Plantar fasciitis is a common problem that one in 10 people will experience in their lifetime. Plantar fasciopathy is an appropriate descriptor because the condition is not inflammatory. Risk factors include limited ankle dorsiflexion, increased body mass index, and standing for prolonged periods of time. Plantar fasciitis is common in runners but can also affect sedentary people. With proper treatment, 80% of patients with plantar fasciitis improve within 12 months. Plantar fasciitis is predominantly a clinical diagnosis. Symptoms are stabbing, nonradiating pain first thing in the morning in the proximal medioplantar surface of the foot; the pain becomes worse at the end of the day. Physical examination findings are often limited to tenderness to palpation of the proximal plantar fascial insertion at the anteromedial calcaneus. Ultrasonography is a reasonable and inexpensive diagnostic tool for patients with pain that persists beyond three months despite treatment. Treatment should start with stretching of the plantar fascia, ice massage, and nonsteroidal anti-inflammatory drugs. Many standard treatments such as night splints and orthoses have not shown benefit over placebo. Recalcitrant plantar fasciitis can be treated with injections, extracorporeal shock wave therapy, or surgical procedures, although evidence is lacking. Endoscopic fasciotomy may be required in patients who continue to have pain that limits activity and function despite exhausting nonoperative treatment options.

Plantar fasciitis, a self-limiting condition, is a common cause of heel pain in adults. It affects more than 1 million persons per year, and two-thirds of patients with plantar fasciitis will seek care from their family physician. Plantar fasciitis affects sedentary and athletic populations. Obesity, excessive foot pronation, excessive running, and prolonged standing are risk factors for developing plantar fasciitis. Diagnosis is primarily based on history and physical examination. Patients may present with heel pain with their first steps in the morning or after prolonged sitting, and sharp pain with palpation of the medial plantar calcaneal region. Discomfort in the proximal plantar fascia can be elicited by passive ankle/first toe dorsiflexion. Diagnostic imaging is rarely needed for the initial diagnosis of plantar fasciitis. Use of ultrasonography and magnetic resonance imaging is reserved for recalcitrant cases or to rule out other heel pathology; findings of increased plantar fascia thickness and abnormal tissue signal the diagnosis of plantar fasciitis. Conservative treatments help with the disabling pain. Initially, patient-directed treatments consisting of rest, activity modification, ice massage, oral analgesics, and stretching techniques can be tried for several weeks. If heel pain persists, then physician-prescribed treatments such as physical therapy modalities, foot orthotics, night splinting, and corticosteroid injections should be considered. Ninety percent of patients will improve with these conservative techniques. Patients with chronic recalcitrant plantar fasciitis lasting six months or longer can consider extracorporeal shock wave therapy or plantar fasciotomy.

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Plantar heel pain is the most prevalent complaint presenting to foot and ankle specialists and may be seen in upwards of 11% to 15% of adults (). Plantar heel pain has been referred to in the published literature by many names including heel spur syndrome, which lends some importance to the radiographic presence of an inferior calcaneal spur to the clinical symptoms. The term plantar fasciitis has been used for years, likely in an attempt to recognize the actual symptoms occurring along the plantar fascia with or without concomitant presence of a spur. More recently, the term plantar fasciosis has been advocated to de-emphasize the presumed inflammatory component and reiterate the degenerative nature of histologic observations at the calcaneal enthesis (, ). Regardless of the exact terminology, the clinician, published literature, and general practice behaviors all describe the same pathology: pain along the proximal plantar fascia and its attachment in the area of the calcaneal tuberosity (Figure 1). The symptoms of plantar heel pain are well known, and diagnosis is relatively straightforward.
The most common cause cited for plantar heel pain is biomechanical stress of the plantar fascia and its enthesis of the calcaneal tuberosity (Figure 2) (, , , , , , , ). Mechanical overload, whether the result of biomechanical faults, obesity, or work habits, may contribute to the symptoms of heel pain. Discussion of a biomechanical etiology usually involves the windlass mechanism and tension of the plantar fascia in stance and gait (, , , , , , , , , , ).

Plantar heel pain (insertional heel pain of the plantar fascia with or without a heel spur) usually occurs because of pathologic stress to plantar soft tissues as a result of biomechanical abnormalities. Localized nerve entrapment may be contributory.
The usual presentation is isolated plantar heel pain when weight is placed on the foot on arising in the morning or after sitting for a period of time. The pain generally decreases after a few minutes of weight-bearing but returns over the course of the day. Other findings may include pain on palpation of the inferior heel, a high body mass index, and a tight Achilles tendon. The diagnosis is based on the history, physical examination, and, when appropriate, radiographs.
Initial treatment options may include patient-directed measures such as regular calf-muscle stretching, cryotherapy, over-the-counter heel cushions and arch supports, weight loss (if indicated), activity limitation, and avoidance of flat shoes and barefoot walking. Treatment may also involve nonsteroidal anti-inflammatory drugs (NSAIDs), padding and strapping of the foot, and, in appropriate patients, corticosteroid injections. If improvement occurs, treatments are continued until symptoms resolve.
If no improvement occurs after six weeks, referral to a podiatric foot and ankle surgeon is appropriate. Initial treatment measures are continued, and additional treatments may include a customized orthotic device, night splinting, a limited number of corticosteroid injections, casting, or use of a fixed-ankle walker-type device during activity. If improvement occurs, treatments are continued until symptoms resolve.
If no improvement occurs after two to three months, initial treatment measures are continued. If not previously used, cast immobilization may be added. Further options include surgery (plantar fasciotomy) and extracorporeal shock wave therapy. Other diagnoses may need to be explored.

Although the plantar fascia (PF) has been studied quite well from a biomechanical viewpoint, its microscopic properties have been overlooked: nothing is known about its content of elastic fibers, the features of the extracellular matrix or the extent of innervation. From a functional and clinical standpoint, the PF is often correlated with the triceps surae muscle, but the anatomical grounds for this link are not clear. The aim of this work was to focus on the PF macroscopic and microscopic properties and study how Achilles tendon diseases might affect it. Twelve feet from unembalmed human cadavers were dissected to isolate the PF. Specimens from each PF were tested with various histological and immunohistochemical stains. In a second stage, 52 magnetic resonance images (MRI) obtained from patients complaining of aspecific ankle or foot pain were analyzed, dividing the cases into two groups based on the presence or absence of signs of degeneration and/or inflammation of the Achilles tendon. The thickness of PF and paratenon was assessed in the two groups and statistical analyses were conducted. The PF is a tissue firmly joined to plantar muscles and skin. Analyzing its possible connections to the sural structures showed that this fascia is more closely connected to the paratenon of Achilles tendon than to the Achilles tendon, through the periosteum of the heel. The PF extended medially and laterally, continuing into the deep fasciae enveloping the abductor hallucis and abductor digiti minimi muscles, respectively. The PF was rich in hyaluronan, probably produced by fibroblastic-like cells described as 'fasciacytes'. Nerve endings and Pacini and Ruffini corpuscles were present, particularly in the medial and lateral portions, and on the surface of the muscles, suggesting a role for the PF in the proprioception of foot. In the radiological study, 27 of the 52 MRI showed signs of Achilles tendon inflammation and/or degeneration, and the PF was 3.43 ± 0.48 mm thick (99%CI and SD = 0.95), as opposed to 2.09 ± 0.24 mm (99%CI, SD = 0.47) in the patients in which the MRI revealed no Achilles tendon diseases; this difference in thickness of 1.29 ± 0.57 mm (99%CI) was statistically significant (P < 0.001). In the group of 27/52 patients with tendinopathies, the PF was more than 4.5 mm thick in 5, i.e. they exceeded the threshold for a diagnosis of plantar fasciitis. None of the other 25/52 paitents had a PF more than 4 mm thick. There was a statistically significant correlation between the thicknesses of the PF and the paratenon. These findings suggest that the plantar fascia has a role not only in supporting the longitudinal arch of the foot, but also in its proprioception and peripheral motor coordination. Its relationship with the paratenon of the Achilles tendon is consistent with the idea of triceps surae structures being involved in the PF pathology, so their rehabilitation can be considered appropriate. Finally, the high concentration of hyaluronan in the PF points to the feasibility of using hyaluronan injections in the fascia to treat plantar fasciitis.

