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Abstract

Plantar fasciitis is the most frequent cause of heel pain. This paper reviewed the state of the art regarding plantar fasciitis, with emphasis on recent studies, giving increasing importance to the gastrocnemius contracture in the pathogenesis and choice of treatment. Non-surgical therapies provide good results in 90% of cases within 6 months, so that surgical treatment is generally reserved for refractory cases. Treatment options were reviewed, including injections, physical therapies and orthotics. In the past century, complete or partial plantar fasciotomy was the surgery of choice, while in recent years, most surgeons agree in choosing a gastroc release technique, in particular the proximal medial gastroc release. It was unclear whether this technique could be extended to all cases of recalcitrant plantar fasciitis. Some studies stated that the contracture of the gastrocnemius is an essential component of recalcitrant plantar fasciitis, even if not always detectable through clinical examination.

Keywords

Plantar fasciitis heel pain gastrocnemius fasciotomy treatment

Introduction

Plantar fasciitis is a very common cause of heel pain and one of the most frequent conditions in an orthopaedic clinic. Nevertheless, there is the risk to underestimate the problem, so that most of the clinicians tend to rely only on personal experience, rather than on the established literature.

We therefore examined the present literature to clarify all the key points about plantar fasciitis, from pathogenesis, through conservative treatment methods, to the actual surgical techniques.

Epidemiology

Heel pain is a very common problem, especially in patients aged 45–65.¹ Among the possible causes of heel pain, plantar fasciitis is certainly the most frequent,² so that its prevalence in the general population is estimated to be 7%, with 12.7% of runners suffering from it at least once in career.³ There is a higher prevalence in athletes,⁴ in overweight patients,^5,6 in the military or in workers standing for prolonged periods. Age is considered a predisposing factor as it decreases tissue elasticity and therefore the ability to absorb mechanical stress.⁷ Gender does not appear to correlate with incidence.⁷ Plantar fasciitis is favoured by the presence of a flat foot, by a cavus foot or by the lower limb length discrepancies.^5,8 Symptoms are more often unilateral, although in 30% of cases they are bilateral.⁸

Anatomy

The plantar fascia can be thought of as the plantar arch chord. It originates from the os calcis distinguishing itself into three bundles: the medial bundle covers the adductor hallucis; the lateral bundle the abductor digiti quinti; the central bundle, which originates from the medial tubercle of the calcaneus, is believed as the true plantar fascia. This entirely covers the intrinsic plantar muscles of the foot, dividing distally into five bands that reach the plantar plates of the metatarsophalangeal joints and consequently insert at the base of the proximal phalanges of the five toes.

Pathogenesis

During the push-off and heel-off phases, the toes dorsiflex and tension the plantar fascia using the metatarsal heads as a fulcrum. This “windlass mechanism” stiffens the plantar arch during the push-off phase and also contributes to hindfoot inversion and external rotation of the leg.⁹ Repeated microtraumas can give rise to a degenerative mechanism at the level of the calcaneal insertion of the fascia, generating inflammation at the base of plantar fasciitis. Actually, thickening and degenerative changes are more common than inflammation, so that the term “plantar fasciopathy” may better define this disease.¹⁰ Occasionally, especially in athletes or workers, there may be an acute lesion of the fascia at the heel insertion, with a tearing sensation.

Pain is often exacerbated in the morning, with difficulty in the first steps. Then pain decreases during the day to recur in the evening after the day's fatigue.

In recent years, increasing attention has been paid to gastrocnemius contracture as an initial cause of plantar fasciitis,¹¹ so much that it has been demonstrated that 83% of patients with recalcitrant plantar fasciitis have limited ankle dorsiflexion.¹² Patients may compensate for the lack of ankle dorsiflexion by increasing eversion through the subtalar joint, resulting in increased dorsiflexion, but with associated valgus deviation of the hindfoot and abduction of the forefoot. This leads to increased stress on the plantar fascia, with eventual attenuation, leading to plantar fasciitis and flatfoot. In the cavus foot instead, the high-arched foot has restricted mobility through the transverse tarsal joints, with inability to dissipate shock from ground strike, thus increasing the load in the plantar fascia.¹³

