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Heel pain, whether plantar or posterior, is predominantly a mechanical pathology although an array of diverse pathologies including neurologic, arthritic, traumatic, neoplastic, infectious, or vascular etiologies must be considered. This clinical practice guideline (CPG) is a revision of the original 2001 document developed by the American College of Foot and Ankle Surgeons (ACFAS) heel pain committee.
This clinical practice guideline (CPG) is based on consensus of current clinical practice and review of the clinical literature. The guideline was developed by the CPG Heel Pain Committee of the American College of Foot and Ankle Surgeons (ACFAS). This is the 2010 revision of the original 2001 CPG document published in the Journal of Foot & Ankle Surgery® (Vol. 40, No. 5, pages 329–340). The guideline and references annotate each node of the corresponding pathways.
The heel is a frequent area of pathology. Pain in the heel may be the result of arthritic, neurologic, traumatic, or other systemic conditions, although the overwhelming cause is mechanical in origin. Careful history and examination are generally indicative of etiology and appropriate diagnostic testing will lead to accurate diagnosis. Treatment is directed toward causative factors.
). Plantar heel pain has been referred to in the published literature by many names including heel spur syndrome, which lends some importance to the radiographic presence of an inferior calcaneal spur to the clinical symptoms. The term plantar fasciitis has been used for years, likely in an attempt to recognize the actual symptoms occurring along the plantar fascia with or without concomitant presence of a spur. More recently, the term plantar fasciosis has been advocated to de-emphasize the presumed inflammatory component and reiterate the degenerative nature of histologic observations at the calcaneal enthesis (
). Regardless of the exact terminology, the clinician, published literature, and general practice behaviors all describe the same pathology: pain along the proximal plantar fascia and its attachment in the area of the calcaneal tuberosity (Figure 1). The symptoms of plantar heel pain are well known, and diagnosis is relatively straightforward.
Fig. 1(A) With plantar fasciitis, tenderness may be localized centrally along the plantar fascia (orange oval), along the plantar medial tuberosity (red circle), or directly plantar to the calcaneal tuberosity (yellow oval). (B) The anatomy of the plantar fascia as shown through MRI. (C) Depicted here are the lines of tension of the plantar fascia and its majority insertional attachment to the medial calcaneal tuberosity.
The most common cause cited for plantar heel pain is biomechanical stress of the plantar fascia and its enthesis of the calcaneal tuberosity (Figure 2) (
). Mechanical overload, whether the result of biomechanical faults, obesity, or work habits, may contribute to the symptoms of heel pain. Discussion of a biomechanical etiology usually involves the windlass mechanism and tension of the plantar fascia in stance and gait (
Fig. 2Plantar heel pain often is related to (A) loading of the calcaneus and the tensile attachment of the plantar fascia, as shown in this MRI scan (B). (C) The weight-bearing lateral radiograph may or may not show an inferior os calcis spur. (D, E) The spur or enthesophyte begins small and may become very large, or on occasion, (F) may even fracture.
A retrospective analysis of 22 patients treated with percutaneous radiofrequency nerve ablation for prolonged moderate to severe heel pain associated with plantar fasciitis.
A retrospective study of radiofrequency thermal lesioning for the treatment of neuritis of the medial calcaneal nerve and its terminal branches in chronic heel pain.
Patients usually present with plantar heel pain upon initiation of weight bearing, either in the morning upon arising or after periods of rest. The pain tends to decrease after a few minutes, and returns as the day proceeds and time on their feet increases. Associated significant findings may include high body mass index (BMI), tightness of the Achilles tendon, pain upon palpation of the inferior heel and plantar fascia, and inappropriate shoe wear (
Many patients will have attempted self-remedies before seeking medical advice. A careful history is important and should include time(s) of day when pain occurs, current shoe wear, type of activity level both at work and leisure, and history of trauma. Presence of sensory disturbances including radiation of pain is generally indicative of neurologic pathology and is important to exclude. An appropriate physical examination of the lower extremity includes range of motion of the foot and ankle, with special attention to limitation of ankle dorsiflexion, palpation of the heel and plantar fascia, observation of swelling or atrophy of the heel pad, presence of hypesthesias or dysthesias, assessment of the architectural alignment of the foot, and angle and base of gait evaluation. The quality and height of the plantar fat pad also have been implicated as factors in plantar heel pain (Figure 3) (
Fig. 3(A) Plantar heel pain may be related to the height of the plantar fat pad, which may be determined from a weight-bearing lateral radiograph. In a slender or elderly individual this may be implicated as a causative factor. (B) This radiograph reveals a 6-mm height to the fat pad in a patient with a cavus architecture, whereas (C) this radiograph shows a patient who was measured at 8 mm in a more normal foot type. (D) Force plate or pressure analysis may demonstrate exaggerated loading of the heels, or (E) clinically the tuberosity may be easily palpable or callus may develop.
