arcu Plantar Heel Pain Alan C League, MD Planar hee! pain isa common condition tha Feved to afect 2 millon Amercans cach ear oul 10, of the general population during thei fecime, Planar fascitis isthe most recognized cause of plantar heel pain iis estimated that 11% to 15% of all report of foot ailments requiring medical attention can he atrib- uted 0 this condition. Plantar fascitis's considered 2 selimiting condition because symptoms resolve in 80% t0 90% of patients within 10 months of onset." Hove this lng tine ital for symptom rc tion causes frustration for patents and. physicians Many other etiologies also can cause plantar hee! pan (Table 1). A thorough paviene history and physical ex- aminaion usually results in an accurate diagnosis. ‘Treatment can then be iiiaed Understanding the complex anatomy of the plantar heel is necessary for accurately diagnosing and teating ‘a patiene with plantar heel pain (Figure I). The hee fat pad isa highly specialized structure, The elastic adipose tissue is organized as spiral fibrous sepa, which are an chored to the calcaneus, the skin, and to each other, ‘The septa are reinforced with elastic fibers that connect the walls and ereate separate fat compartments. The thickness of the far pad begins to deteriorate in people ‘older than 40 years, resulting in a diminished ability to absorb impact. “The plantar fascia is a strong, fibrous aponeurosis that originates from the plantar tuberosity of the calex res and fans out into three bands that inser into the bases of the proximal phalanges. The central band an atomically and structurally dominates the medial and lateral bands, and the thick plantar fat pad provects and cushions the origi. The midsubscance can be pal pated subcutaneously when the plancar fascia is ten soned. Dorsiflexion of the tors (especially the hallux) Activates the windlass mechanism, which passively ten sions the plantar fascia an elevaes the medial longi tinal arch, An understanding of also is imperative he (Figure 2}, The posterior ul tunnel i dived into three fe neuroanatomy ofthe hel agnoing planar beep inal nerve hin che sal Neches meal ealenea ‘medial plantar, and lateral plantar nerves. The medial caleaneal branch is the most posterior ofthe three and provides sensation to the medial and plantar hecl. The ‘medial plantar nerve is the anterior branch of the pos terior tibial nerve; it passes deep to the abductor hall cis muscle and distally where it divides. The lateral plantar nerve is located posterior and lateral to the me dial plantar branch. The first branch of the lateral plan- tar nerve (FBLPN}, the nerve 0 the abductor digit ‘unc, has been implicated in plantar heel pain.” En trapment of this nerve can occur as it passes between the deep fascia of the abductor hallucis muscle and the ‘medial caudal margin ofthe quadratus plantae muscle. Plantar fasciitis is defined as a localized inflammation and degeneration ofthe proximal plantar aponeurosis. ‘The most common site of involvement is near the origin. Differential Diagnosis for Pontar fascia Pantrfscits Rupture of plantar facia Enthesopathy Rheurnatord arts Seronegativespondoarthropathy Stemi upus erythematosus Ghptaline athropaties Prorat ets one "akeaneus ses fracture {akaneus cotion Osteomyelitis Neoplasm Softtisue at pad atrophy revlation Tichemla Nerve nvapment ofthe fist branch ofthe lateral planar nerve Tarsal tunnel syndrome Neuropathy ietabol) RadiuopatyCur Plantar Heel Pain Plantar heel pain is a common condition 1 Gee ates? milion Amcicay nena aed 16 of the general population daring thei lifetime: Plantar fasitis 8 the most recognized cause of planar heel paint is estimated that 11% to 15% ofall epors of foot ailments requicing medica attention can be ai ted to this condition’ Plantar facts comsidered self-limiting condition because symptoms resolve in 0% to 90% of patients within 10 months of onset" However, this long time interval for symptom resol tion causes frustation for patiens and. physicians Many other etiologies also can cause plantar heel pain (able 1A hosouph pate hor and phys ex mination ‘usally rests in an accurate Giagnosis Gemcariknend cn Understanding the complex anatomy of the plantar heel is necessary for accurately diagnosing and treating 4 patient with plantar hee! pain (Figure 1). The heel fat pad isa highly specialized structure. The elastic adipose {issue is organized as spiral fibrous septa, which are an thored to the calcaneus, the skin, and to each