Plantar fascia (PF) is a heterogeneous thickness structure across plantar foot. It is important significance to investigate the biomechanical behavior of the medial, middle and lateral PF regions. To investigate the non-uniform macro/micro structures of the different PF regions, the uniaxial tensile test of PF strips were performed to assess the mechanical behavior of PF. A scanning electron microscope (SEM) was used to visualize and measure the micro morphology of PF associated with collagen fibers. A three-dimensional foot finite element (FE) model was developed to quantify the tensile behavior of the internal PF. The elastic modulus of the lateral PF component (1560 MPa) was observed, followed by the medial (701 MPa), the central (1100 MPa) and the lateral (714 MPa) portions in the central component. Elongation of the central portion (0.192) was lower than the medial (0.223) and the lateral (0.227) portions. The corresponding SEM images showed that the fibers of the central portion were more densely packed and thicker compared to the ambilateral portions in the central component. While the FE model prediction also suggested that the greater elastic modulus of the central PF portion had lower strain (0.192) versus the ambilateral portions. Therefore, the lower elongation and greater elastic modulus at the central portion of PF would probably have a high risk of PF injury. The findings showed a relation between the mechanical tension and fibrous morphology of PF. This information would have a better understanding of the PF pathophysiology diseases related to tear and injury of PF.

Current treatments of plantar fasciitis are based on the premise that the Achilles tendon (AT) and plantar fascia (PF) are mechanically directly linked, which is an area of debate. The aim of this study was to assess the morphological relationship between the AT and PF. Nineteen cadaveric feet were x-ray imaged, serially sectioned and plastinated for digital image analyses. Measurements of the AT and PF thicknesses and cross-sectional areas (CSA) were performed at their calcaneal insertion. The fiber continuity was histologically assessed in representative subsamples. Strong correlations exist between the CSA of the AT and PF at calcaneal insertion and the CSA of PF's insertional length (r = 0.80), and between the CSAs of AT's and PF's insertional lengths. Further correlations were observed between AT and PF thicknesses (r = 0.62). This close morphological relationship could, however, not be confirmed through x-ray nor complete fiber continuity in histology. This study provides evidence for a morphometric relationship between the AT and PF, which suggests the presence of a functional relationship between these two structures following the biological key idea that the structure determines the function. The observed morphological correlations substantiate the existing mechanical link between the AT and PF via the posterior calcaneus and might explain why calf stretches are a successful treatment option for plantar heel pain.

Background: Although plantar fasciitis is the most common cause of heel pain, little has been reported on the incidence rates of this disorder. We sought to determine the incidence rate and demographic risk factors of plantar fasciitis in an ethnically diverse and physically active population of United States military service members.

Methods: A query was performed with use of the Defense Medical Epidemiology Database for the International Classification of Diseases, Ninth Revision, Clinical Modification, code for plantar fasciitis (728.71). Multivariate Poisson regression analysis was used to estimate the rate of plantar fasciitis per 1000 person-years, while controlling for sex, race, rank, service, and age.

Results: The overall unadjusted incidence rate of plantar fasciitis was 10.5 per 1000 person-years. Compared with men, women had a significantly increased adjusted incidence rate ratio for plantar fasciitis of 1.96 (95% confidence interval, 1.94 to 1.99). The adjusted incidence rate ratio for black service members compared with white service members was 1.12 (95% confidence interval, 1.09 to 1.12). With junior officers as the referent category, junior enlisted, senior enlisted, and senior officer rank groups had a significantly increased adjusted incidence rate ratio for plantar fasciitis: 1.20 (95% confidence interval, 1.18 to 1.23), 1.19 (95% confidence interval, 1.17 to 1.22), and 1.56 (95% confidence interval, 1.52 to 1.61), respectively. Compared with service members in the Air Force, those in the Army and Marines had a significantly increased adjusted incidence rate ratio for plantar fasciitis of 1.85 (95% confidence interval, 1.82 to 1.87) and 1.28 (95% confidence interval, 1.25 to 1.30), respectively. The adjusted incidence rate ratio for the age group of forty years old or more compared with the twenty to twenty-four-year-old group was 3.42 (95% confidence interval, 3.34 to 3.51).

Conclusions: Female sex; black race; junior enlisted, senior enlisted, and senior officer rank groups; service in the Army or Marines; and increasing age are all risk factors for plantar fasciitis.

Plantar fasciitis, a self-limiting condition, is a common cause of heel pain in adults. It affects more than 1 million persons per year, and two-thirds of patients with plantar fasciitis will seek care from their family physician. Plantar fasciitis affects sedentary and athletic populations. Obesity, excessive foot pronation, excessive running, and prolonged standing are risk factors for developing plantar fasciitis. Diagnosis is primarily based on history and physical examination. Patients may present with heel pain with their first steps in the morning or after prolonged sitting, and sharp pain with palpation of the medial plantar calcaneal region. Discomfort in the proximal plantar fascia can be elicited by passive ankle/first toe dorsiflexion. Diagnostic imaging is rarely needed for the initial diagnosis of plantar fasciitis. Use of ultrasonography and magnetic resonance imaging is reserved for recalcitrant cases or to rule out other heel pathology; findings of increased plantar fascia thickness and abnormal tissue signal the diagnosis of plantar fasciitis. Conservative treatments help with the disabling pain. Initially, patient-directed treatments consisting of rest, activity modification, ice massage, oral analgesics, and stretching techniques can be tried for several weeks. If heel pain persists, then physician-prescribed treatments such as physical therapy modalities, foot orthotics, night splinting, and corticosteroid injections should be considered. Ninety percent of patients will improve with these conservative techniques. Patients with chronic recalcitrant plantar fasciitis lasting six months or longer can consider extracorporeal shock wave therapy or plantar fasciotomy.

Plantar fasciitis is the most common foot condition treated by health care providers. It has been estimated that plantar fasciitis occurs in approximately 2 million Americans each year and affects as much as 10% of the population over the course of a lifetime. In 2000, the Foot and Ankle Special Interest Group of the Orthopaedic Section, APTA surveyed over 500 members and received responses from 117 therapists. Of those responding, 100% indicated that plantar fasciitis was the most common foot condition seen in their clinic. Rome et al68reported that plantar fasciitis accounts for 15% of all adult foot complaints requiring professional care and is prevalent in both nonathletic and athletic populations. Taunton et al82conducted a retrospective case-control analysis of 2002 individuals with running-related injuries who were referred to the same sports medicine center. They reported that plantar fasciitis was the most common condition diagnosed in the foot and represented 8% of all injuries.

Background: Plantar fasciitis (PF) is the most common cause of heel pain in adults, and the number of patients and medical expenses are increasing annually. However, studies on this condition are lacking. There is a need to investigate universally administered PF treatment and the associated costs. Therefore we analyzed the South Korean Health Insurance Review and Assessment Service data to investigate the distribution and healthcare usage of patients with PF.

Methods: A cross-sectional retrospective observational design was used in this study. Patients diagnosed with PF (ICD-10 code M72.2) between January 2010 and December 2018 in South Korea, of whom 60,079 had used healthcare at least once, were included in the study. We assessed healthcare usage and cost due to PF, treatment method, and visit route. All statistical analyses were performed with descriptive statistics using SAS 9.4 version.

Results: The number of treated cases of PF and patients with PF was 11,627 cases and 3,571 patients in 2010, respectively, which increased annually to 38,515 cases and 10,125 patients by 2018, respectively. The 45-54-year-old age group had the highest number of patients; the patient population was predominantly women. Physical therapy was used frequently in Western medicine (WM) institutions, where > 50% of the medicines prescribed to outpatients were analgesics. In contrast, acupuncture therapy was most commonly used in Korean medicine (KM) institutions. A high percentage of patients who visited a KM institution, followed by a WM institution, and then returned to the same KM institution had visited the WM institution for radiological diagnostic examination.

Conclusion: This study analyzed nine years of period data from a patient sample of claims data from the Health Insurance Review and Assessment Service to examine the current status of health service use for PF in Korea. We obtained information on the status of WM/KM institution visits for PF treatment, which could be useful for health policymakers. Study findings regarding treatments often used in WM/KM, the frequency of treatments, and their costs could be used as basic data by clinicians and researchers.