Following physical evaluation, appropriate radiographs (weight-bearing views preferred) may be helpful. Biomechanical interpretation of weight-bearing radiographs may provide insight into architectural faults. An infracalcaneal spur frequently is associated with the symptomatology of plantar fasciitis, although its presence or absence may not necessarily correlate with the patient's symptoms (
). Radiographic identification of a plantar heel spur usually indicates that the condition has been present for at least 6 to 12 months, whether having been symptomatic or asymptomatic (Figure 2). As a rule, the longer the duration of heel pain symptoms, the longer will be the period to final resolution of the condition (
The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: a randomized, prospective, placebo-controlled study.
). Patient-directed treatments appear to be as important as these approaches in resolving symptoms. Such treatments include regular Achilles and plantar fascia stretching (
Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up.
), avoidance of flat shoes and barefoot walking, cryotherapy applied directly to the affected part, over-the-counter arch supports and heel cups, and limitation of extended (high-impact) physical activities (
). Patients usually have a clinical response within 6 weeks of initiation of treatment. If improvement is noted, the initial therapy program is continued until symptoms are resolved. If little or no improvement is noted, the patient should be referred to a foot and ankle surgeon if not already under this specialist's care.
Fig. 4The Plantar Heel Pain Treatment Ladder illustrates the stepwise approach to the ubiquitous condition of plantar heel pain. Initial treatment alternatives should be simple and cost-effective, whereas more resistant cases require more aggressive treatment. Few patients with plantar heel pain require surgical or invasive treatment therapies.
The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: a randomized, prospective, placebo-controlled study.
Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up.
The second tier of the treatment ladder includes continuation of the initial (tier 1) treatment options with considerations for additional therapies: orthotic devices (
Intralesional autologous blood injection compared to corticosteroid injection for treatment of chronic plantar fasciitis. A prospective, randomized, controlled trial.
[Botulinum toxin A–therapy option in cases of chronic plantar fasciitis?—an open treatment attempt with 9 patients and a one year observation period.].
Manual physical therapy and exercise versus electrophysical agents and exercise in the management of plantar heel pain: a multicenter randomized clinical trial.
). In patients with a high BMI, a consultation and referral for an appropriate weight-loss program may be considered. Clinical response to this second tier of treatment will usually occur within 2 to 3 months in 85% to 90% of patients (
). For those who have shown improvement, continuation of tier 1 and tier 2 therapies should be continued until resolution of symptoms. Following a therapeutic regimen as outlined in Pathway 2, 90% to 95% of patients experience resolution of symptoms within 1 year (
Intralesional autologous blood injection compared to corticosteroid injection for treatment of chronic plantar fasciitis. A prospective, randomized, controlled trial.
[Botulinum toxin A–therapy option in cases of chronic plantar fasciitis?—an open treatment attempt with 9 patients and a one year observation period.].
Manual physical therapy and exercise versus electrophysical agents and exercise in the management of plantar heel pain: a multicenter randomized clinical trial.
The third tier of treatment continues tier 1 and/or 2 programs with consideration of surgical management. Options at this time may include surgical plantar fasciotomy using a recognized technique. This may entail endoscopic plantar fasciotomy, in-step fasciotomy, or minimally invasive surgical technique (
A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome.
Extracorporeal shock wave therapy for chronic painful heel syndrome: a prospective, double blind, randomized trial assessing the efficacy of a new electromagnetic shock wave device.
Extracorporeal shockwave therapy versus placebo for the treatment of chronic proximal plantar fasciitis: results of a randomized, placebo-controlled, double-blinded, multicenter intervention trial.
Randomized, placebo-controlled, double-blind clinical trial evaluating the treatment of plantar fasciitis with an extracoporeal shockwave therapy (ESWT) device: a North American confirmatory study.
Extracorporeal shock wave therapy for the treatment of chronic plantar fasciitis: indications, protocol, intermediate results, and a comparison of results to fasciotomy.
Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis: results of a confirmatory randomized placebo-controlled multicenter study.
Extracorporeal shock-wave therapy (ESWT) with a new-generation pneumatic device in the treatment of heel pain. A double blind randomised controlled trial.
A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome.
A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome.
A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome.
A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome.
Fig. 5Operative treatment of plantar fasciitis may include (A) open plantar fasciotomy, (B) minimally invasive plantar fasciotomy, or (C) instep plantar fasciotomy. (D) Extracorporal shockwave therapy has become a popular alternative to traditional surgical approaches.
In some cases, multiple etiologic factors including nerve entrapment may be implicated, necessitating the combination of nerve release and plantar fasciotomy (see Neurologic section, Pathway 4). Radiofrequency coblation of the plantar fascia as well as radiofrequency nerve ablation and cryoprobe have been advocated more recently as an alternative surgical approach to chronic heel pain (
A retrospective analysis of 22 patients treated with percutaneous radiofrequency nerve ablation for prolonged moderate to severe heel pain associated with plantar fasciitis.
A retrospective study of radiofrequency thermal lesioning for the treatment of neuritis of the medial calcaneal nerve and its terminal branches in chronic heel pain.
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