Proximal plantar fasciitis is a common cause of heel pain in adults. The plantar fascia is a fibrous aponeurosis that originates from the medial tubercle of the calcaneus and provides dynamic shock absorption and static support to the longitudinal arch. Individuals with pes planus (i.e., flat feet) or pes cavus (i.e., high arches) are at increased risk for developing plantar fasciitis. In athletes, overuse is the most common cause of plantar fasciitis. The pain of proximal plantar fasciitis is usually caused by collagen degeneration at the medial tubercle of the calcaneus (i.e., origin of the plantar fascia). It is caused by repetitive microtears of the plantar fascia that overcome the body's ability to repair itself.
Classically, the defining sign of plantar fasciitis is that the worst pain occurs with the first few steps in the morning. Patients often notice pain with the initiation of activity that lessens as activity continues. Pain may also be associated with prolonged standing. In more severe cases, the pain will also worsen toward the end of the day. A history of an increase in weight-bearing activities is common, especially those involving running, which causes microtrauma to the plantar fascia.
On examination, the patient is maximally tender at the anteromedial region of the calcaneus. The patient may also have pain along the proximal plantar fascia. The pain is often exacerbated by passive dorsiflexion of the toes or by having the patient stand on the tips of the toes. Diagnostic testing is usually not indicated. Plantar fasciitis is often called heel spurs because of the commonly associated x-ray findings, but 15% to 25% of the asymptomatic population has heel spurs, and many symptomatic individuals do not. Diagnostic testing is indicated in atypical cases of heel pain (Table 63-1), or in patients who are not responding to appropriate treatment.
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TABLE 63-1. DIFFERENTIAL DIAGNOSIS OF HEEL PAIN |
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Plantar fasciitis is usually a self-limiting condition, but it may take 6 to 18 months to resolve. Rest alone is an effective treatment, but it is poorly accepted as a treatment modality by athletes, active adults, and persons whose occupations require extensive walking. Often, a planned period of “relative rest” that substitutes less damaging alternative forms of activity can increase the compliance with treatment. For long-term therapy, correct the problems that place individuals at increased risk for plantar fasciitis, such as increased weight-bearing activity, high intensity of activity, hard walking or running surfaces, and worn shoes.
The most common conservative treatment for plantar fasciitis is stretching and strengthening programs to correct functional risk factors such as tightness of
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the gastrocsoleus complex and weakness of the intrinsic foot muscles. Other commonly used treatments include use of orthotics, nonsteroidal antiinflammatory drugs (NSAIDs), iontophoresis, ice, heat, heel cups, night splints, and plantar strapping. For individuals with flat feet, shoes with better longitudinal arch support may help.
Corticosteroid injections work best when administered early in the course of plantar fasciitis but are often reserved for recalcitrant cases. Some authorities recommend a foot radiograph before injecting steroids to rule out a tumor. Steroids can be injected through plantar or medial approaches with or without ultrasound guidance. Studies have found that steroid treatments have a success rate of at least 70%.
Rupture of the plantar fascia is a treatment risk found in up to 10% of patients after injection. Long-term plantar fascia rupture may be common. However, most individuals with rupture of the plantar fascia have resolution of symptoms with rest and rehabilitation. Other possible risks include fat pad atrophy, ecchymosis, and infection.
INDICATIONS
ABSOLUTE CONTRAINDICATIONS
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RELATIVE CONTRAINDICATIONS
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PROCEDURE
Place the patient in a comfortable position. Clean the injection area with alcohol. Choose a 21- or 22-gauge needle that is 1 inches long. Find the point of maximal tenderness, which is usually at or near the plantar fascia insertion on the calcaneus.
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(1) Find the point of maximal tenderness, which is usually at or near the plantar fascia insertion on the calcaneus. |
PITFALL: Use of a short, smaller-diameter needle may cause less discomfort, but it may fail to reach the intended area at the fascia insertion.
Using sterile technique, insert the needle 1 to 2 cm above the sole, just past the end of the plantar fascia insertion on the calcaneus, aiming for the end of the bone. The needle is “walked” down the bone, successively redirected toward the toes, until the distal end is reached. When the distal end bone or midline of the foot is reached, inject about 0.5 mL of Celestone or similar steroid 2–3 mL of diluted, with 1% lidocaine into the aponeurosis in a fan shape just distal to the insertion.
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(2) Medial approach. |
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Using sterile technique, insert the needle at a 30-degree angle into the tendon at the point of maximal tenderness. Inject about 1 to 4 mL of diluted Celestone into the aponeurosis in a fan shape just distal to the insertion.
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(3) Plantar approach. |
PITFALL: Do not allow any steroid to leak into the fat pads on the plantar aspect of the foot, because this may cause fat atrophy or necrosis. If the specialized plantar fat pad atrophies, it is gone forever. Some authorities recommend against the direct plantar approach to avoid injury to this specialized cushioning fat beneath the heel.
Following the injection, hold pressure for 2 minutes to decrease bruising and prevent steroid spread.
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(4) Apply pressure to the injection site for 2 minutes to decrease bruising and prevent the steroid from spreading. |
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CODING INFORMATION
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INSTRUMENT AND MATERIALS ORDERING
Common materials for plantar fasciitis injection, including a 3- or 5-mL syringe, 1% lidocaine without epinephrine, or 1% procaine, and 22-, 25-, or 27-gauge needles of various lengths. Injectable steroids can be found in local pharmacies. Consult the ordering information inChapter 65. A suggested tray for performing soft-tissue aspirations and injections is listed in Appendix D. Skin preparation recommendations appear in Appendix H.
BIBLIOGRAPHY
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