Plantar fasciitis

from Wikipedia, the free encyclopedia
Classification according to ICD-10
M 72.2 Plantar fasciitis
ICD-10 online (WHO version 2019)

Plantar fasciitis is a painful irritation of the eponymous plantar fascia on the sole of the foot. The plantar fascia or aponeurosis plantaris is a fascia plate that starts from the heel bone and runs in a fan shape to the tip of the foot. With chronic irritation of the fascia at the heel bone, calcium deposits can occur. The resulting change appears in the X-ray image as a supposed heel spur . In contrast to painful plantar fasciitis, the heel spur on the sole of the foot is an often symptom-free incidental finding in X-ray diagnostics of the foot.


Plantar fasciitis is the leading cause of heel pain. Around 10 percent of the population will suffer from this disease once in a lifetime. Women are affected more often than men; the frequency increases with age and with the body mass index (BMI) of the patient. About 70 percent of all patients are obese . People with flat feet , arched feet and different leg lengths are more common among patients with plantar fasciitis. Occupational groups who stand or walk for a long time as well as runners ( runner's heel ) are also more frequently affected. In athletes with plantar fasciitis, there is no connection between the incidence of the disease and BMI or weight.

Disease emergence

Calcaneus = heel bone, metatarsus = metatarsal bone, talus = ankle bone, navicular = scaphoid bone
Geometric change of the longitudinal vault in different phases of a step.

As an explanatory model in order to understand the formation of plantar fasciitis, is often on the windlass mechanism : (translated as winches resorted mechanism): Accordingly, constitute the heel bone, metatarsal and Talonaviculargelenk (between talus and navicular ) the arc of a truss and the plantar fascia, the Drawstring that connects the calcaneus and metatarsals. This framework is the longitudinal arch of the foot, which absorbs the vertical forces when walking and running, so it acts like a shock absorber.

While walking or running, the geometry of the framework changes: When stepping on , the foot is pronated , that is, the foot initially turns inward; this increases the distance between the calcaneus and metatarsal bone, so that the plantar aponeurosis is stretched. During the push, the foot supinates , in other words, it is straightened with the help of a number of muscles. For example, the gastrocnemius and soleus muscles, which are connected to the heel bone via the Achilles tendon, are involved . The plantar aponeurosis now acts like a rope winch and reduces the distance between the heel bone and the metatarsal arch, which raises the longitudinal arch again.

It is discussed that various malfunctions during gait can cause excessive stress on the plantar aponeurosis:

For example , if the Achilles tendon is too tight , the foot cannot be sufficiently angled upwards (dorsiflexion) during movement, which many patients compensate for with excessive pronation, i.e. overpronation. The weakness of other muscles of the leg, such as the gluteal muscles, gluteus medius , gluteus minimus and tensor fasciae latae muscles , can also lead to greater stress on the framework if this disrupts their shock-absorbing effect. Finally, there are a number of misalignments of the foot that also lead to overpronation.

Clinical manifestations

Dorsiflexion and plantar flexion

Often there is pain on the inner (medial) side of the sole of the heel, which is most pronounced in the morning after getting up or after a long break ("starting pain"). During these rest phases, the foot tends to plantar flexion , i.e. to a slightly stretched toe, which relieves the plantar aponeurosis (no stretching). In the case of stress such as walking, the aponeurosis is stretched again when the foot rolls off ( dorsiflexion of the foot and toes), which initially causes pain. This property is used in clinical examinations by bending the toes up during the Windlass test . This pain diminishes after a short time, but can become worse again after prolonged exertion during the day.

To avoid the pain when stepping on, some patients walk on their toes. Palpation , that is, pressing the heel, creates a sharp stabbing pain.

In 30 percent of all cases, plantar fasciitis occurs on both feet at the same time. 80 percent of all patients also have a shortening of the Achilles tendon . More than 80 percent of patients have overpronation . The ability to bend the foot (i.e. bring it into dorsiflexion) is almost always limited.

Plantar fasciitis is self-limiting and usually improves within a year regardless of treatment.

In some cases, the plantar fasciitis can be associated with a posterior tibial dysfunction : here the tendon of one of the muscles that stabilizes the ankle joint is abnormally changed. Since both the plantar aponeurosis and the posterior tibial muscle normally support the longitudinal arch, their diseases lead to increased pronation of the foot and thus to tensile stress on the tibial nerve  - a tarsal tunnel syndrome occurs. The combination of plantar fasciitis, tibial posterior dysfunction and tarsal tunnel syndrome is called the Heel-Pain Triad .