The heel spur, present in 13% of the population,¹⁴ is located at the origin of the flexor digitorum brevis, adjacent to the plantar fascia, but has no definite relationship to fasciitis,¹⁵ despite a higher incidence (75%) of heel spurs in patients suffering from plantar fasciitis, compared to 63% in asymptomatic patients.¹⁶

Differential diagnosis

Heel pain may also be associated with entrapment of the mixed nerve for the abductor digiti quinti (Baxter's nerve), first branch of the lateral plantar nerve, which runs between the quadratus plantar muscles (cranially) and the adductor hallucis and flexor digitorum brevis muscles (plantarly). It innervates the periosteum of the plantar surface of the calcaneus and the calcaneal fat pad to the skin of the lateral aspect of the calcaneus (sensory component), while it’s motor component innervates the flexor digitorum brevis, abductor digiti quinti and quadratus plantae. In this case, the pain, of the neurotic type, is often present even at rest, accompanied by paresthesias on the sole of the foot and by the presence of a positive Tinel test.

The medial calcaneal nerve may also be compressed. It originates below the medial malleolus from the posterior tibial nerve before its bifurcation into the medial and lateral plantar nerves. It is a sensory nerve that innervates the medial periosteum of the calcaneus and the corresponding skin.

Other possible causes of heel pain are rheumatic diseases, stress fractures of the calcaneus, Sever's calcaneal apophysitis, neuropathies and plantar abscesses in diabetic patients.

Investigations

In the diagnostic phase, the characteristics of the pain and the search for the trigger points are of great help. The physical examination must evaluate the presence of a cavus or flat foot, a varus or valgus hindfoot and a rigid or elastic foot and must determine whether the triceps surae allows ankle dorsiflexion up to 10° or at least up to the neutral position. This assessment may be performed with the subtalar joint locked in neutral position and with the navicular reduced on the talar head using the examiner's thumb. In this position, ankle dorsiflexion is assessed with the knee extended, and then with the knee flexed. If the retraction is indifferent in the two positions, this means that the soleus component is also involved, while if the retraction resolves with 20° of knee flexion, this indicates that it only concerns the gastrocnemius muscle.¹⁷ This condition has been shown to be among the predisposing factors to develop plantar fasciitis.¹⁸

Special tests should include a Tinel test along with the distal portion of the tibial nerve to search for a tarsal tunnel syndrome and a calcaneus squeeze test in the suspect of a calcaneal stress fracture.

The first instrumental examination to be performed is the x-ray of the foot under weight-bearing, which can give us important informations on the morphology of the foot (cavus, flat, arthritic). X-rays often show a heel spur, which cannot be correlated with certainty to plantar fasciitis.¹⁹

Ultrasound gives us information about the structure of the fascia, which can present inflammation, degenerative areas or tears. It can be important in the follow-up of the disease to evaluate the effectiveness of the treatment.

The most important exam, but not routinely necessary, is the MRI, which allows to accurately determine the state of the plantar fascia, and at the same time to evaluate bone edema at the heel insertion of the fascia, or even stress fractures. CT and bone scintigraphy are exams now superseded by MRI.

Electromyography can be used for suspected neurologic causes of heel pain in patients presenting with sensory disturbances or proximal/distal radiation.

Non-surgical management

The first therapeutic approach to plantar fasciitis is certainly non-surgical, providing satisfactory results in a large percentage of patients. In fact, after six months of non-operative treatment approximately 90% of patients obtained symptoms relief. On the other hand, 10% of the patients experience a recalcitrant plantar fasciitis, which do not respond to conservative management and may need surgery.²⁰

In the acute phase, when the symptoms are disabling and a more painful area can be identified, a local infiltration with corticosteroids can be performed, which can be repeated weekly for three times at all. It is advisable to insert the needle from the medial side to reach the calcaneal tubercle tangentially, avoiding infiltrations from the plantar side, which cross the richly innervated fat pad, being painful for the patient. Steroid infiltrations are of great help in the acute phase due to their anti-inflammatory efficacy, but they may increase the risk of plantar fascia rupture and fat pad atrophy.

