This document contains information from Dr. Bahaa Ali Kornah, a professor of orthopedics at Al-Azhar University in Cairo, Egypt, on the topic of plantar fasciitis. It defines plantar fasciitis as inflammation of the plantar fascia at its origin on the heel bone. It discusses the anatomy of the foot and plantar fascia, risk factors for developing plantar fasciitis like obesity and tight calf muscles, symptoms of pain with walking or standing, and treatments including rest, ice, stretches, orthotics, and corticosteroid injections.

1. Dr.Bahaa Ali Kornah
Prof. Of Orthopedic
Al-Azhar University
Cairo -Egypt
Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
Plantar Fasciitis

2. Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
Dr. Bahaa Ali Kornah
Prof.. Of Orthopedic
Al-Azhar University
Cairo - Egypt
Bahaa Kornah. Al-Azhar Un. Cairo EGYPT
‫وبركاته‬ ‫هللا‬ ‫ورحمة‬ ‫عليكم‬ ‫السالم‬

3. • “Not Plantar Fasciitis”: the differential
diagnosis and management of heel pain
syndrome
• "Plantar Heel Pain"
Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

4. WHO CAN DRIVE CARS!
• WHO HAD DRIVING LICENCE !
Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

5. Objectives
• Learn the anatomy of the foot.
• terms associated with plantar fasciitis.
• the causes of plantar fasciitis and why it
occurs.
• able to evaluate plantar fasciitis.
• current treatments as well as the
rehabilitation for plantar fasciitis.
• methods available for the prevention of
plantar fasciitis.

6. Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

7. • A condition caused by inflammation of the
aponeurosis at its origin on the calcareous
The term plantar fasciitis is often used to
describe a clinical condition in which the
patient has pain in the plantar aspect of the
heel.
Plantar fasciitis is reported to be the most
common cause of inferior heel pain in adults.
Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

8. Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

9. Epidemiology demographics
– affects men and women equally
• 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)
Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

10. Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
Anatomy
• The plantar fascia is a thin layer
of connective tissue supporting
the arch of the foot

11. Anatomy
PF is closely connected to the paratenon of Achilles tendon,
through the periosteum of the heel. Hence it is functionally
& structurally continuous with TA

12. Anatomy
• The anatomy of ;
(a) Plantar fascia, (b) Calcaneus,
(c) Arches of the foot,
(d) Nerves, (e) Fat pad.
• The plantar fascia is divided into three areas
central, medial, and lateral.
• The central component is the major functional
portion of the plantar fascia.

13. Anatomy
• The central part is the strongest
and thickest. It is narrow
posterior, where it is attached
to the medial process of the
calcaneal tuberosity. It
becomes broader and
somewhat thinner as it diverges
towards the metatarsal heads.
Just proximal to these it divides
into five bands, one for each
toe.
Plantar fascia and its three strips

14. Biomechanics
• The heel pad is
clearly the first line
of defense against
very high impact-
loading energies and
forces incident on
the foot at heel-
strike. Confinement of the heel pad by
external support increases the
thickness of the fat pad and the
shock absorbency

15. Biomechanics
• Arches of the foot:
• Support for the medial
longitudinal arch of the foot
can be described using two
models,
• The beam model describes
the arch as a curved,
segmented beam that is
supported by densely
connected joints. Weight
applied to the arch is
supported at the heel and
forefoot, and applied load
generates compression
dorsally and tension
plantarly.
Beam model of the medial longitudinal
arch

16. Biomechanics
• The truss model ; describes the
arch as two beams connected
superiorly by a pivot and
inferiorly with a tie rod. The
plantar aponeurosis is a major
component of the static
and dynamic structural support
mechanisms of the foot. In
neutral stance, both
compressive and tensile loads,
which provide intrinsic stability
to the foot, are produced during
load transmission.
Truss model of the medial
longitudinal arch

17. Biomechanics

18. Biomechanics

19. Pathophysiology
• Pathology described as :
• (1) Overuse,
• (2) Inflammation and Degeneration,
• (3) Heel Fat Pad atrophy and
• (4) Spur Formation
• Overuse injuries result from repetitive sub
traumatic forces. Breakdown of microscopic tissue
occurs faster than the tissue can heal or repair
itself. The results are inflammation, degeneration
of involved tissues.

20. Pathophysiology
– chronic overuse leads to micro
tears 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 wellBahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

21. Pathophysiology
• Plantar fascia is a multilayered
fibrous aponeurosis, composed
of both collagen fibers and
elastic fibers.
• Both the collagen fibers and
the elastic fibers changed from
a wavy to a straight
configuration as stress was
applied to it.

22. Pathophysiology
• The reactive tissue at the insertion formed new
connective tissue as a reaction to constant stress and
over time, progressed from fibro cartilage to cartilage
to bone.
• The spur lies in the origin of the plantar fascia, or in
the origin of the flexor digitorum Brevis muscle.
)A) ِِ) B( )C)
Radiographic taken, a) At presentation, b)After four month ,(c)
After tow years. Showing the development of spur (Jeffrey, et
al., 2001).

