![]() ![]() When considering the diagnosis of plantar fasciitis, one should consider fat pad contusion or atrophy, stress fractures, and nerve entrapments such as tarsal tunnel syndrome in the differential. It may also be beneficial to assess a patient's gait to assess for biomechanical factors or predisposing factors mentioned previously. ![]() Secondary findings may include a tight Achilles heel cord, pes planus, or pes cavus. Specifically, passive dorsiflexion of the first metatarsophalangeal joint is known as the windlass (or Jack's) test and considered a positive test if pain is reproduced. Pain can also be reproduced with passive dorsiflexion of the foot and toes. Pain can usually be reproduced by palpating the plantar medial calcaneal tubercle at the site of the plantar fascial insertion on the heel bone. Pain often decreases with ambulation or beginning an athletic activity, but then increases throughout the day as activity increases. Long periods of standing, or in severe cases, sitting for prolonged periods, will also exacerbate symptoms. ![]() ![]() They will often describe the pain as sharp and worst with the first few steps out of bed in the morning. Patients will often present with a history of progressive pain at the inferior and medial heel, but can, however, radiate proximally in more severe cases. Plantar fasciitis has been found to be associated with various seronegative spondyloarthropathies, but in approximately 85% of cases, there are no known systemic factors. It is often associated with runners and older adults, but other risk factors include obesity, heel pad atrophy, aging, occupations requiring prolonged standing, and weight-bearing. Approximately 50% of patients with this condition will also have heel spurs, but the spurs themselves are not the cause. It is thought that these tight muscles can alter the normal biomechanics of ambulation. Tight gastrocnemius, soleus, and/or other posterior leg muscles have also been commonly found in patients with this condition. Pes cavus can cause excessive strain on the heel because the foot does not effectively evert or absorb shock. Pes planus can cause increased strain at the origin of the plantar fascia. Some predisposing factors are pes planus, pes cavus, limited ankle dorsiflexion, and excessive pronation or supination. This is often an overuse injury that is primarily due to a repetitive strain causing micro-tears of the plantar fascia but can occur as a result of trauma or other multifactorial causes. The majority of cases are managed non-surgically but recurrence of pain is frustrating. Plantar fasciitis is not easy to treat and patient dis-satisfaction is common with most treatments. The classic presentation is of sharp localized pain at the heel. The cause of plantar fasciitis is multifactorial but most cases result from overuse stress. Plantar fasciitis is very common in the US with millions experiencing heel pain every year. Despite the diagnosis containing the segment "itis," this condition is notably characterized by an absence of inflammatory cells. The fascia itself is important in providing support for the arch and providing shock absorption. The plantar fascia plays an important role in the normal biomechanics of the foot and is composed of three segments, all of which arise from the calcaneus. Plantar fasciitis is the result of degenerative irritation of the plantar fascia origin at the medial calcaneal tuberosity of the heel as well as the surrounding perifascial structures. ![]()
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