Among the infiltrative therapies, platelet-rich plasma (PRP) demonstrated anti-inflammatory properties, but without adverse effects on the plantar fascia structure, containing growth factors and anti-inflammatory cytokines.²¹ The beneficial effects obtained in the acute phase tend to decline in patients treated with steroids, while after PRP injections they are maintained even after 12 months, thanks to the regenerative effects.³

Botulinum toxin injections relax the calf muscles, which decreases the stress in the plantar fascia.¹⁹ Infiltrative therapies must be combined with stretching exercises of the triceps surae, to be performed with the knee extended. Literature demonstrated a low to moderate degree of evidence for the use of stretching exercises,²² related to the important role of the brevity of the Achilles-calcaneal-plantar system.²³ The efficacy of specific plantar fascia stretching was also highlighted.²⁴ Massage of the plantar fascia at the level of the plantar arch is also usually recommended, avoiding direct treatment of the painful area.

Longitudinal arch supports for fasciitis must be semi-rigid, ending behind the metatarsal heads, following the shape of the foot, relieving the painful area. Among the orthoses, gel heel cups or full-length shoe insoles should also be mentioned. Pre-fabricated foot orthotics demonstrated to be more effective than custom shoe inserts.²⁵

Night splinting, supported by conflicting data, can be used to prevent plantar fascia contracture in patients with prevalent morning pain. Their use is often limited by poor compliance because of discomfort leading to sleep disturbance.²⁶

Anti-inflammatory drugs are often prescribed but are rarely effective. The use of taping was described.²⁷ Acupuncture demonstrated good short-term results, with no long-term confirmations.²⁸ A low to moderate level of evidence has also been associated with trigger point dry needling.²⁹

Shock wave therapy^30,31 is not intended to disrupt the plantar spur as often believed. In fact, they have the purpose of creating microtraumas to the plantar fascia, which induces tissue regeneration and angiogenesis. Systematic reviews have concluded satisfactory short-term pain relief and functional outcomes, although long-term efficacy remains unknown because of lack of long-term data.³² Since it is often a painful therapy, its use in the acute phase is inadvisable.

The acute lesions of the plantar fascia, often affecting sportsmen, never require a surgical treatment. They are often the result of a pre-existing plantar fasciitis, so they can therefore be considered as a spontaneous fasciotomy. Treatment of acute plantar fascia injuries therefore requires a rigid brace for up to 3 weeks, with weight bearing allowed as tolerated. Physical therapy is then started.³³

Surgical treatment must be reserved for refractory cases after 6 months of medical and physical therapy. It is first necessary to explain to the patient the expected results and possible complications.

Plantar fasciotomy

In the period 1963–1995, complete fasciotomy was described as the standard technique in 21 clinical studies.³⁴ In 1991, Barret and Day advocated the complete resection of the plantar fascia.³⁵ However, 2 years later, the same authors recommended the release of the medial two-thirds of the fascia.³⁶ Four years far from their initial recommendation, their final advice was to release the medial third of the fascia.³⁷ The reason for this change in the amount of the release was the potential lateral column destabilization for the disruption of the locking mechanism of the calcaneocuboid joint. The windlass mechanism may also be affected by complete proximal fascia release.³⁸

This operation can be easily performed through a longitudinal incision of about 3 cm, performed medially to the calcaneal tubercle, at the transition between the plantar and the dorsal skin, to avoid damaging the plantar fat pad. It is recommended to remove 1 cm of fascia length, always on the medial side, to avoid scar tissue formation.

In the post-operative period, the use of a foot-leg brace locked at the right angle is advised for 3 weeks, with weight bearing allowed according to pain tolerance. Satisfactory results were reported in just 60% of patients, with an average time of 10 weeks required for complete recovery.³⁹

The disadvantages of this procedure are represented by the possible alteration of the windlass effect that leads to potential biomechanical impairments such as plantar fascia rupture, lateral column and sinus tarsi pain, iatrogenic flatfoot, metatarsalgia and stress fractures, together with a painful hypertrophic scar and secondary Baxter's nerve entrapment.¹⁰

It is not recommended to remove the heel spur as it is not the cause of the pain and also because this can stimulate new ossification with spur recurrence.

When signs of compression of Baxter's nerve are detected, and a nerve release is advised, the only release of the deep (cranial) fascia of the adductor hallucis is recommended. Isolating the nerve is not always possible, and it would require considerable muscle trauma, with bleeding and scar tissue formation and with the risk of damaging the nerve, and subsequent formation of a painful neuroma.

The association of medial calcaneal drilling to stimulate neoangiogenesis and scar tissue was also described.²⁶

Endoscopic fascia release was also described, with good results but with a demanding learning curve and with transient plantar paresthesias in 13% of the cases.⁴⁰

Gastroc release

The widespread diffusion of gastrocnemius contracture is today recognized, being present in about 88% of the population with a symptomatic foot, against 43% of asymptomatic patients,¹⁸ and more generally in 60% of the total population.^18,41 This situation can in fact be correlated with various foot problems, such as Achilles tendinopathies, Haglund's disease, plantar fasciitis, tibialis posterior tendinopathy, progressive arch collapse, metatarsalgia, Morton's neuroma and diabetic ulcers. Regarding plantar fasciitis, 83% of patients with recalcitrant plantar fasciitis have limited ankle dorsiflexion.¹²

When a shortening of the gastrocnemius is present, the Achilles tendon produces an early transfer of forces to the heel and therefore to the plantar fascia when the knee extends in the push-off phase, with increased tension, and overloading the anterior portion of the foot.

In the case of plantar fasciitis with associated gastrocnemius contracture, we must consider a gastroc release procedure, with the advantage of restoring the extensibility of the triceps surae, with a consequent lower tension transfer to the plantar fascia, while avoiding acting directly on the plantar fascia, which could cause the disadvantages described above. In addition, recovery times with this type of procedure are generally shorter.

The gastroc release can be performed at various levels, considering that a more proximal operation corrects less but has shorter recovery times, while a more distal operation allows more extensive corrections but has longer recovery times.⁴²

The first description of the gastroc release was that from Silfverskiold, in which a transverse incision was made in the distal part of the popliteal fossa, transecting both heads of the gastrocnemius muscle just distal to the knee joint.¹⁷ Later, Barouk described the release of only the medial head of the gastrocnemius, through a small transverse medial incision.⁴³ More distally, the Baumann technique involves transecting the deep (anterior) gastrocnemius aponeurosis at the junction of proximal and middle muscle belly.⁴⁴ The Strayer procedure requires the transection of the superficial distal musculotendinous junction of the gastrocnemius.⁴⁵ The Vulpius procedure requires the release of both the gastrocnemius and soleus aponeurosis at the junction of the middle and distal third of the gastrocnemius muscle, when both are involved.⁴⁶ Distally, the Hoke procedure involves three percutaneous hemisections of the Achilles tendon.⁴⁷

Each of these interventions offers advantages and disadvantages. The Silfverskiold procedure has now been superseded, being more invasive and risky due to the presence of posterior vascular-nervous structures. Since the medial head has a calibre of 2.4 times the lateral,⁴⁸ it is logical to assume that the release of the medial head can be sufficient, as with the Barouk procedure. Furthermore, this latter technique demonstrated to be safe, offering better cosmetic results, allowing early weight bearing and not causing strength deficits.²⁰ The disadvantages are the limited correction capability and the prone position, which is not suitable for performing associated procedures. When plantar fasciitis is treated in isolation without performing associated procedures, this intervention must be considered very useful and practical, with patient satisfaction reaching 95% and with return to work and sports at three weeks on average.³⁹

Another very common procedure is the Strayer technique, being simple and able to be performed in both prone and supine position, therefore in association with any other procedure. Potential disadvantages include sural nerve injury, scar visibility and a small degree of differential calf atrophy and muscle contour change noted after release.^49,50

Achilles tendon lengthening offers extreme corrective power, but clearly injures the Achilles tendon, resulting in delayed recovery times and possible loss of strength. Weakening is limited in children, but more evident in the adults. For this reason, when retraction affects both components (gastrocnemius and soleus), the Vulpius technique may be preferable in adults.