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Plantar heel pain is the most prevalent complaint presenting to foot and ankle specialists and may be seen in upwards of 11% to 15% of adults (). Plantar heel pain has been referred to in the published literature by many names including heel spur syndrome, which lends some importance to the radiographic presence of an inferior calcaneal spur to the clinical symptoms. The term plantar fasciitis has been used for years, likely in an attempt to recognize the actual symptoms occurring along the plantar fascia with or without concomitant presence of a spur. More recently, the term plantar fasciosis has been advocated to de-emphasize the presumed inflammatory component and reiterate the degenerative nature of histologic observations at the calcaneal enthesis (, ). Regardless of the exact terminology, the clinician, published literature, and general practice behaviors all describe the same pathology: pain along the proximal plantar fascia and its attachment in the area of the calcaneal tuberosity (Figure 1). The symptoms of plantar heel pain are well known, and diagnosis is relatively straightforward.
The most common cause cited for plantar heel pain is biomechanical stress of the plantar fascia and its enthesis of the calcaneal tuberosity (Figure 2) (, , , , , , , ). Mechanical overload, whether the result of biomechanical faults, obesity, or work habits, may contribute to the symptoms of heel pain. Discussion of a biomechanical etiology usually involves the windlass mechanism and tension of the plantar fascia in stance and gait (, , , , , , , , , , ).

Plantar fasciitis is a musculoskeletal disorder primarily affecting the fascial enthesis. Although poorly understood, the development of plantar fasciitis is thought to have a mechanical origin. In particular, pes planus foot types and lower-limb biomechanics that result in a lowered medial longitudinal arch are thought to create excessive tensile strain within the fascia, producing microscopic tears and chronic inflammation. However, contrary to clinical doctrine, histological evidence does not support this concept, with inflammation rarely observed in chronic plantar fasciitis. Similarly, scientific support for the role of arch mechanics in the development of plantar fasciitis is equivocal, despite an abundance of anecdotal evidence indicating a causal link between arch function and heel pain. This may, in part, reflect the difficulty in measuring arch mechanics in vivo. However, it may also indicate that tensile failure is not a predominant feature in the pathomechanics of plantar fasciitis. Alternative mechanisms including 'stress-shielding', vascular and metabolic disturbances, the formation of free radicals, hyperthermia and genetic factors have also been linked to degenerative change in connective tissues. Further research is needed to ascertain the importance of such factors in the development of plantar fasciitis.

Overuse injuries are suggested to result from repetitive microdamage eliciting pain in the affected tissue. Therapy commonly focuses on the area of symptom localization; however, such approach may oversimplify the true etiopathology. This review hypothesizes that the development of some sports-related soft tissue disorders, such as plantar fasciitis or lumbago, is promoted by pathologically altered force transmission from anatomically connected structures.

Plantar fasciitis is a common problem that one in 10 people will experience in their lifetime. Plantar fasciopathy is an appropriate descriptor because the condition is not inflammatory. Risk factors include limited ankle dorsiflexion, increased body mass index, and standing for prolonged periods of time. Plantar fasciitis is common in runners but can also affect sedentary people. With proper treatment, 80% of patients with plantar fasciitis improve within 12 months. Plantar fasciitis is predominantly a clinical diagnosis. Symptoms are stabbing, nonradiating pain first thing in the morning in the proximal medioplantar surface of the foot; the pain becomes worse at the end of the day. Physical examination findings are often limited to tenderness to palpation of the proximal plantar fascial insertion at the anteromedial calcaneus. Ultrasonography is a reasonable and inexpensive diagnostic tool for patients with pain that persists beyond three months despite treatment. Treatment should start with stretching of the plantar fascia, ice massage, and nonsteroidal anti-inflammatory drugs. Many standard treatments such as night splints and orthoses have not shown benefit over placebo. Recalcitrant plantar fasciitis can be treated with injections, extracorporeal shock wave therapy, or surgical procedures, although evidence is lacking. Endoscopic fasciotomy may be required in patients who continue to have pain that limits activity and function despite exhausting nonoperative treatment options.

Plantar fasciitis, a self-limiting condition, is a common cause of heel pain in adults. It affects more than 1 million persons per year, and two-thirds of patients with plantar fasciitis will seek care from their family physician. Plantar fasciitis affects sedentary and athletic populations. Obesity, excessive foot pronation, excessive running, and prolonged standing are risk factors for developing plantar fasciitis. Diagnosis is primarily based on history and physical examination. Patients may present with heel pain with their first steps in the morning or after prolonged sitting, and sharp pain with palpation of the medial plantar calcaneal region. Discomfort in the proximal plantar fascia can be elicited by passive ankle/first toe dorsiflexion. Diagnostic imaging is rarely needed for the initial diagnosis of plantar fasciitis. Use of ultrasonography and magnetic resonance imaging is reserved for recalcitrant cases or to rule out other heel pathology; findings of increased plantar fascia thickness and abnormal tissue signal the diagnosis of plantar fasciitis. Conservative treatments help with the disabling pain. Initially, patient-directed treatments consisting of rest, activity modification, ice massage, oral analgesics, and stretching techniques can be tried for several weeks. If heel pain persists, then physician-prescribed treatments such as physical therapy modalities, foot orthotics, night splinting, and corticosteroid injections should be considered. Ninety percent of patients will improve with these conservative techniques. Patients with chronic recalcitrant plantar fasciitis lasting six months or longer can consider extracorporeal shock wave therapy or plantar fasciotomy.

Discussion of a biomechanical etiology usually involves the windlass mechanism and tension of the plantar fascia in stance and gait (, , , , , , , , , , ).
Localized nerve entrapment of the medial calcaneal or muscular branch off the lateral plantar nerve may be a contributing factor (, , , , , , , , , , , , , , , , , , , , , ).
Patients usually present with plantar heel pain upon initiation of weight bearing, either in the morning upon arising or after periods of rest. The pain tends to decrease after a few minutes, and returns as the day proceeds and time on their feet increases. Associated significant findings may include high body mass index (BMI), tightness of the Achilles tendon, pain upon palpation of the inferior heel and plantar fascia, and inappropriate shoe wear (, , , , , , ).
Many patients will have attempted self-remedies before seeking medical advice. A careful history is important and should include time(s) of day when pain occurs, current shoe wear, type of activity level both at work and leisure, and history of trauma. Presence of sensory disturbances including radiation of pain is generally indicative of neurologic pathology and is important to exclude. An appropriate physical examination of the lower extremity includes range of motion of the foot and ankle, with special attention to limitation of ankle dorsiflexion, palpation of the heel and plantar fascia, observation of swelling or atrophy of the heel pad, presence of hypesthesias or dysthesias, assessment of the architectural alignment of the foot, and angle and base of gait evaluation. The quality and height of the plantar fat pad also have been implicated as factors in plantar heel pain (Figure 3) (, , , , ).
Following physical evaluation, appropriate radiographs (weight-bearing views preferred) may be helpful.

Plantar heel pain (insertional heel pain of the plantar fascia with or without a heel spur) usually occurs because of pathologic stress to plantar soft tissues as a result of biomechanical abnormalities. Localized nerve entrapment may be contributory.
The usual presentation is isolated plantar heel pain when weight is placed on the foot on arising in the morning or after sitting for a period of time. The pain generally decreases after a few minutes of weight-bearing but returns over the course of the day. Other findings may include pain on palpation of the inferior heel, a high body mass index, and a tight Achilles tendon. The diagnosis is based on the history, physical examination, and, when appropriate, radiographs.
Initial treatment options may include patient-directed measures such as regular calf-muscle stretching, cryotherapy, over-the-counter heel cushions and arch supports, weight loss (if indicated), activity limitation, and avoidance of flat shoes and barefoot walking. Treatment may also involve nonsteroidal anti-inflammatory drugs (NSAIDs), padding and strapping of the foot, and, in appropriate patients, corticosteroid injections. If improvement occurs, treatments are continued until symptoms resolve.
If no improvement occurs after six weeks, referral to a podiatric foot and ankle surgeon is appropriate. Initial treatment measures are continued, and additional treatments may include a customized orthotic device, night splinting, a limited number of corticosteroid injections, casting, or use of a fixed-ankle walker-type device during activity. If improvement occurs, treatments are continued until symptoms resolve.
If no improvement occurs after two to three months, initial treatment measures are continued. If not previously used, cast immobilization may be added. Further options include surgery (plantar fasciotomy) and extracorporeal shock wave therapy. Other diagnoses may need to be explored.