The diagnosis can be made solely on the basis of clinical symptoms, such as the typical heel pain in the morning and the tenderness of the sole of the foot as well as the Windlass test described above. Since the dorsiflexion of the foot is often limited, there are a number of methods to quantify it. Imaging diagnostics , for example sonography (ultrasound), is only necessary if the plantar fasciitis does not respond to conservative treatment and invasive methods such as local injections are considered. For reasons of differential diagnosis , other imaging methods are also used, such as X-ray diagnostics or, in rarer cases, magnetic resonance imaging (MRI) or skeletal scintigraphy .

Imaging procedures

Lateral x-ray of the metatarsus (right) and heel (left), with a lower heel spur (lower left).

50 percent of all X-rays show heel spurs in plantar fasciitis patients , the result of calcium storage in the tendon. This heel spur is usually at the origin of the quadratus plantae muscle ; also the abductor hallucis less often or the abductor digiti minimi can calcifications on tendon ( enthesopathy be seen). Conversely, the heel spur is also seen in 13 percent of all x-rays that were not taken for plantar fasciitis. The heel spur is seen as a secondary disease due to tensile stress and not as the cause of plantar fasciitis. Fatigue fractures and some tumors may be detected and suggest a cause other than plantar fasciitis for heel pain.

Plantar fasciitis on ultrasound. The plantar aponeurosis is the horizontal band between the calipers. Below this is the heel bone in the lower left corner of the picture.

In the case of plantar fasciitis, the ultrasound examination (sonography) shows a thickening of the plantar aponeurosis. The aponeurosis is either at least 4.0 mm thick or 0.6 mm thicker at the attachment point on the heel bone than on the other foot. Diffuse hypoechoic surfaces (shown dark in the ultrasound) are also seen, which are interpreted as water retention ( edema ) due to the smallest cracks. Increased blood flow ( hyperemia ) is found in around 40 percent of all patients , which indicates an acute course. With a chronic course, hyperemia is not determined. The thickness of the plantar aponeurosis decreases with successful treatment, which is why it can be used as an objective measure.

Skeletal scintigraphy and magnetic resonance imaging can detect other causes of pain in the sole of the foot.

Differential diagnosis

In 20 percent of all cases of pain in the sole of the foot, either a nerve compression syndrome in the tarsal tunnel or in the first branch of the plantar nerve ( nervus calcaneus medialis ) is responsible for the symptoms. In the case of the tarsal tunnel syndrome , masses such as ganglions , varicose veins , but also a thickened tendon, particularly of the tibialis posterior muscle, can compress the tibial nerve and thus cause pain. The nervus calcaneus medialis , also called Baxter nerve ( Baxter neuropathy ), is either narrowed by the abductor hallucis muscle or by the thickened plantar fascia in the presence of plantar fasciitis.

Rheumatological causes such as ankylosing spondylitis , reactive arthritis, and rheumatoid arthritis are rare causes of heel pain, especially if they occur on both sides. While ankylosing spondylitis and reactive arthritis are more common in men, rheumatoid arthritis is more often responsible for bilateral heel pain in women.

Other causes of pain in the fat pad of the heel are inflammation, edema , cracks or if rheumatic nodules have formed in them. A tear in the plantar fascia is rarely the cause of heel pain - usually these cases are very active patients or patients who have received a cortisone injection . The differential diagnoses also include osteoarthritis, osteomyelitis and bone fractures that are not visible on X-rays , and in extremely rare cases tumors .


Studies on histological tissue samples from patients from whom parts of the plantar aponeurosis had been removed as part of a fasciotomy revealed various changes: Inflammatory changes were found in only 21 percent of all patients. Another 25 percent showed structural changes in the connective tissue, such as those that occur in plantar fibromatosis. In the remaining 54 percent of all patients, neither inflammatory nor structural changes in the tendon plate were detected. Instead, the findings mainly included degeneration of the connective tissue (myxoid degeneration) and the plantar aponeurosis itself, cracks in the plantar aponeurosis and enlargement of the bone marrow vessels . These different results are interpreted as an indication that there are different mechanisms in the development of the disease, which also explains the different effectiveness of different treatment methods.


When plantar fasciitis come antiinflammatory effective measures used even if rare classic on the soles of inflammation by Galen present (redness and warmth often lacking). The range of treatment methods used ranges from relief by means of shoe insoles or tape bandages to anti- inflammatory drugs to radiation therapy, which is rarely used . Usually several treatment methods are combined.

Few studies have looked at the therapeutic effectiveness of individual methods; the level of evidence is rarely high. 90 percent of all patients experience an improvement in their condition with the help of conservative therapy within the first six months. Only after this period will other procedures be used.

Non-drug therapy

First of all, it is recommended to avoid overstressing the foot and, for example, to pause sports such as running or various jumping sports that involve high impacts.

