Plantar Fasciitis

Patients typically complain of heel pain accompanying the first steps in the morning after getting up. Others report heel pain after standing from a prolonged sitting position. In long-standing cases; pain might persist throughout walking and rest times. Tenderness usually elicited inferiorly over the medial calcaneal tubercle.

Heel Fat Pad Atrophy

Patients present with diffuse central plantar heel pain precipitated by barefoot walking on the hard surfaces. Tenderness can be elicited on the central part of the calcaneus.

Calcaneal Stress Fractures

Patients present with diffuse heel pain and positive squeeze test (tenderness on medial and lateral compression of the calcaneus).

Tarsal Tunnel Syndrome

Patients present with pain, tingling and hypoesthesia along the whole plantar surface.  Tapping on the area behind the medial malleolus provokes a positive Tinel’s sign.

Medial Calcaneal Neuropathy

Patients will present with burning pain and paresthesia on the skin over the calcaneus. Pain does not radiate distally as in cases of the entrapment of the tibial nerve or Baxter's nerve. Tinel’s sign might be positive over the medial surface of the calcaneal bone.

Baxter Nerve Neuropathy

Patients have a sharp, radiating pain along the course of Baxter's nerve. Pain is worse after activities (e.g., walking) and at night. A positive Tinel's sign and maximal tenderness can be elicited at the above-mentioned two points of nerve entrapment.

S1 Radiculopathy

Patients might have a history of chronic low back pain. Clinically, radicular pain and numbness from back down to the heel. A positive straight leg raises test, a crossed straight leg rises test, or a Lasegue test can provoke it. The examiner might find a decreased sensation over the skin of the sole, heel and lateral foot. The physical examination might reveal the weakness of the gastrocnemius, gluteus maximus, hamstring, peroneal and foot muscles and diminished ankle reflex.

Systemic Causes

Symmetric or asymmetric polyarthritis, uveitis, psoriasis, lower gastrointestinal symptoms, enthesitis, balanitis, dactylitis, sacroiliitis, and spondylitis should be screened.

Most heel pain causes can be diagnosed clinically.[4][5][6][7]

Laboratory

The laboratory tests include acute phase reactants, Rheumatoid factor, Anti-Cyclic Citrullinated Peptide Antibodies, HLA-B27 For systemic causes of the plantar heel pain.

Plain Radiographs and Computed Tomography

Clinicians can order them to diagnose stress fractures and plantar calcaneal spurs.

Musculoskeletal Ultrasound

In patients with plantar fasciitis, the investigators may find thickening of the plantar fascia (greater than 4 mm) on the medial tuberosity of the calcaneus. An increase in vascularity under power Doppler ultrasound is not a common finding in plantar fasciitis.

Physicians can diagnose heel fat pad atrophy when they find the heel fat pad is thinner than 12 to 14 mm in non-weight bearing conditions.

The cross-sectional area of tibial nerve at the tarsal tunnel greater than 9.26 mm² or side-to-side difference greater than 0.8 to 1.76 mm² is diagnostic for the tarsal tunnel syndrome.

The Medial calcaneal and Baxter's nerves are small nerves. Their size was around 3 mm and 2 mm, respectively. To confirm the diagnosis of the entrapment of the medial calcaneal and Baxter's nerves, clinicians should compare the symptomatic side with the asymptomatic one and or perform ultrasound-guided diagnostic blocks.

In cases of Baxter nerve entrapment, ultrasound can show changes in the muscles (quadratus plantae, flexor digitorum brevis, and abductor digiti minimi) supplied by the nerve distal to the site of entrapment.

Regarding SpA, ultrasound can detect sub-entheseal erosions, enthesitis, and enthesophytes at the attachment of the plantar fascia to the calcaneus.

Electrophysiologic Studies

It is helpful in the diagnosis of tarsal tunnel syndrome, entrapment of the medial calcaneal nerve, diabetic polyneuropathy, and S1 radiculopathy.

Magnetic Resonance Imaging

A useful imaging modality to diagnose plantar fasciitis, entrapment of the tibial nerve at the posterior tarsal tunnel, bone cysts, stress fractures, tumors, among others.

Plantar Fasciitis

Treatment is usually conservative, including weight reduction, shoe modification, stretching, and NSAIDs. Nonresponders can benefit from shockwave therapy, ultrasound-guided corticosteroid injection or autologous blood-derived products (platelet rich plasma).

Hsiao et al. concluded that autologous blood-derived products, followed by corticosteroids, were best in providing relief from pain at three months. Shockwave therapy and autologous blood-derived products had a similar effect of pain relief at six months and were better than corticosteroids at that time.

As regards the placement of the injection, particularly corticosteroids above or below the plantar fascia, Gurcay et al. found that injection of corticosteroid deep to the fascia might cause a greater reduction in plantar fascia thickness, pain, and disability and improved foot-related quality of life. Recalcitrant cases will need surgery.[8][9]

Heel Fat Pad Atrophy

Rest, ice, NSAIDs, heel cups, proper footwear, and taping might be used successfully for reduction of pain and improvement of foot related activities of daily living.

Calcaneal Stress Fractures

Treatment aims to provide a satisfactory environment for healing and prevention of progression of the fracture, and subsequently, pain relief and improvement of activities of daily living ensue.

Treatment options include bed rest, four-point weight bearing with crutches and a 0.5-inch sponge rubber insert in the shoes. Also, NSAIDs, calcium, vitamin D and calcitonin injections can be useful. Pulsed magnetic field therapy helps pain reduction and promotes healing. Treatments for underlying systemic illness are mandatory.

Entrapment Neuropathies

NSAIDs and anticonvulsants can help reduction of symptoms. Non- responders can benefit from ultrasound-guided corticosteroid injection, hydrodissection using dextrose 5%, radiofrequency or cryoablation. Recalcitrant cases or severe cases might need surgical decompression.

• Achilles tendon injuries 

• Distal plantar fasciitis

• Haglund syndrome

• Plantar fibromatosis

• Tarsal tunnel syndrome

• The plantar calcaneal spurs are not a common cause of the plantar heel pain. Spurs are present in 50% of patients with plantar fasciitis. Over 15% of the general population has a radiologically asymptomatic spur.
• Repeated corticosteroid injection, for treatment of the plantar fasciitis, can lead to heel fat pad atrophy and rupture of the plantar fascia, due to attenuation of the fascia.
• Physicians should treat the  underlying cause of the plantar fasciitis, such as flat feet and ankle instability; otherwise, symptoms will recur shortly after the injection under ultrasound guidance.

General ultrasound criteria for entrapment neuropathies include:

1. The cross-sectional area is more than 2 standard deviations above the mean reference value.
2. Change in the echotexture of the affected nerve, like being hypoechoic.
3. Notching and flattening of the nerve at the entrapment site.
4. Change in the fascicle size (enlargement of fascicles within the affected nerve).

The evidence supports none of the commonly available treatments over another for managing the plantar heel pain. However, local injection of corticosteroids, alone or in combination with exercise therapy, and extracorporeal shock wave therapy have the higher effectiveness in reliving plantar heel pain and improving function compared with other treatments in the short term, medium term and long term. [Level I]