Plantar fasciitis, a self-limiting condition, is a common cause of heel pain in adults. It affects more than 1 million persons per year, and two-thirds of patients with plantar fasciitis will seek care from their family physician. Plantar fasciitis affects sedentary and athletic populations. Obesity, excessive foot pronation, excessive running, and prolonged standing are risk factors for developing plantar fasciitis. Diagnosis is primarily based on history and physical examination. Patients may present with heel pain with their first steps in the morning or after prolonged sitting, and sharp pain with palpation of the medial plantar calcaneal region. Discomfort in the proximal plantar fascia can be elicited by passive ankle/first toe dorsiflexion. Diagnostic imaging is rarely needed for the initial diagnosis of plantar fasciitis. Use of ultrasonography and magnetic resonance imaging is reserved for recalcitrant cases or to rule out other heel pathology; findings of increased plantar fascia thickness and abnormal tissue signal the diagnosis of plantar fasciitis. Conservative treatments help with the disabling pain. Initially, patient-directed treatments consisting of rest, activity modification, ice massage, oral analgesics, and stretching techniques can be tried for several weeks. If heel pain persists, then physician-prescribed treatments such as physical therapy modalities, foot orthotics, night splinting, and corticosteroid injections should be considered. Ninety percent of patients will improve with these conservative techniques. Patients with chronic recalcitrant plantar fasciitis lasting six months or longer can consider extracorporeal shock wave therapy or plantar fasciotomy.

Discussion of a biomechanical etiology usually involves the windlass mechanism and tension of the plantar fascia in stance and gait (, , , , , , , , , , ).
Localized nerve entrapment of the medial calcaneal or muscular branch off the lateral plantar nerve may be a contributing factor (, , , , , , , , , , , , , , , , , , , , , ).
Patients usually present with plantar heel pain upon initiation of weight bearing, either in the morning upon arising or after periods of rest. The pain tends to decrease after a few minutes, and returns as the day proceeds and time on their feet increases. Associated significant findings may include high body mass index (BMI), tightness of the Achilles tendon, pain upon palpation of the inferior heel and plantar fascia, and inappropriate shoe wear (, , , , , , ).
Many patients will have attempted self-remedies before seeking medical advice. A careful history is important and should include time(s) of day when pain occurs, current shoe wear, type of activity level both at work and leisure, and history of trauma. Presence of sensory disturbances including radiation of pain is generally indicative of neurologic pathology and is important to exclude. An appropriate physical examination of the lower extremity includes range of motion of the foot and ankle, with special attention to limitation of ankle dorsiflexion, palpation of the heel and plantar fascia, observation of swelling or atrophy of the heel pad, presence of hypesthesias or dysthesias, assessment of the architectural alignment of the foot, and angle and base of gait evaluation. The quality and height of the plantar fat pad also have been implicated as factors in plantar heel pain (Figure 3) (, , , , ).
Following physical evaluation, appropriate radiographs (weight-bearing views preferred) may be helpful.

Plantar fasciitis is a common problem that one in 10 people will experience in their lifetime. Plantar fasciopathy is an appropriate descriptor because the condition is not inflammatory. Risk factors include limited ankle dorsiflexion, increased body mass index, and standing for prolonged periods of time. Plantar fasciitis is common in runners but can also affect sedentary people. With proper treatment, 80% of patients with plantar fasciitis improve within 12 months. Plantar fasciitis is predominantly a clinical diagnosis. Symptoms are stabbing, nonradiating pain first thing in the morning in the proximal medioplantar surface of the foot; the pain becomes worse at the end of the day. Physical examination findings are often limited to tenderness to palpation of the proximal plantar fascial insertion at the anteromedial calcaneus. Ultrasonography is a reasonable and inexpensive diagnostic tool for patients with pain that persists beyond three months despite treatment. Treatment should start with stretching of the plantar fascia, ice massage, and nonsteroidal anti-inflammatory drugs. Many standard treatments such as night splints and orthoses have not shown benefit over placebo. Recalcitrant plantar fasciitis can be treated with injections, extracorporeal shock wave therapy, or surgical procedures, although evidence is lacking. Endoscopic fasciotomy may be required in patients who continue to have pain that limits activity and function despite exhausting nonoperative treatment options.

Plantar fasciitis, a self-limiting condition, is a common cause of heel pain in adults. It affects more than 1 million persons per year, and two-thirds of patients with plantar fasciitis will seek care from their family physician. Plantar fasciitis affects sedentary and athletic populations. Obesity, excessive foot pronation, excessive running, and prolonged standing are risk factors for developing plantar fasciitis. Diagnosis is primarily based on history and physical examination. Patients may present with heel pain with their first steps in the morning or after prolonged sitting, and sharp pain with palpation of the medial plantar calcaneal region. Discomfort in the proximal plantar fascia can be elicited by passive ankle/first toe dorsiflexion. Diagnostic imaging is rarely needed for the initial diagnosis of plantar fasciitis. Use of ultrasonography and magnetic resonance imaging is reserved for recalcitrant cases or to rule out other heel pathology; findings of increased plantar fascia thickness and abnormal tissue signal the diagnosis of plantar fasciitis. Conservative treatments help with the disabling pain. Initially, patient-directed treatments consisting of rest, activity modification, ice massage, oral analgesics, and stretching techniques can be tried for several weeks. If heel pain persists, then physician-prescribed treatments such as physical therapy modalities, foot orthotics, night splinting, and corticosteroid injections should be considered. Ninety percent of patients will improve with these conservative techniques. Patients with chronic recalcitrant plantar fasciitis lasting six months or longer can consider extracorporeal shock wave therapy or plantar fasciotomy.

US has shown good sensitivity (80%) and specificity (88%) in the diagnosis of plantar fasciitis when compared to MRI []. A diagnostic accuracy of 69% for abnormal focal echogenicity within the plantar fascia, 60% for edema around the plantar fascia, 78% for perifascial edema, 69% for rupture of the plantar fascia, and 56% for an associated calcaneal spur have been found for US, using MRI as the reference standard []. Kapoor et al [] showed higher sensitivity and specificity of US elastography when compared to US in the detection of plantar fasciitis (95% and 100% versus 66% and 75%, respectively), using MRI as the reference standard. US has been shown to be useful in the diagnosis of complete and partial tears of the plantar fascia []. Some authors regard US to be superior to MRI in differentiating true fiber interruption and tearing of the plantar fascia from edema [].

MRI allows accurate characterization of the plantar fascia and adjacent soft-tissues and bones, and several imaging findings have been described in patients with plantar fasciitis and partial or complete tears of the plantar fascia on MRI []. Given that, some of the findings in patients with plantar fasciitis are nonspecific; these findings can also be seen in asymptomatic patients. MRI should always be correlated with clinical symptoms to avoid overcalling plantar fasciitis. Although no significant differences have been found in plantar fascia thickness on US and MRI, MRI is currently considered the most sensitive imaging study in the diagnosis of plantar fasciitis []. There is no relevant literature supporting the routine use of contrast in the diagnosis of plantar fasciitis or tears.

Purpose: To evaluate the sonographic findings of plantar fasciitis.

Materials And Methods: Both feet of 15 patients who had a clinical diagnosis of plantar fasciitis were evaluated with ultrasound (US) by using a 7.0-MHz linear-array transducer. Heel pain was unilateral in 11 patients and bilateral in four. Sagittal sonograms were obtained, and the thickness of the plantar fascia was measured at its proximal end near its insertion into the calcaneus. Other observations included hypoechoic fascia, fiber rupture, perifascial fluid collections, and calcifications. Both feet of 15 healthy volunteers were also evaluated as a control group.

Results: Plantar fascia thickness was significantly increased in the heels in patients with plantar fasciitis (3.2-6.8 mm; mean, 5.2 mm +/- 1.13) compared with their asymptomatic heels (2.0-4.0 mm; mean, 2.9 mm +/- 0.70) (P < .0001) and compared with the heels of the patients in the control group (1.6-3.8 mm; mean, 2.6 mm +/- 0.48) (P < .0001). The proximal plantar fascia of 16 (84%) symptomatic heels were diffusely hypoechoic compared with none of the patients' asymptomatic heels and only one heel of a patient in the volunteer group. No fascia rupture, perifascial fluid collection, or calcifications were identified.

Conclusion: Increased thickness of the fascia and hypoechoic fascia are sonographic findings of plantar fasciitis. US may be a valuable noninvasive technique for the diagnosis of plantar fasciitis.

Splaying of the metatarsals or soft-tissue density may be demonstrated but is not diagnostic [].
Though radiography is typically insensitive in the diagnosis of fasciitis, it should be the initial imaging study in patients with a painful heel. Evidence supports the use of weightbearing radiographs in this instance []. The combination of thickened plantar fascia and fat pad abnormalities on radiographs has a sensitivity of 85% and a specificity of 95% for plantar fasciitis [].

Plantar fasciitis is a clinical diagnosis and is often combined with some form of imaging to validate the diagnosis. The clinical utility of lateral X-rays lies in the fact that they are relatively inexpensive and may contribute to ruling out other osseous causes of pain. In this study 106 (27 plantar fasciitis (PF) and 79 controls) plain non-weight bearing lateral X-rays were examined by a blind examiner to document the key features of the lateral X-ray between images of individuals with and without plantar fasciitis. As expected calcaneal spurs were observed in both groups (85% PF and 46% controls). However, plantar fascia thickness and fat pad abnormalities resulted in the best group differentiation (p<0.0001) with sensitivity of 85% and specificity of 95% for plantar fasciitis. It was concluded that the key radiological features that differentiate the groups were not spurs but rather changes in the soft tissues. If it is deemed necessary to confirm the diagnosis of typical plantar fasciitis with imaging, a lateral non-weight bearing X-ray should be the first choice investigation especially if these key features are noted.

Imaging studies are typically not necessary for the diagnosis of plantar fasciitis. Imaging would appear to be most useful to rule out other possible causes of heel pain or to establish a diagnosis of plantar fasciitis if the health care provider is in doubt. Plantar fascia thickness and fat-pad abnormalities observed from radiographs are the 2 best factors for group differentiation of plantar fasciitis.59Evidence of calcaneal spurs is not a key radiographic feature to distinguish differences in individuals with plantar fasciitis in comparison to controls.59

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Plantar heel pain is the most prevalent complaint presenting to foot and ankle specialists and may be seen in upwards of 11% to 15% of adults (). Plantar heel pain has been referred to in the published literature by many names including heel spur syndrome, which lends some importance to the radiographic presence of an inferior calcaneal spur to the clinical symptoms. The term plantar fasciitis has been used for years, likely in an attempt to recognize the actual symptoms occurring along the plantar fascia with or without concomitant presence of a spur. More recently, the term plantar fasciosis has been advocated to de-emphasize the presumed inflammatory component and reiterate the degenerative nature of histologic observations at the calcaneal enthesis (, ). Regardless of the exact terminology, the clinician, published literature, and general practice behaviors all describe the same pathology: pain along the proximal plantar fascia and its attachment in the area of the calcaneal tuberosity (Figure 1). The symptoms of plantar heel pain are well known, and diagnosis is relatively straightforward.
The most common cause cited for plantar heel pain is biomechanical stress of the plantar fascia and its enthesis of the calcaneal tuberosity (Figure 2) (, , , , , , , ). Mechanical overload, whether the result of biomechanical faults, obesity, or work habits, may contribute to the symptoms of heel pain. Discussion of a biomechanical etiology usually involves the windlass mechanism and tension of the plantar fascia in stance and gait (, , , , , , , , , , ).

Plantar heel pain (insertional heel pain of the plantar fascia with or without a heel spur) usually occurs because of pathologic stress to plantar soft tissues as a result of biomechanical abnormalities. Localized nerve entrapment may be contributory.
The usual presentation is isolated plantar heel pain when weight is placed on the foot on arising in the morning or after sitting for a period of time. The pain generally decreases after a few minutes of weight-bearing but returns over the course of the day. Other findings may include pain on palpation of the inferior heel, a high body mass index, and a tight Achilles tendon. The diagnosis is based on the history, physical examination, and, when appropriate, radiographs.
Initial treatment options may include patient-directed measures such as regular calf-muscle stretching, cryotherapy, over-the-counter heel cushions and arch supports, weight loss (if indicated), activity limitation, and avoidance of flat shoes and barefoot walking. Treatment may also involve nonsteroidal anti-inflammatory drugs (NSAIDs), padding and strapping of the foot, and, in appropriate patients, corticosteroid injections. If improvement occurs, treatments are continued until symptoms resolve.
If no improvement occurs after six weeks, referral to a podiatric foot and ankle surgeon is appropriate. Initial treatment measures are continued, and additional treatments may include a customized orthotic device, night splinting, a limited number of corticosteroid injections, casting, or use of a fixed-ankle walker-type device during activity. If improvement occurs, treatments are continued until symptoms resolve.
If no improvement occurs after two to three months, initial treatment measures are continued. If not previously used, cast immobilization may be added. Further options include surgery (plantar fasciotomy) and extracorporeal shock wave therapy. Other diagnoses may need to be explored.

Plantar heel pain is a prevalent condition affecting 10% of the population, with plantar fasciitis being the most common cause. Plantar calcaneal spurs are frequently associated with plantar fasciitis, yet their role in the condition and surgical outcomes remains unclear. This study investigates the impact of plantar calcaneal spur excision on the outcomes of plantar fascia surgery, utilizing a radiofrequency microtenotomy and bone marrow aspiration technique. A retrospective review of 136 plantar fascia surgeries was conducted with 83 cases including plantar calcaneal spur excision. Demographic and operative factors were analyzed. Outcomes included time to weight-bearing in a boot and shoes, symptom resolution, and complications. Plantar calcaneal spur excision was associated with a statistically significant delay in symptom resolution (p = 0.006) and time to weight-bearing in shoes (p = 0.020). A statistically significant difference was observed regarding operative laterality, with right-sided surgeries demonstrating an increased time to symptom resolution (p = 0.007) and a higher retreatment rate (p = 0.017) compared to left-sided surgeries. There was no significant difference in complication rates or the need for retreatment between excision and non-excision groups. These findings highlight the need for careful consideration of plantar calcaneal spur excision in surgical planning for plantar fasciitis, with implications for patient education and management strategies.

Background: This study classified plantar heel spurs and their relationship to plantar fasciitis.

Methods: Patients included those with plantar fasciitis who were treated from 2012 through 2013. Plantar heel spur shape and size were assessed radiographically and correlated to function and pain before and after treatment. Function and pain were scored with the Foot and Ankle Ability Measures and a visual analog scale, respectively. This study included 109 patients with plantar fasciitis.

Results: The plantar heel spur shape was classified as 0/absent in 26 patients, 1/horizontal in 66 patients, 2/vertical in 4 patients, and 3/hooked in 13 patients. The plantar heel spur size was less than 5 mm in 75 patients, 5-10 mm in 28 patients, and greater than 10 mm in 6 patients. Initially, patients with any shape or size to their spur had no difference in function and pain. With treatment, patients with horizontal and hooked spurs had the greatest improvement in function and pain (P < .05). With treatment, patients with larger spurs had the greatest improvement in function and pain (P < .05).

Conclusion: Plantar heel spurs can be classified by shape and size in patients with plantar fasciitis. Before treatment, neither the spur shape nor size significantly correlated with symptoms. After treatment, patients with larger horizontal or hooked spurs had the greatest improvement in function and pain. These findings may be important when educating patients about the role of heel spurs with plantar fasciitis and the effect of nonsurgical treatment with certain spurs.

Level Of Evidence: Level III, comparative series.

It is unclear whether plantar and posterior heel spurs are truly pathological findings and whether they are stimulated by traction or compression forces. Previous histological investigations focused on either one of the two spur locations, thereby potentially overlooking common features that refer to a uniform developmental mechanism. In this study, 19 feet from 16 cadavers were X-ray scanned to preselect calcanei with either plantar or posterior spurs. Subsequently, seven plantar and posterior spurs were histologically assessed. Five spur-free Achilles tendon and three plantar fascia entheses served as controls. Plantar spurs were located either intra- or supra-fascial whereas all Achilles spurs were intra-fascial. Both spur types consistently presented a trabecular architecture without a particular pattern, fibrocartilage at the tendinous entheses and the orientation of the spur tips was in line with the course of the attached soft tissues. Spurs of both entities revealed tapered areas close to their bases with bulky tips. Achilles and plantar heel spurs seem to be non-pathological calcaneal exostoses, which are likely results of traction forces. Both spur types revealed commonalities such as their trabecular architecture or the tip direction in relation to the attached soft tissues. Morphologically, heel spurs seem poorly adapted to compressive loads.

Objective: To describe the structure and significance of subcalcaneal heel spurs associated with the plantar fascia.

Methods: The enthesis of the plantar fascia was removed from 17 elderly cadavers by sagittal saw cuts either side of the medial tuberosity, radiographs were taken, and the tissue was processed for routine histology. Sagittal sections were stained with toluidine blue, Masson's trichrome, or alcian blue, and sections were matched with the corresponding radiographs.

Results: Spurs develop on the deep surface of the plantar fascia but their formation is heralded by degenerative changes that occur within it. According to differences between small and large spurs, we propose that there are 3 stages in their development: (1) an initial formation of cartilage cell clusters and fissures at the plantar fascia enthesis; (2) thickening of the subchondral bone plate at the enthesis as small spurs form; (3) development of vertically oriented trabeculae buttressing the proximal end of larger spurs. The spurs grow by a combination of intramembranous and chondroidal ossification.