23. 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
Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

24. Etiology
• Plantar fasciitis is a clinical syndrome. The
etiology are all uncertain.
• Risk factors include the following
• Change in walking or running habits or surface,
• Occupation with prolonged weight bearing,
• Use of shoes with poor cushioning and
• Obesity or sudden weight gain.

25. Why this injury occurs (con’t)
• several risk factors, they include:
• Flat feet
• High arched, rigid feet
• Increasing age and family tendency
• Running on toes, hills or very soft surfaces (sand)
• Poor arch support in shoes
• Rapid change in activity level

26. Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

27. Diagnosis
Patients typically complain of pain that starts
with the first few steps in the morning or after
prolonged sitting start-up pain

28. Most common Signs & Symptoms
Pain
Tenderness
Antalgic gait

29. 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
• 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 group of patients
• indicative of entrapment or irritation of the first branch of the lateral
plantar nerve (Baxter's nerve)
Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

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31. Diagnosis
Location of pain is
vital to diagnosis, it
is around the area
of the medial
calcaneal tuberosity
The red mark indicates the typical
point of maximal tenderness in plantar
fasciitis .The blue mark indicates the
location of tenderness in heel pain
caused by thinning of the heel fat pad

32. Where is the pain

33. Diagnosis
Palpate the plantar fascia
for tenderness or swelling.
Tenderness is noted with
considerable pressure
over the medial proximal
aspect of the plantar
fascia.
The point of maximal tenderness for plantar
fasciitis is along the plantar medial heel
(point of finger

34. Diagnosis
The medial tubercle is not
really sharp and distinct unless
it is associated with heel spur.
Palpation of the medial calcaneal
tubercle usually elicits pain in
patients presenting with plantar
fasciitis

35. Examination
heel compression for stress fx Tinel’s test for tarsal tunnel or ADQ

36. 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
Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

37. Studies
•Labs
• not routinely indicated
• useful if other causes of heel pain are suspected
• inflammatory arthritis
• infection
•EMG
• useful to rule out entrapment
Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

38. Differential diagnosis
• Nerve
• sciatica; tarsal tunnel syndrome, FBLPN (N to ADQ)
• Soft tissue
• fibromatosis, bursitis, bruise, fat-pad atrophy,
Inflammatory,
• Bone
• stress fracture, infection, tumour, Paget’s,
Metabolic

39. Differential Diagnosis
• Tarsal tunnel syndrome,
• Entrapment of the first branch of the lateral
planter nerve,
• Heel pad disorders,
• Calcaneal fracture,
• Plantar neuroma,
• Plantar fascial rupture and
• Tendinous Lésions

41. Pharmacology
NSAIDs medication
Cortisone injections.

42. Physical Therapy
More than 90% of patients with
plantar fasciitis will improve
within 10 months of starting
simple treatment methods.

43. General Measures
Rest
Ice
(20 min; 3-4x/day)

44. Taping
No studies have
adequately
evaluated the
effectiveness of
taping or
strapping for
managing
plantar fasciitis.

45. Shoeinserts

46. Night splints

47. Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
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

48. prefabricated shoe inserts
Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

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50. Treatment of Plantar Fasciitis
•The Slant-board Stretch & the Stair stretch

51. Rehabilitation (con’t)
• PHASE 2- Rehabilitation Phase:
• Further decrease pain and inflammation:
– ultrasound
– phonophoresis
– neuroprobe
– contrast baths
• Maintain/increase flexibility of injured (and
surrounding) tissue:
– gentle stretching exercises: calf, hamstring, posterior
muscle groups

52. Rehabilitation (con’t)
• PHASE 3- Functional Phase:
• Functionally strengthen intrinsic muscles of
the foot
– closed chain therapeutic exercise
• Doming of Arch (towel toe curl)
• Protect injured area during functional activity
– taping
– stability running or other appropriate athletic
shoes
– orthoses as needed

53. Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
•Extracorporeal Shock Wave Therapy
•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 follow-up

54. Surgical Treatment
Several surgical procedures have been described
for the treatment of recalcitrant plantar fasciitis,
including
• Gastronomies recession
• Plantar fasciotomy,
• Neurolysis,
• Heel spur excision,
• Calcaneal decompression and
• Recently endoscopic plantar fasciotomy

55. Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
•Operative
• gastronomies recession
• indications
• no clear indications established
•surgical release with plantar fasciotomy
• indications
• persistent 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

56. Gastroc lengthening

57. Gastroc lengthening
Classic Strayer lengthening

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59. Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
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
•Plantar fascia rupture
• risk factors = athletes, minimalist runners,
corticosteroid injections
• treat with cast immobilization

60. Conclusion
• Plantar fasciitis is an inflammatory condition of the foot
• may be acute or insidious.
• in individuals 30-60 years of age, and
• equally in men and women.
• Pain is severe with initial weight bearing and subsides after
several steps.
• The terms plantar fasciitis, heel spur,
and heel spur syndrome are synonymous.
• Consider non-operative measures always
• .
Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

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65. Bahaa Ali Kornah
bkornah@gmail.com
‫د‬/‫قرنة‬ ‫بهاء‬Bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT