of
NSAIDs, whereas 28% felt that they
were ineffective. Recently, in a pro-
spective, double-blind randomized
controlled study, Donley et al27 com-
pared the pain and disability scores
between a group treated with an
NSAID (celecoxib) and a placebo
group. Although a trend toward im-
proved pain relief was seen in the
NSAID group, no statistical signifi-
cance was obtained between the two
treatment arms. To date, no study
has specifically examined the effec-
tiveness of this treatment alone.
Orthoses/Inserts
Foot orthoses are designed to op-
timize biomechanical loading of the
foot, decrease excessive pronation,
off-load the plantar fascia at its ori-
gin, and recreate the shape of the heel
pad. Commonly used orthoses in-
clude prefabricated silicone/rubber
heel cups, prefabricated arch sup-
ports, felt pads, and custom arch sup-
ports. Pfeffer et al4 randomized 236
patients into five treatment groups:
one control and four with different
shoe inserts. The patients treated
with the prefabricated inserts (ie, sil-
icone heel pad, felt pad, rubber heel
cup) had superior improvement in
heel pain. A later participant-blinded,
randomized controlled trial divided
135 patients into three groups (sham
orthosis, off-the-shelf orthosis, cus-
tomized orthosis).28 At the 12-month
review, there was no significant dif-
ference between all groups.
Physical Therapy
Many local therapy modalities
have been proposed for treatment of
plantar fasciitis. Support for thera-
pies such as icing, heat, and massage
has largely been based on anecdotal
data. One prospective, double-blind
randomized controlled study did not
demonstrate any benefit from mag-
netic insoles.7 Other small, random-
ized controlled trials showed no
evidence to support therapeutic ul-
trasound, low-intensity laser thera-
py, or exposure to an electron-
generating device.3
Gudeman et al29
compared iontophoresis of dexa-
methasone with a placebo group in a
prospective, double-blind, random-
ized controlled study; these authors
reported a benefit in pain relief with
the treatment group at 2 weeks but
no statistically significant difference
at 1 month.29
A stretching program has tradi-
tionally been the primary treatment
therapy modality for patients with
plantar fasciitis. Protocols have var-
ied from Achilles tendon stretching
to plantar fascia–specific stretching.
The goal of plantar fascia–specific
stretching is to optimize tissue ten-
sion through a controlled stretch of
the plantar fascia by recreating the
windlass mechanism (Figure 2). An
Achilles tendon–stretching program
typically involves several stretches
that attempt to maximize the length
of both the gastrocnemius and soleus
muscle groups (Figure 3). One recent
prospective, nonblinded, randomized
controlled study by DiGiovanni et
al30
compared these two protocols.
The authors showed that heel pain
Steven K. Neufeld, MD, and Rebecca Cerrato, MD
Volume 16, Number 6, June 2008 341

5. was eliminated or improved at 8
weeks in 52% of patients treated
with the plantar fascia–specific
stretching program versus only 22%
of patients participating in the Achil-
les tendon–stretching program. The
2-year follow-up study reported no
difference between the two groups.30
Injections
Despite the widespread practice of
treating plantar fasciitis by injection
of corticosteroids, typically com-
bined with a local anesthetic, there is
limited evidence of its effectiveness
in providing sustained pain relief.
One study found improved symp-
toms at 1 month but not at 6 months
compared with a control group.31
Re-
cently, interest has developed in the
use of ultrasonography to improve
the accuracy, and therefore the out-
come, of corticosteroid injection. A
study by Tsai et al32 using this tech-
nique showed a lower recurrence rate
of heel pain. However, a second study
by Kane et al25
did not demonstrate
ultrasound-guided injection to be any
more effective than the palpation-
guided technique. Complications as-
sociated with corticosteroid injection
have been reported, including rup-
ture of the plantar fascia and fat pad
atrophy.33
Over the past several years, botu-
linum toxin A (BTX-A) has been in-
creasingly used for various medical
conditions, including chronic tennis
elbow (ie, lateral epicondylitis). In-
terest in its possible role in the treat-
ment of plantar fasciitis has led to
several recent clinical trials studying
its efficacy.34,35 It is proposed that
botulinum toxin may be effective
not only secondary to paralysis of
the injected muscles (ie, abductor
hallucis, flexor digitorum brevis,
quadratus plantae) but also because
of direct analgesic and anti-
inflammatory properties.35 Babcock
et al34
studied the effect of BTX-A
in a double-blind, randomized con-
trolled trial. The authors demon-
strated statistically significant im-
provement in the BTX-A group in all
studied measures, with no side ef-
fects. These patients, however, were
followed for only 8 weeks. Further
investigation with larger numbers
and longer follow-up are needed be-
fore the role of botulinum toxin in-
jections in the treatment of plantar
fasciitis is established.
Night Splints and Walking
Casts
The use of night splints has been
postulated to help alleviate morning
start-up pain by maintaining fascia
stretching during long periods of
rest. Wapner and Sharkey,36 who rec-
ommended 5º of dorsiflexion in the
splint, reported that 11 of their 14
patients (79%) improved. Yet recent
large, randomized controlled trials
have produced conflicting results. A
crossover prospective randomized
trial of 37 patients with chronic
plantar fasciitis found a benefit of
night splinting worn for 1 month.37
Conversely, in a prospective ran-
domized study of 116 patients, Probe
et al38 found no statistically signifi-
cant benefit in adding night splint-
ing to a standard nonsurgical proto-
col of anti-inflammatory medication
and stretching.
Tisdel and Harper39 hypothesized
that a short period of casting would
unload the heel and immobilize the
plantar fascia, thus minimizing re-
petitive microtrauma. Several retro-
spective studies have supported the
efficacy of casting;6,39 however, no
prospective controlled trials of im-
mobilization have been published.
Extracorporeal Shock
Wave Therapy
Extracorporeal shock wave therapy
(ESWT) is a recent and increasingly
popular therapeutic approach used
to treat recalcitrant plantar fasciitis.
It has been shown to be effective in
60% to 80% of cases. ESWT is based
on lithotripsy technology, in which
shock waves (ie, acoustic impulses)
are targeted to the plantar fascia or-
igin. Three modalities that can be
used to generate the shock wave in-
clude electrohydraulic, electromag-
netic, and piezoelectric. Currently,
the US Food and Drug Administra-
tion has approved electrohydraulic
(high-energy) and electromagnetic
(low-energy) devices for the treat-
ment of chronic plantar heel pain.2
However, the therapeutic mecha-
nism involved still remains a topic
of speculation. Ogden et al40
have
hypothesized that the shock waves
cause a controlled microdisruption
of plantar fascial tissue, which ini-
tiates a healing response within the
fascia. It is thought that this re-
sponse promotes revascularization,
releases local growth factors; re-
cruits appropriate stem cells, and al-
lows the fascia to adapt to biologic
and biomechanical demands. Since
1996, there have been many reports
of good and excellent results from
the use of ESWT application for
plantar fasciitis, both in Europe and
the United States.40-43
Currently, no consensus exists
concerning the repeated use of low-
energy shock waves39
versus high-
energy waves.40,44 Low-energy ESWT
is defined as shock waves between
0.04 and 0.12 mJ/mm2, and high-
Figure 2
Plantar fascia–specific stretch. With
the ankle dorsiflexed, the toes are
dorsiflexed using the patient’s one
hand. The stretch is confirmed by
palpating the tension in the plantar
fascia with the other hand.
Plantar Fasciitis: Evaluation and Treatment
342 Journal of the American Academy of Orthopaedic Surgeons

6. energy ESWT is at levels >0.12 mJ/
mm2. In the past few years, results of
several well-designed, randomized
controlled studies have supported
both approaches. In their prospective
randomized trial, Rompe et al43
con-
cluded that, at 6 and 12 months,
three treatments with 2,100 low-
energy shocks were safe and effec-
tive at reducing morning pain in the
treatment group compared with the
control group. Maier et al42 reported
good or excellent results in 75% of
48 heels after low-energy shock
waves were applied three times at
weekly intervals. In their prospec-
tive randomized trial, Ogden et al40
reported that a single application of
1,500 high-energy shocks was safe,
with good results in 47% of their pa-
tients. Buch et al44
reported that
62% of patients who received one
application of 3,800 high-energy
shocks had good results.
In a randomized, placebo-con-
trolled, double-blind clinical trial,
Kudo et al45 confirmed that, at 3
months, there was a statistically sig-
nificant improvement in symptoms
in a treatment group that received one
application of 3,800 high-energy
shock waves. In another randomized
controlled trial, 83% of patients who
received 1,500 high-energy shocks in
a single session reported good or ex-
cellent results at a follow-up of 72
months.46 The authors did not report
any ill effects from the ESWT treat-
ment.
The procedure is commonly per-
formed with the patient under con-
scious sedation along with regional
anesthesia (ankle block). It is well
tolerated by patients, and no serious
side effects have been reported.43
Current indications for ESWT in-
clude 6 months of plantar fasciitis
heel pain that has been recalcitrant
to at least three nonsurgical thera-
py modalities. Contraindications to
ESWT include patients with hemo-
philia, coagulopathies, malignancy,
and open bone growth physes.
Surgical Treatment
Although plantar fasciitis is often a
self-limited problem that does not
cause excessive disability in most pa-
tients, surgery may be indicated when
symptoms persist. Unfortunately, no
randomized controlled studies have
evaluated the effectiveness of surgery
in comparison with nonsurgical treat-
ment programs to manage these
cases.
Plantar fasciotomy, either partial
or complete, is the common surgical
procedure chosen for treating recal-
citrant cases. Although it has been
reported to have an acceptable suc-
cess rate,14,47,48
several studies have
shown that <50% of patients report-
ed satisfaction following surgery and
that many patients continue to have
functional limitations.49
Release of the plantar fascia has
risks of complications and can be as-
sociated with prolonged healing and
rehabilitation times. Plantar fascia
release is thought to alter the biome-
chanics of the foot and decrease foot
arch stability. Partial and total re-
lease of the plantar fascia has been
shown to decrease tarsal arch height,
lead to increased strain of the cuboid
attachment areas of the plantar liga-
ments, and intensify stress in the
midfoot and metatarsal bones. Post-
operatively, patients may experience
acute plantar fasciitis, forefoot stress
fractures, calcaneal and cuboid frac-
tures, and medial or lateral column
foot pain.14,50 Biomechanical and
finite-element studies have shown
that release of >40% of the plantar
fascia has detrimental effects on oth-
er ligamentous and bony structures
in the foot; therefore, releases should
be limited.50
A large number of surgical tech-
niques have been described for plan-
Figure 3
Achilles tendon stretch. A, An Achilles tendon–stretching protocol should involve gentle ankle dorsiflexion with both the knees
flexed to isolate the soleus muscle. B, The knee is extended to involve the entire gastrocnemius–soleus complex. C, Ankle
dorsiflexion over a stool or step will maximize the length of the Achilles tendon.
Steven K. Neufeld, MD, and Rebecca Cerrato, MD
Volume 16, Number 6, June 2008 343

7. tar fasciitis, including endoscopic
plantar fascia release. There is little
consensus, however, as to the best
surgical technique, and no studies
directly compare open surgery with
endoscopic procedures. When there
is suspicion of entrapment of the cal-
caneal branches of the tibial nerve,
particularly the FBLPN, nerve de-
compression can be performed.16
The patient lies supine on the op-
erating room table, and an ankle or
popliteal nerve block is performed.
A tourniquet is not routinely used.
A 5-cm oblique incision is made on
the medial heel just above the
weight-bearing skin of the heel pad.
The superficial fascia of the abductor
hallucis muscle is divided. The mus-
cle is retracted superiorly. The
FBLPN lies between the deep fascia
of the abductor hallucis muscle and
the medial border of the quadratus
plantae muscle. This taut fascia is
carefully divided, thus decompress-
ing the nerve. A small portion of the
plantar fascia near its insertion to
the os calcis is incised. A heel spur,
if present, is carefully removed.
When endoscopic plantar fasciot-
omy is performed, a 1-cm incision is
made along the medial heel just an-
terior to the weight-bearing plantar
skin. A hemostat is used to bluntly
dissect down to the plantar fascia, and
the subcutaneous layer is freed from
its inferior edge. In the pathway
created by the hemostat, a blunt
obturator/cannula is introduced from
medial to lateral, inferior to the fas-
cia. The obturator is removed, and a
30°, 4.0-mm endoscope is placed
within the cannula. The plantar fas-
cia can be seen superiorly. Care is
taken to transect the medial 25% to
50% of the central plantar fascia us-
ing a disposable cannulated knife. A
stop-device is used to prevent exces-
sive transection.
Because of the relative ease and
increased popularity of procedure,
the American Orthopaedic Foot and
Ankle Society (AOFAS) developed a
position statement regarding heel
surgery that is based on expert opin-
ion.51 Essentially, the society recom-
mends nonsurgical treatment before
undergoing surgical treatment. Non-
surgical treatment should be used
for a minimum of 6 months and,
preferably, for 12 months because
>90% of patients respond positively
to nonsurgical management. The
AOFAS recommends initial treat-
ments with heel padding, medica-
tions, and stretching; custom
orthoses and extended physical ther-
apy are used as a second-line option.