Conclusion: Contrary to popular belief, subcalcaneal heel spurs cannot be traction spurs as they do not develop within the plantar fascia itself. They are thus fundamentally different from heel spurs in the Achilles tendon. We suggest instead that they develop as a consequence of degenerative changes that occur in the plantar fascia enthesis.

Plantar heel pain (insertional heel pain of the plantar fascia with or without a heel spur) usually occurs because of pathologic stress to plantar soft tissues as a result of biomechanical abnormalities. Localized nerve entrapment may be contributory.
The usual presentation is isolated plantar heel pain when weight is placed on the foot on arising in the morning or after sitting for a period of time. The pain generally decreases after a few minutes of weight-bearing but returns over the course of the day. Other findings may include pain on palpation of the inferior heel, a high body mass index, and a tight Achilles tendon. The diagnosis is based on the history, physical examination, and, when appropriate, radiographs.
Initial treatment options may include patient-directed measures such as regular calf-muscle stretching, cryotherapy, over-the-counter heel cushions and arch supports, weight loss (if indicated), activity limitation, and avoidance of flat shoes and barefoot walking. Treatment may also involve nonsteroidal anti-inflammatory drugs (NSAIDs), padding and strapping of the foot, and, in appropriate patients, corticosteroid injections. If improvement occurs, treatments are continued until symptoms resolve.
If no improvement occurs after six weeks, referral to a podiatric foot and ankle surgeon is appropriate. Initial treatment measures are continued, and additional treatments may include a customized orthotic device, night splinting, a limited number of corticosteroid injections, casting, or use of a fixed-ankle walker-type device during activity. If improvement occurs, treatments are continued until symptoms resolve.
If no improvement occurs after two to three months, initial treatment measures are continued. If not previously used, cast immobilization may be added. Further options include surgery (plantar fasciotomy) and extracorporeal shock wave therapy. Other diagnoses may need to be explored.

Plantar fasciitis, a self-limiting condition, is a common cause of heel pain in adults. It affects more than 1 million persons per year, and two-thirds of patients with plantar fasciitis will seek care from their family physician. Plantar fasciitis affects sedentary and athletic populations. Obesity, excessive foot pronation, excessive running, and prolonged standing are risk factors for developing plantar fasciitis. Diagnosis is primarily based on history and physical examination. Patients may present with heel pain with their first steps in the morning or after prolonged sitting, and sharp pain with palpation of the medial plantar calcaneal region. Discomfort in the proximal plantar fascia can be elicited by passive ankle/first toe dorsiflexion. Diagnostic imaging is rarely needed for the initial diagnosis of plantar fasciitis. Use of ultrasonography and magnetic resonance imaging is reserved for recalcitrant cases or to rule out other heel pathology; findings of increased plantar fascia thickness and abnormal tissue signal the diagnosis of plantar fasciitis. Conservative treatments help with the disabling pain. Initially, patient-directed treatments consisting of rest, activity modification, ice massage, oral analgesics, and stretching techniques can be tried for several weeks. If heel pain persists, then physician-prescribed treatments such as physical therapy modalities, foot orthotics, night splinting, and corticosteroid injections should be considered. Ninety percent of patients will improve with these conservative techniques. Patients with chronic recalcitrant plantar fasciitis lasting six months or longer can consider extracorporeal shock wave therapy or plantar fasciotomy.

The quality and height of the plantar fat pad also have been implicated as factors in plantar heel pain (Figure 3) (, , , , ).
Following physical evaluation, appropriate radiographs (weight-bearing views preferred) may be helpful. Biomechanical interpretation of weight-bearing radiographs may provide insight into architectural faults. An infracalcaneal spur frequently is associated with the symptomatology of plantar fasciitis, although its presence or absence may not necessarily correlate with the patient's symptoms (). Radiographic identification of a plantar heel spur usually indicates that the condition has been present for at least 6 to 12 months, whether having been symptomatic or asymptomatic (Figure 2). As a rule, the longer the duration of heel pain symptoms, the longer will be the period to final resolution of the condition (, ).
Initial treatment options (see Plantar Heel Pain Treatment Ladder, Figure 4) may include padding and strapping of the foot (, ), therapeutic orthotic insoles (, , , , , , ), oral anti-inflammatories (), and a corticosteroid injection localized to the area of maximum tenderness (, , , , ). Patient-directed treatments appear to be as important as these approaches in resolving symptoms. Such treatments include regular Achilles and plantar fascia stretching (, ), avoidance of flat shoes and barefoot walking, cryotherapy applied directly to the affected part, over-the-counter arch supports and heel cups, and limitation of extended (high-impact) physical activities (, , , ). Patients usually have a clinical response within 6 weeks of initiation of treatment. If improvement is noted, the initial therapy program is continued until symptoms are resolved. If little or no improvement is noted, the patient should be referred to a foot and ankle surgeon if not already under this specialist's care.
Treatment options have been graded according to the levels of evidence and grades of recommendation shown in Table 1().

Background: Plantar fasciitis is the most common cause of heel pain. It may remain symptomatic despite conservative treatment with orthoses and analgesia. There is conflicting evidence concerning the role of extracorporeal shock wave therapy (ESWT) in the management of this condition.

Questions/purposes: We investigated whether there was a significant difference in the change of (1) VAS scores and (2) Roles and Maudsley scores from baseline when treated with ESWT and placebo. Specifically we compared overall improvement from baseline composite VAS, reduction in overall VAS pain, success rate of improving overall VAS pain by 60%, success rate of improving VAS pain by 60% when taking first steps, doing daily activities, and during application of a pain pressure meter.

Methods: MEDLINE, Embase, and CINAHL databases were searched from January 1980 to January 2013 and a double extraction technique was used to obtain relevant studies. Studies had to be prospective randomized controlled trials on adults and must not have used local anesthesia as part of their treatment protocol. Studies must have specifically recruited patients who continued to be symptomatic despite a minimum of 3 months of conservative treatments. All papers were assessed regarding their methodologic quality and a meta-analysis performed. Seven prospective randomized controlled trials were included in this study. There were 369 patients included in the placebo group and 294 in the ESWT group.

Results: After ESWT, patients had better composite VAS scores (random effects model, standardized mean difference [SMD] = 0.38; 95% CI, 0.05, 0.72; z = 2.27). They also had a greater reduction in their absolute VAS scores compared with placebo (random effects model, SMD = 0.60; 95% CI, 0.34, 0.85; z = 4.64). Greater success of improving heel pain by 60% was observed after ESWT when taking first steps (random effects model, risk ratio [RR] = 1.30; 95% CI, 1.04, 1.62; z = 2.29) and during daily activities (random effects model, RR = 1.44; 95% CI, 1.13, 1.84; z = 2.96). Subjective measurement of pain using a pressure meter similarly favored ESWT (random effects model, RR = 1.37, 95% CI, 1.06, 1.78; z = 2.41). There was a significant difference in the change to "excellent - good" Roles and Maudsley scores in favor of the ESWT group.

Conclusions: ESWT is a safe and effective treatment of chronic plantar fasciitis refractory to nonoperative treatments. Improved pain scores with the use of ESWT were evident 12 weeks after treatment. The evidence suggests this improvement is maintained for up to 12 months. We recommend the use of ESWT for patients with substantial heel pain despite a minimum of 3 months of nonoperative treatment.

The objective of this study was to evaluate the effectiveness of extracorporeal shock wave therapy (ESWT) in treating chronic plantar fasciitis. An online database search was conducted for studies using ESWT in managing chronic plantar fasciitis. Eleven high-quality randomized controlled trials were included in the meta-analysis and showed that ESWT was more effective in reducing morning pain (weighted mean difference, -0.77 [95% confidence interval {CI}, -1.30 to -0.25]; odds ratio, 0.65 [95% CI, 0.42-1.00]). Moderate-intensity ESWT was more effective in decreasing overall and activity pain (weighted mean difference, -6.6 [95% CI, -6.74 to -6.46], and weighted mean difference, 0.47 (95% CI, 0.30-0.74). Both moderate- and high-intensity ESWT were more effective in improving functional outcome, with odds ratios of 0.51 (95% CI, 0.30-0.84) and 0.47 (95% CI, 0.29-0.75). The adverse effects that were seen more in ESWT were pain on the calcaneal area and calcaneal erythema. This study concludes that moderate- and high-intensity ESWT were effective in the treatment of chronic plantar fasciitis.

Background: The effectiveness of extracorporeal shock wave therapy in the treatment of plantar fasciitis is controversial. The objective of the present study was to test whether focused extracorporeal shock wave therapy is effective in relieving chronic heel pain diagnosed as plantar fasciitis.

