Plantar fasciitis

Last revised by Daniel J Bell on 10 Jul 2022

Plantar fasciitis (rare plural: plantar fasciitides) refers to inflammation of the plantar fascia of the foot. It is considered the most common cause of heel pain.

Some publications consider plantar fasciitis to be synonymous with plantar fasciopathy 10,11, although others consider the latter entity to represent a broader range of pathologies with the former specifically having an inflammatory component.

Commonest cause of heel pain in adults ref.

Pain on the undersurface of the heel on weight-bearing is the principal complaint. It can be worse when weight is borne after a period of rest (e.g. in the morning) and eases with walking. Passive dorsiflexion of the toes may exacerbate discomfort.

Plantar fasciitis is generally a low-grade inflammatory process involving the plantar aponeurosis with or without the involvement of the perifascial structures.

It may arise from several factors:

Plain film features are non-specific but may show an associated plantar calcaneal spur although this is also seen in asymptomatic individuals. The thickness of the fascia may be increased to more than 4.5 mm.

Ultrasound is often the initial imaging modality of choice; it typically shows increased thickness of the fascia (>4.5 mm) and a hypoechoic fascia 3

Signal characteristics of affected tissues include:

  • T1/PD: intermediate signal
  • T2: high signal
  • STIR: very sensitive in the detection of both fascial and perifascial edema, which appear as poorly marginated areas of high signal intensity

Other MRI features include:

  • plantar fascial thickening: often fusiform and typically involves the proximal portion and extends to the calcaneal insertion 
  • increased T2/STIR signal intensity of the proximal plantar fascia 
  • edema of the adjacent fat pad and underlying soft tissues 
  • limited marrow edema within the medial calcaneal tuberosity may also be seen

Management options are usually conservative. Local injection of steroids +/- local anesthetic may be useful to manage symptoms. Ultrasound-guided steroid injection has been shown to be effective in short-term (four-week) pain relief with reduced thickness of the plantar fascia at three months 2. A posterior tibial nerve block can be performed prior for a less painful plantar fascia injection.

Specific plantar fascia stretching exercises performed daily have been shown to reduce short term (≤8 weeks) and long term (2 years) pain 8.

Other supportive measures include weight reduction in obese patients, rest, non-steroidal anti-inflammatory drugs (NSAIDs) and reduction of weight-bearing pressure (soft rubber heel pad, molded orthosis, or heel cup or soft-soled shoes).

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Cases and figures

  • Case 1
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  • Case 2: with infection
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  • Case 3
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  • Case 4
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  • Case 5
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  • Case 6: ultrasound
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  • Case 7
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  • Case 8
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  • Case 9
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  • Case 10: nodular plantar fasciitis
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  • Case 11
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  • Case 12
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  • Case 13
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  • Case 14: involving the lateral cord
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