Plantar fasciosis is pain at the site of the attachment of the plantar fascia and the calcaneus, with or without accompanying pain along the medial band of the plantar fascia. Diagnosis is mainly clinical. Treatment involves calf muscle and plantar soft-tissue foot-stretching exercises, night splints, orthotics, and shoes with appropriate heel elevation.

Syndromes of pain in the plantar fascia have been called plantar fasciitis; however, because there is usually no inflammation, plantar fasciosis is more correct. Other terms used include calcaneal enthesopathy pain or calcaneal spur syndrome; however, there may be no bone spurs on the calcaneus. Plantar fasciosis may involve acute or chronic stretching, tearing, and degeneration of the fascia at its attachment site.

Etiology

Recognized causes include shortening or contracture of the calf muscles and plantar fascia. Risk factors for such shortening include a sedentary lifestyle, occupations requiring sitting, very high or low arches in the feet, and chronic wearing of high-heel shoes. The disorder is also common among runners and dancers and may occur in people whose occupations involve standing or walking on hard surfaces for prolonged periods. Disorders that may be associated with plantar fasciosis are obesity, RA, reactive arthritis, and psoriatic arthritis. Multiple injections of corticosteroids may contribute by causing degenerative changes of the fascia and possible loss of the cushioning subcalcaneal fat pad.

Symptoms and Signs

Plantar fasciosis is characterized by pain at the bottom of the heel with weight bearing, particularly when first arising in the morning; pain usually abates within 5 to 10 min, only to return later in the day. It is often worse when pushing off of the heel (the propulsive phase of gait) and after periods of rest. Acute, severe heel pain, especially with mild local puffiness, may indicate an acute fascial tear. Some patients describe burning or sticking pain along the plantar medial border of the foot when walking.

Diagnosis

• Pain reproduced by calcaneal pressure during dorsiflexion

Other disorders causing heel pain can mimic plantar fasciosis:

• Throbbing heel pain, particularly when the shoes are removed or when mild heat and puffiness are present, is more suggestive of calcaneal bursitis (see Foot and Ankle Disorders: Inferior Calcaneal Bursitis).
• Acute, severe retrocalcaneal pain, with redness and heat, may indicate gout.
• Pain that radiates from the low back to the heel may be an S1 radiculopathy due to an L5 disk herniation.

Plantar fasciosis is confirmed if firm thumb pressure applied to the calcaneus when the foot is dorsiflexed elicits pain. Fascial pain along the plantar medial border of the fascia may also be present. If findings are equivocal, demonstration of a heel spur on x-ray may support the diagnosis; however, absence does not rule out the diagnosis, and visible spurs are not generally the cause of symptoms. Also, infrequently, calcaneal spurs appear ill defined on x-ray, exhibiting fluffy new bone formation, suggesting spondyloarthropathy (eg, ankylosing spondylitis, reactive arthritis). If an acute fascial tear is suspected, MRI is done.

Treatment

• Splinting, stretching, and cushioning or orthotics

To alleviate the stress and pain on the fascia, the person can take shorter steps and avoid walking barefoot. Activities that involve foot impact, such as jogging, should be avoided. The most effective treatments include the use of in-shoe heel and arch cushioning with calf-stretching exercises and night splinting devices that stretch the calf and plantar fascia while the patient sleeps. Prefabricated or custom-made foot orthotics may also alleviate fascial tension and symptoms. Other treatments may include activity modifications, NSAIDs, weight loss in obese patients, cold and ice massage therapy, and occasional corticosteroid injections. However, because corticosteroid injections can predispose to plantar fasciosis, many clinicians limit these injections. For recalcitrant cases, physical therapy, oral corticosteroids, and cast immobilization should be used before surgical intervention is considered.

Key Points

• Plantar fasciosis involves various syndromes causing pain in the plantar fascia.
• Various lifestyle factors and disorders increase risk by leading to shortened calf muscles and plantar fascia.
• Pain at the bottom of the heel worsens with weight bearing, particularly when pushing off the heel and over the course of the day.
• Confirm the diagnosis by reproducing pain with calcaneal pressure exerted by the thumb during dorsiflexion.
• Treat at first with in-shoe heel and arch cushioning, calf-stretching exercises, and splinting devices worn at night.

Last full review/revision December 2012 by Kendrick Alan Whitney, DPM

Content last modified January 2013