Methods: Two hundred and fifty subjects were enrolled in a prospective, multicenter, double-blind, randomized, and placebo-controlled U.S. Food and Drug Administration trial. Subjects were randomized to focused extracorporeal shock wave therapy (0.25 mJ/mm(2)) or placebo intervention, with three sessions of 2000 impulses in weekly intervals. Primary outcomes were both the percentage change of heel pain on the visual analog scale composite score (pain during first steps in the morning, pain with daily activities, and pain with a force meter) and the Roles and Maudsley score at twelve weeks after the last intervention compared with the scores at baseline.

Results: Two hundred and forty-six patients (98.4%) were available for intention-to-treat analysis at the twelve-week follow-up. With regard to the first primary end point, the visual analog scale composite score, there was a significant difference (p = 0.0027, one-sided) in the reduction of heel pain in the extracorporeal shock wave therapy group (69.2%) compared with the placebo therapy group (34.5%). Extracorporeal shock wave therapy was also significantly superior to the placebo therapy for the Roles and Maudsley score (p = 0.0006, one-sided). Temporary pain and swelling during and after treatment were the only device-related adverse events observed.

Conclusions: The results of the present study provide proof of the clinically relevant effect size of focused extracorporeal shock wave therapy without local anesthesia in the treatment of recalcitrant plantar fasciitis, with success rates between 50% and 65%.

Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background: Radial extracorporeal shock wave therapy is an effective treatment for chronic plantar fasciitis that can be administered to outpatients without anesthesia but has not yet been evaluated in controlled trials.

Hypothesis: There is no difference in effectiveness between radial extracorporeal shock wave therapy and placebo in the treatment of chronic plantar fasciitis.

Study Design: Randomized, controlled trial; Level of evidence, 1.

Methods: Three interventions of radial extracorporeal shock wave therapy (0.16 mJ/mm(2); 2000 impulses) compared with placebo were studied in 245 patients with chronic plantar fasciitis. Primary endpoints were changes in visual analog scale composite score from baseline to 12 weeks' follow-up, overall success rates, and success rates of the single visual analog scale scores (heel pain at first steps in the morning, during daily activities, during standardized pressure force). Secondary endpoints were single changes in visual analog scale scores, success rates, Roles and Maudsley score, SF-36, and patients' and investigators' global judgment of effectiveness 12 weeks and 12 months after extracorporeal shock wave therapy.

Results: Radial extracorporeal shock wave therapy proved significantly superior to placebo with a reduction of the visual analog scale composite score of 72.1% compared with 44.7% (P = .0220), and an overall success rate of 61.0% compared with 42.2% in the placebo group (P = .0020) at 12 weeks. Superiority was even more pronounced at 12 months, and all secondary outcome measures supported radial extracorporeal shock wave therapy to be significantly superior to placebo (P < .025, 1-sided). No relevant side effects were observed.

Conclusion: Radial extracorporeal shock wave therapy significantly improves pain, function, and quality of life compared with placebo in patients with recalcitrant plantar fasciitis.

Author List: Hye Chang Rhim, Jaehyung Shin, Jane Kang, Paige Dyrek, Zack Crockett, Pearl Galido, Carrie Wade, Karsten Hollander, Joanne Borg-Stein, Steven Sampson, Adam S Tenforde

Objective: To determine the efficacy of extracorporeal shockwave therapy (ESWT) and investigate outcomes following the use of ESWT for athletes and physically active individuals.

Design: Systematic review.

Data Sources: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and searched four databases: PubMed (NLM), Embase (Elsevier), CINAHL Complete (EBSCO) and Web of Science (Clarivate).

Eligibility Criteria For Selecting Studies: Included studies were randomised controlled trials, cohort and case-control studies, cases series and reports that evaluated outcomes following ESWT for athletes, physically active individuals and occupational groups requiring regular physical activity such as military cadets.

Results: 56 studies with 1874 athletes or physically active individuals were included. Using the Oxford level of evidence rating, included studies were 18 level I (32.1%), 3 level II (5.4%), 10 level III (17.9%), 13 level IV (23.2%) and 12 level V (21.4%). Based on the level I studies, ESWT may be effective alone in plantar fasciitis, lateral epicondylitis and proximal hamstring tendinopathy and as an adjunct to exercise treatment in medial tibial stress syndrome and osteitis pubis in athletes or physically active individuals. In most studies, athletes were allowed to continue activities and training and tolerated ESWT with minimal side effects.

Conclusion: ESWT may offer an efficacious treatment alone or as an adjunct to concurrent exercise therapy in selected sports-related injuries and without major adverse events. Further high-level research is needed to better define the role and clinical outcomes of ESWT.

Background: Plantar fasciitis (PF) is a common foot disorder with variability in treatment strategy. Two effective management techniques include platelet-rich plasma (PRP) injections and extracorporeal shock wave therapy (ESWT). The purpose of this meta-analysis is to compare the effectiveness of PRP vs ESWT in the management of PF.

Methods: A systematic search was performed of PubMed, Cochrane, and Google Scholar for randomized controlled trials comparing PRP to ESWT. Studies met inclusion criteria if mean and SDs for visual analog scale (VAS) pain scores and plantar fascia thickness (PFT) were reported. Mean differences were used to compare VAS pain score and PFT between PRP and ESWT.

Results: Six randomized controlled trials, comparing a total of 214 subjects in the PRP group and 218 subjects in the ESWT group, were analyzed. A significantly greater statistical improvement was seen in the PRP group in VAS pain (mean difference = -0.67 [95% CI -1.16, -0.18], P = .007) and plantar fascia thickness (PFT) (mean difference = -0.56 [95% CI -0.77, -0.35], P < .001).

Conclusion: PRP had a statistically higher pain reduction than ESWT, but the difference does not reach clinical significance in this meta-analysis.

Plantar fasciitis is often cause of heel pain, especially in sporting-related activities. Different conservative measures for the management of plantar fasciitis were compared in several researches. The purpose of this retrospective study was to evaluate and compare clinical outcomes of chronic plantar fasciitis treated with ultrasound-guided platelet-rich plasma (PRP) and focal ultrasound-guided extracorporeal shockwave therapy (ESW). Secondarily, results on subpopulation of athletes were recorded. Fifty-five patients treated for plantar fasciitis were included, 24 among them were competitive or recreational athletes. Treatment outcomes were assessed using Visual Analog Scale and Foot Function Index before and after treatment. Time to return to sport among patients practicing sporting activities was recorded. Before treatment, no differences were observed between groups in terms of age, gender, body mass index, and months of follow up. From baseline to final follow-up assessment, significant improvement was observed in all the outcomes measures. The subgroup analysis showed no differences between patients stratified for type of treatment and sport/nonsport practitioners. The overall failure rate was higher, although not significant, in patients who underwent ESW therapy and they required a higher number of orthopedic visits. Among sports practitioners the mean time to return to sport (months) was faster in PRP group than ESW group (p = .044). PRP and ESW represent both reliable solutions for plantar fasciitis leading to good results in terms of patients' satisfaction, pain, and clinical outcomes. However, after treatment with PRP injections less recurrences in overall population and faster return to sporting activities in sports practitioners were observed.

Objective: To compare the efficacy of autologous blood-derived products (ABPs), CSs and shock-wave (SW) therapy in the treatment of plantar fasciitis.

Methods: Electronic databases were searched for studies that compared ABPs, CSs and SW therapy for the treatment of plantar fasciitis, published up to June 2014. The primary and secondary outcomes were reduction in visual analogue scale (VAS) score at 3 and 6 months and odds ratio of treatment success, respectively. Groups were compared by traditional pair-wise meta-analysis and by network meta-analysis.

Results: Seven randomized controlled trials and three quasi-experimental studies that included 604 patients were enrolled. Pair-wise meta-analysis indicated a trend favouring ABPs over CSs regarding VAS reduction at 3 months; this benefit was significant in a subgroup analysis of platelet-rich plasma (PRP) vs CSs. There were no significant between-group differences in VAS reduction at 6 months and in treatment success. Network meta-analysis showed that ABPs had the highest probability of being the best treatment at 3 months, but ABPs were slightly inferior to SW for VAS reduction at 6 months. Although SW therapy had the highest likelihood of treatment success, the between-group differences in probabilities were less remarkable than those for pain reduction at 3 and 6 months.

