Plantar fasciitis is the most common cause of plantar heel pain in active individuals. The plantar fascia is a fibrous band of tissue that originates at the medial calcaneal tubercle, fans out across the plantar aspect of the foot, and then splits before inserting into the plantar aspects of the proximal
Figure 30-43 Heterotopic ossification noted after syndesmosis ankle sprain.
(Courtesy James L. Moeller, MD.)
phalanges. Plantar fasciitis is an overuse injury often seen in people who stand for prolonged periods, as well as in runners and regular exercisers. Many believe plantar fasciitis is an inflammatory condition, but it is more likely caused by chronic changes and microtears of the fascia.
Patients present with plantar heel pain. Pain has often been present for several months before presentation. The pain is often described as sharp and stabbing and tends to be worst in the morning, on arising from prolonged sitting, and after standing for prolonged periods. Other symptoms, such as bruising, swelling, weakness, numbness, and tingling, are uncommon. The primary finding on physical examination reveals tenderness over the origin of the plantar fascia.
Treatment protocols are variable, and it may take several months for the patient to feel significant pain relief. Most treatment plans include plantar fascia stretching, ice or ice massage, heel cushioning, and analgesic medication. NSAIDs are often used, but are helpful most likely because of their analgesic, not anti-inflammatory, effects. Other common treatment options include night splints, physical therapy, orthotic devices, and cortisone injection. Cortisone injection reduces pain from plantar fasciitis, but the mechanism is unclear (Hunt and Sevier, 2004). Cortisone is a potent anti-inflammatory, but as previously stated, chronic plantar fas-ciitis is probably not an inflammatory problem. Risks with cortisone injection include plantar fascia rupture and necrosis of the plantar fat pad, the natural heel cushion. These adverse outcomes should be reviewed with patients before injection.
New modalities for the treatment of plantar fasciitis are under investigation. Extracorporeal shock wave therapy has shown mixed results (Rompe et al., 2002, 2003). Prolother-apy and autologous blood injection involve injecting substances into the area of pathology. Dry needling is also being
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Review of the shoulder exam with specific instructions on physical exam.
studied. None of these options has proved to be consistently helpful. Surgical intervention is sometimes needed in recalcitrant cases.
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