Plantar fasciitis

55 yo school teacher present with several weeks of heel pain...

Most common cause of heel pain -> plantar fasciitis

Pathology is more degenerative than inflammatory so the name should be probably different.

Classic presentation:
- intense, sharp pain with first couple steps in AM
- pain located at the plantar fascia origin (medial tubercle of calcaneus)
- no neurologic symptoms

"windlass test" - passive dorsiflexion of the toes reproduces pain (specific, not sensetive -> negative test tells you nothing)

Hx:
- location of pain
- trauma
- CTD
- exacerbating factors (walking barefoot, flat shoes)

Physical exam
- location of pain (plantar fascia origin)
- anatomical deformities (pes planus, pes cavus, loss of heel fat pad)
- windlass test
- neuro exam for motor and sensory abnl (tarsal tunnel Tinel's test -> do it on the medial side!)

Tx:
- wt loss
- exercise! (stretching fascia and strengthening calf, eg. dynamic stretching rolling a can)
- footwear, arch support, NO heel cups
- physical therapy (if pt needs help w/ exercises)

- pain control (tylenol > nsaids, since no inflammation)
- steroid injection (no good data, similar outcomes)
- surgery (last resort)

Ddx:
1. Plantar fascia rupture (acute, ecchymosis)

2. calcaneal fracture (acute injury, point tenderness, pain w/ simult compression of lateral and medial calcaneal surfaces)

3. calcaneal stress fracture (h/o running etc, point tenderness, pain w/ simult compression..)

4. calcaneal apophysitis (Sever dz) -> adolescents

5. tendinitis (pain with resisted motions)

6. bursitis (retrocalcaneal with swelling and erythema)

7. heel fat pad syndrome (diffuse tenderness of the entire body of calcaneus, fat pad atrophy)

7. nerve entrapment (neuro changes, eg. Tinel test positive)

8. longitudinal arch strain (tenderness over longitudinal arch esp mid or anterior)

9. Paget's dz (can occur in bones of foot usually calcaneus, h/o headaches, hearing loss, bowed tibias, kyphosis)

10. tumor (constant deep bone pain; late constitutional symptoms)


reference: ITC in Annals of Int Med, Jan 3 2012