Relief of the tendon of the sole of the foot is also achieved by lifting the arch of the foot. Because with a lowered arch of the foot (flat foot, pronation position of the foot, age-related sagging of the inner edge of the foot), the plantar aponeurosis is overstretched and this in turn can lead to plantar fasciitis.

Orthopedic insoles

With shoe insoles, the inner edge of the foot is raised and the tendons on the sole of the foot are relieved. A blinded , randomized and controlled study compared custom-made and manufactured orthopedic insoles with placebo soles. It could be shown that the "function" was statistically significantly improved after three and twelve months for both custom-made and made-to-measure insoles , whereas there was no statistically significant difference in pain. Other studies confirm that there is no difference between made-to-measure and made-up insoles; but also speak of a reduction in pain. Insoles are recommended because they are designed to reduce overpronation of the foot, which is believed to lead to overloading of the plantar aponeurosis. However, it does not seem to prevent the foot from moving inwards, but rather to provide support in the longitudinal direction, which has the effect of reducing pain.

With so-called low-dye taping , the longitudinal arch of the foot is supported with a tape bandage in order to reduce the tension that affects the plantar aponeurosis when walking. The effectiveness of the taping could be shown.

In a study, stretching exercises for the Achilles tendon and the plantar aponeurosis brought about a significant improvement in the first two months compared to no treatment; by stretching the Achilles tendon, the tension and constant pull on the plantar fascia are reduced. Stretching the plantar aponeurosis appears to be more of an improvement than stretching the Achilles tendon during these first two months.

Greaves for the night are intended to prevent the foot rests in the plantarflexierten position and the plantar fascia contracts. In fact, they can relieve the pain from plantar fasciitis in some cases.

There is anecdotal evidence for the effect of manual or instrumental massages to relax the muscle fascia (myofascial release) , which is supposed to improve blood circulation and thus healing.

Medical therapy

In addition, drugs from the group of non-steroidal anti-inflammatory drugs in tablet form are often used. (The ointment or gel form is rarely sufficiently effective due to the low penetration depth). These cause irritation / inflammation ( anti-inflammatory effect) and subsequently pain relief ( analgesic effect).

Injecting corticosteroids near the plantar fascia can be effective for up to six months. It carries rare risks, including shrinkage of the fat pad in the heel and the subsequent tendency to tear the plantar fascia. In particular, if the drug was not injected under the plantar aponeurosis using ultrasound guidance. The sonographically measured thickness of the plantar aponeurosis shrinks after the injection; this is accompanied by reduced pain.

One of the new treatments is injecting platelet-rich plasma (PRP), which draws the patient's own blood. After treating the blood in a centrifuge, a blood plasma with a high proportion of platelets is created , which is injected to better heal the cracks in the plantar aponeurosis. Initial studies in comparison with corticosteroids have confirmed the effectiveness of PRP treatment and speak of a possible higher effectiveness with a lower risk. Similar PRP works Autohemotherapy , but in the whole blood is used. Since there are no high quality studies with large numbers of patients, none of the methods are used as routine treatment.

Botulinum toxin injections are still in the trial phase; but have shown the first promising results. The botulinum toxin is either injected directly into the plantar fascia, combined into the plantar fascia and its origin (Babcock technique) or also into the three-headed calf muscle to relax it and thereby reduce the tensile load at the origin of the plantar fascia. In a randomized and controlled study, patients who had received a botulinum toxin injection also had significantly less pain twelve months after the injection . A review article showed mostly good results for this therapy method. Also, glucose was tested. With dry needling , only a local anesthetic is injected, but then the plantar aponeurosis is repeatedly pricked with a needle in order to reduce the tension. Other methods are iontophoresis , in which an applied electrical direct current is supposed to improve the absorption of corticosteroids, and proliferation therapy , in which a concentrated sugar solution is injected.

Other therapy methods

Extracorporeal shock wave therapy is intended to create the smallest cracks in the plantar aponeurosis and thereby provoke the body to a healing inflammatory reaction that increases blood flow. This means that growth factors are increasingly transported into the tissue for healing. Several studies have compared extracorporeal shock wave therapy with placebo treatment; the results are inconsistent. The results were both no statistically significant improvement and less pain within the first three months.

About 1 percent of all patients suffer from the symptoms of plantar fasciitis even after one year of treatment and are therefore referred for surgery. Various methods are used, none of which have been widely studied. Both open and minimally invasive fasciotomy are performed. Usually, less than half of the plantar aponeurosis is removed in order to prevent the arch of the foot from collapsing. In some selected cases with neurological symptoms, the lateral platar nerve is relaxed.

An additionally diagnosed heel spur is never removed.

Individual evidence

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