Conclusion: ABPs, followed by CSs, were best in providing relief from pain at 3 months. SW therapy and ABPs had similar probabilities of providing pain relief at 6 months, and were better than CSs at that time. Subgroup analysis indicated that an ABP regimen consisting of platelet-rich plasma improves treatment efficacy.

The objective of this network meta-analysis (NMA) was to assess the pain relief performance of eight different plantar fasciitis therapies, including nonsteroidal anti-inflammatory medications, corticosteroid injections (CSs), autologous whole blood, platelet-rich plasma (PRP), extracorporeal shockwave therapy (ESWT), ultrasound therapy (US), botulinum toxin A (BTX-A), and dry needling (DN). Published prospective or randomized controlled trials (RCTs) as for the above eight therapies were identified by searching CNKI, PubMed, and Embase. Mean difference (MD) and 95% credible intervals (CrIs) of visual analogue scale (VAS) were used to evaluate multiaspect comparisons. The ranking result was obtained by utilizing surface under cumulative ranking curve (SUCRA). Node-splitting plots were conducted to assess the consistency between direct and indirect evidence. Egger's test and funnel plots were performed to examine publication bias. Forty-one trials with a total of 2,889 cases were involved in this NMA. In terms of 1-month VAS, only ESWT turned out to be of better efficacy than placebo (MD = -3.3; Cr

I: [-5.3, -1.1]). No statistically significant difference was found between pair-wise comparisons concerning 2-month VAS. ESWT also demonstrated better efficacy as for 3-month results (MD = -2.7; Cr

I: [-4.2, -1.3]). Besides, CSs was significantly better than placebo as well in 3-month results (MD = -2.1; Cr

I: [-4.1, -0.19]). With regard to 6-month VAS results, ESWT performed better than placebo (MD = -3.0; Cr

I: [-5.0, -0.51]). According to the SUCRA, ESWT ranked the first as for all seven outcomes. ESWT might be the optimal treatment. In addition, BTX-A and PRP were considered as suboptimal.

Background: Plantar fasciitis is the most common cause of heel pain in adults. Multiple conservative treatment plans exist; however, some cases do not obtain significant clinical improvement with conservative treatment and require further intervention. This retrospective case study evaluated the success rate of percutaneous plantar fasciotomy and confounding comorbidities that negatively affect outcomes.

Methods: A series of 41 patients treated with percutaneous plantar fasciotomy using the Topaz EZ microdebrider coblation wand were invited to participate in this retrospective follow-up study, and 88% ( = 36) participated. A limited chart review was completed and the patients answered a survey with the visual analog scale (VAS) for pain and the Foot and Ankle Ability Measure (FAAM) questionnaire. Average outcomes were calculated and 45 variables were analyzed to determine if they were statistically significant confounders. Patients had symptoms for an average of 3 years before the procedure and were contacted for follow-up at an average of 14 months after the procedure.

Results: The average VAS for pain score was 1.3 ± 1.8 and the average FAAM score was 92 ± 15. Eighty-nine percent of patients had a successful outcome, defined as FAAM greater than 75. In addition, patients at 18 months postprocedure reported complete or near-complete resolution of symptoms with an FAAM score greater than 97. Concurrent foot pathologies (eg, tarsal tunnel syndrome), oral steroid treatment prior to the procedure, and immobilization with a boot prior to the procedure were statistically significant negative confounders ( < .05). Being an athlete was a positive confounder ( = .02).

Conclusion: Percutaneous plantar fasciotomy using a microdebrider coblation was an effective treatment for plantar fasciitis, particularly without concurrent foot pathology, with a low risk of complications.

Level Of Evidence: Level IV, retrospective case series.

Plantar fasciitis, the most common cause of pain in the inferior heel, accounts for 11% to 15% of all foot symptoms requiring professional care among adults. The present study reports the results of a minimally invasive surgical treatment of chronic plantar fasciitis. All patients with plantar fasciitis who had undergone percutaneous latticed plantar fasciotomy at 3 clinical sites from March 2008 to March 2009 were included in the present study. The follow-up evaluations for this treatment were conducted using the Mayo clinical scoring system. We investigated 17 patients with recalcitrant chronic plantar fasciitis who had undergone this treatment within a follow-up period of ≥13 months. All procedures were performed in the clinic with the patient under local anesthesia. No wound infections or blood vessel or nerve damage occurred. At a mean follow-up period of 16.0 ± 2.29 (range 13 to 21) months, significant improvement was seen in the preoperative mean Mayo score (from 12.06 ± 2.54 to 89.76 ± 4.28, p < .001) and no patient had developed symptom recurrence. Also, none of the patients had developed complex regional pain syndrome. All patients were able to return to regular shoe wear by 3 weeks postoperatively. The technique of plantar fasciitis with percutaneous latticed plantar fasciotomy could be a promising treatment option for patients with recalcitrant chronic plantar fasciitis.

A retrospective study was done to evaluate patient pain level and satisfaction after a percutaneous plantar fasciotomy. Between 1990 and 1996, 51 patients underwent percutaneous plantar fasciotomy for chronic plantar fasciitis associated with heel pain syndrome. All patients had undergone at least 6 months of conservative therapy. A questionnaire incorporating a visual analog pain scale was used to determine the effectiveness and patient satisfaction of the procedure. Of 35 patients who responded to the questionnaire, 27 were female and eight were male, ranging in age from 31 to 76 years with an average age of 47 years. Follow-up time after surgery ranged from 12 to 57 months, with an average of 34 months. Utilizing a visual analog pain scale, results showed a preoperative pain level of 8.7 (+/- 1.2) with a range of 6-10. Pain level at follow-up was 2.1 (+/- 2.7) with a range of 0-10. Eighty-three percent of the patients stated that the procedure met or exceeded their expectations. Percutaneous plantar fasciotomy is a simple and cost-effective method for surgical intervention of chronic heel pain syndrome. Complications are rare and the results compare favorably with other reported more invasive and costly techniques.

Purpose: Plantar fasciitis (PF) is the most common cause of plantar heel pain. Conservative treatment and corrections of risks factors are the first line of care. For the 10% of patients who do not respond to conservative treatment, surgical release can offer relief of symptoms. Due to the critical role of the PF in the function of the foot and its architectural maintenance, its surgical release could cause a collapse of the internal arch of the foot and an alteration of its function. With the hypothesis that an isolated percutaneous PF release may not lead to these alterations of the foot while providing relief to the patients, we evaluated the radiological evolution and clinical results of this surgery after one year.

Material And Method: Between January 2013 and Augustus 2017, we conducted a single arm monocentric prospective study on 22 patients (25 feet) aged from 33 to 84 years, with plantar fasciitis and failure of conservative management who benefited a percutaneous total plantar fasciotomy through a plantar approach. The American Orthopedic Foot and Ankle Score (AOFAS) and the Djian-Annonier's angle were evaluated preoperatively and postoperatively.

Results: Among the 22 patients, sixteen patients were female and six patients were male. Three patients (2 females and 1 male) for six feet were operated for bilateral plantar fasciitis. The mean pre-operative Djian-Annonier's angle was 117.6° (range 101-132.9°), and the mean post-operative angle was 119.3° (range 102-137°). There was no statistically significant difference in Djian-Annonier's angle before and after surgery. The mean pre-operative AOFAS was 42.8 (range 32-51). The scores at 15 days, six weeks, and three months show a gradual increase up to 89.9 in the results with significant differences between the groups (p < 0.05). There was no difference between the scores after three months.

Conclusion: Complete percutaneous plantar fasciotomy is simple and safe and allows a quick recovery to activity without impacting the MLA.

Minimally invasive surgery for the treatment of recalcitrant heel pain is a relatively new approach. To compare the 2 approaches, a retrospective chart review was conducted of 53 patients (55 feet) who had undergone surgical treatment of plantar fasciitis by either open fasciotomy with heel spur resection or percutaneous medial fascial release. The outcomes measures included perioperative pain and the interval to return to full activity. Pain was measured on a subjective 10-point visual analog scale. Of the 55 fasciotomies performed, 23 were percutaneous and 32 were open, with adjunctive heel spur resection. The percutaneous group experienced a mean pain reduction of 5.69 points at the first postoperative visit, whereas open fasciotomy group experienced a mean pain reduction of 3.53 points. At 12 months postoperatively, no statistically significant difference was found in the pain levels between the 2 groups. The results also showed that the percutaneous group returned to normal activity an average of 2.82 weeks (p < .001) faster than the open group. In the patient cohorts studied, percutaneous medial fascial release was as effective at resolving recalcitrant plantar fasciitis pain as the open procedure and involved less postoperative pain and a faster return to full activity.