Furthermore, a medical evaluation
should be considered before surgery,
and the patient must be advised of
the risks and complications of sur-
gery. In addition, an open procedure,
as opposed to an endoscopic proce-
dure, should be done when nerve
compression is involved. This rec-
ommendation is based on sugges-
tions that the risk of nerve injury
may be higher with endoscopic pro-
cedures than with open procedures.
A new, less invasive surgical tech-
nique using bipolar radiofrequency
microtenotomy (TOPAZ MicroDe-
brider; ArthroCare Sports Medicine,
Sunnyvale, CA) has been described to
treat recalcitrant plantar fasciitis.52
Radiofrequency stimulation, both in
the heart and in wound healing, has
led to increased angiogenesis. Inves-
tigators have reported that this tech-
nique was technically simple to per-
form and was much less invasive
than conventional surgery. Patients
had a rapid and uncomplicated recov-
ery and reported minimal to no pain
7 to 10 days following the procedure.
Pain relief persisted or improved
through 24 months.52 Although
promising, this procedure has not
been studied in a prospective, ran-
domized trial in patients with plan-
tar fasciitis.
Summary
In our algorithm for the treatment of
plantar fasciitis, the patient initially
is counseled to pursue daily activi-
ties as tolerated; pain should be the
guide to his or her activities. When
a patient can tolerate over-the-
counter anti-inflammatory medica-
tions, these are recommended. Nar-
cotics are not routinely prescribed. A
pair of heel pads or over-the-counter
orthoses are dispensed at the time of
the first office visit, and patients are
given handouts describing an exer-
cise program (Figures 2 and 3).These
exercises should be done before get-
ting out of bed in the morning, in the
afternoon, and before bedtime, as
well as after any period of prolonged
sitting. In addition, a night splint is
often fitted to keep the plantar fascia
stretched during sleep. The patient
is reassured that surgery is uncom-
mon. Frequently, patients come into
the office with radiographs showing
a heel spur and request to have it re-
moved. The physician should at-
tempt to minimize the role of the so-
called spur, which often requires
counseling to dispel myths that the
patient was told from friends or oth-
er clinicians.
According to this algorithm, the
patient is treated for approximately
4 to 6 weeks. When the pain is not
controlled, multiple treatment mo-
dalities are attempted to manage the
pain, assuming that the fasciitis runs
its course and resolves on its own.
First, a corticosteroid injection is
given in the region of the anterome-
dial calcaneal tuberosity, followed
by immobilization in a cast or Cam
walker. Second, physical therapy is
started, a custom orthosis with a
deep heel cup is made, and pre-
scription-strength NSAIDs are giv-
en. In addition, a lateral radiograph
of the heel is taken prior to any an-
ticipated invasive procedure to rule
out a stress fracture or other patho-
logic process.
Rarely, at a follow-up visit, ap-
proximately 4 to 6 weeks later, the
patient still reports discomfort. If
some improvement has been made,
the treatment plan is continued. If
no improvement is noted, MRI may
then be ordered to help confirm the
diagnosis of plantar fasciitis, partic-
ularly when there are other con-
Plantar Fasciitis: Evaluation and Treatment
344 Journal of the American Academy of Orthopaedic Surgeons

8. founding pathologic conditions or
when the course is atypical.
Alternative treatment may be
considered, such as the use of ESWT.
Finally, if the patient has failed all
other treatments and has significant
pain that prevents him or her from
work and recreation, surgery is of-
fered. When surgery is necessary, we
prefer a small plantar medial inci-
sion with either release of the medi-
al one-third edge of the plantar fascia
or decompression of the FBLPN,
along with the subtotal plantar fas-
cia release.
Nonsurgical treatment of proxi-
mal plantar fasciitis has a reported
success rate of 85% to 90%.19,53
The
clinician needs to counsel the pa-
tient that it may take as long as 6 to
12 months for all pain to resolve.
Surgical treatment of plantar fasci-
itis should be considered only as a fi-
nal resort when prolonged nonsurgi-
cal treatment (>12 months) fails to
provide pain relief. When fasciotomy
is necessary, partial release of <40%
is recommended.50
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Plantar Fasciitis: Evaluation and Treatment
346 Journal of the American Academy of Orthopaedic Surgeons