It is not clear whether the gastroc release should be performed only in patients with contracted gastrocnemius or in all. Some authors consider this contracture a “sine qua non” condition in recalcitrant plantar fasciitis,²⁰ although not always detectable by clinical examination. Moreover, the studies underlined that there is no general consensus on the definition of gastrocnemius tightness and on the reliability of Silfverskiold's test.⁵¹

Discussion

We have undertaken a review of the general literature on plantar fasciitis as this is one of the most frequent problems in the orthopaedic clinic. It is very important to know in depth the various therapeutic possibilities in order to be able to illustrate the patient the advantages and disadvantages of the treatment to choose, avoiding relying only on common experience.

The limitations of this study were in the narrative nature of the review, lacking a systematic analysis of the results of the procedures described.

It clearly emerged from the literature that 90% of plantar fasciitis obtained good results from 6 to 12 months of non-surgical treatment. Treatment options include injections, physical therapies and orthotics. Steroid infiltrations are the most practiced, with good results in the acute phase, but with a tendency to worsen over the months. This problem can be partially resolved by the use of PRP, which combines an anti-inflammatory effect with a regenerative potential, with results that are maintained over time. The problem of PRP is the scarce availability, together with the high costs.

Among the orthoses, the prefabricated ones are more effective. Among physical therapies, only shock waves were supported by scientific evidence. Stretching of the gastrocnemius and plantar fascia was supported by the literature, confirming the importance of the Achilles-calcaneal-plantar system in the genesis of plantar fasciitis.

Precisely this last aspect has been developed in recent years, leading to the belief that the contracture of the gastrocnemius is the basis of most cases of plantar fasciitis. For this reason, in recent years, planar fasciotomy, first complete and then partial, has been superseded by gastroc release procedures. It is not clear whether gastroc release can be applied to all cases of fasciitis, regardless of a positive Silfverskiold's test. Some studies indicate that it is possible to apply it to all cases,²⁰ as they consider this tightness a “sine qua non” condition in recalcitrant plantar fasciitis,²⁰ and also because Silfverskiold's test failed to show absolute reliability.⁵¹

According to current knowledge, it can be stated that the standard procedure for the surgical treatment of plantar fasciitis today is the proximal release of the medial head of the gastrocnemius, according to Barouk. This is a simple and safe technique, with a 95% satisfaction rate, to be compared with the 60% expected after plantar fasciotomy, with the possibility of immediate postoperative bearing and so with a shorter recovery time of 3 weeks on average, compared to the 10 weeks expected for plantar fasciotomy.³⁹ Compared to the Strayer, the Barouk technique has less risk of neurological injury and strength deficit and does not give changes in the calf muscle profile.³⁹ However, the Strayer procedure can be performed in the supine position, allowing other associated procedures to be performed where necessary.

The Vulpius technique should not be ignored in cases of contracture of both components (gastrocnemius and soleus).

In a recent consensus on the treatment of recalcitrant plantar fasciitis, 27% of the orthopaedic surgeons chose gastrocnemius release as a surgical treatment after 10 months of non-surgical attempts, while 21% of the surgeons choose open partial fasciotomy with nerve decompression, and 5% choose endoscopic partial plantar fasciotomy.⁵²

In our experience, medial plantar fasciotomy should be reserved for cases of plantar fasciitis without gastrocnemius retraction. This often occurs in pes cavus, when dorsiflexion is allowed beyond 10°, as a release of the gastrocnemius would lead to a greater calcaneal pitch with worsening of the cavus and possible anterior ankle pain.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Francesco Di Caprio

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Plantar fasciitis: A literature review

Abstract

Keywords

Introduction

Epidemiology

Anatomy

Pathogenesis

Differential diagnosis

Investigations

Non-surgical management

Plantar fasciotomy

Gastroc release

Discussion

Footnotes

Declaration of conflicting interests

Funding

ORCID iD

References