other. ‘The septa are reinforced with elastic fibers that connect the walls and create separate fat compartments. The thickness of the far pad begins to deteriorate in people ‘older than 40 years, resulting in a diminished ability to absorb impact. ‘The plantar fascia is a strong, fibrous aponeurosis that originates from the plantar tuberosity ofthe calea- evs and fans ut ins three bands tha sett the bases of the proximal phalanges, The central band an- comically and structurally dominates che medial and Iateral bands, and the thick plantar far pad prosests and cushions the origin. The midsubstance can be pal- pated subcutancously when the plantar fascia is ten- Sioned. Dorsiflexion of the toes (especially the hallux) activate the windlass mechanism, which passively ten~ Sions the plantar fascia and elevates the medial longitu- dinal arch. ‘An understanding of the neuroanatomy of the hee! ako imperative when dngroning plata Het Pt {Figure 2), The posterior tibial nerve within the tarsal fumed inc tree Branches medial asane Tecan Academy of Onhopaede Sarsons medial plantar, and lateral plantar nerves. The medial caleaneal branch is the most posterior of the three and provides sensation to the medial and plantar hecl. The medial plantar nerve is the anterior branch of the pos terior tibial nerves it passes deep to the abductor hallu cis muscle and distally where it divides. The lateral plantar nerve is located posterior and lateral to the me: dial plantar branch. The first branch ofthe lateral plan. tar nerve (FBLPN}, the nerve t0 the abductor digit 4uini, has been implicated in plantar heel pain.” En: trapment of this nerve can occur as it passes between the deep fascia of the abductor hallucis muscle and the ‘medial caudal margin of the quadratus plantae muscle. Plantar fasciitis is defined as a localized inflammation and degeneration of the proximal plantar aponcurosis ‘The most common site of involvement is near the origin Differential Diagnosis for Plantar F Plantar fascia Plantar fscitis Rupture of plantar facia Enthesopathy ‘Rheumatoid artis: Seronegativespondyloarthvopathy Sjsternclupus erythematosus Crstaline arthrepathies Poviatc arthritis Bone (Cakcaneus stress fracture Geanevs contusion Osteomyelitis Neopiesm Soft tisue Fat pad atrophy Girclation Ischemia Nerve Entrapment ofthe fist branch ofthe lateral plantar nerve Tas tunnel syndrome Neuropathy (metabolic) Radiclopathy ————————ii oeeneennmmmemmaraeeanaaenee! 3 Section 6: Special Problems of the Foot and Ankle —— in mechanical overload and excessive oF chin he fc which the medial tuberosity of the cafes. Similar to that a process chronic tendon disorders, pathologic findings have in- strain produces mic’ tory response." Re cluded degenerative changes inthe planta fascia with eventually incites an inflammarory fener” Be fibroblastic. probiferation and limited inflammatory peated Ca ne SHronie inflammation followed by Sse There is general agreement inthe heratre 6 eu gay alo have been re ported in patients with FBLPN entrapment; evidence of Perineural fibrosis and hypertrophy has been ob- served." | History Although the differential diagnosis of plantar heel pain is broad, a thorough history and physical examination ‘can usually provide the clinician with the correct diag hnosis, Most differential diagnoses can be included or ‘excluded based on the patient's history; howeves, i is important to consider unusual causes. The presence of | constitutional symptoms such as fevers, chills, or | ‘weight loss can be indicative of a neoplasm or infec tion. A recent increase in activity of training may pre dispose patients to stress fractures, which arc fren present with medial and lateral caleaneal wall pain. A ‘warm and swollen heel should be evaluated co exslude stress fracture or infection from the diagnosis. Plantar fasciitis is the most common cause of plantar heel pain and typically presents with the insidious onser cof “start-up” pain, This sharp, stabbing pain is local ized to the plantar medial aspect of the heel and occurs when arising from bed in the morning or from a chair after sitting for an extended period. Stact-up pain diss pates afer a short period of weight bearing. Patients frequently describe an achy pain at the end of the day, ‘especially following prolonged weight-bearing activi ties. If untreated, the pain may worsen over timc, re Coronal ros section ofthe hindfoot shows the felatonship among the plantar #9 plantar Feel ped, andthe FBLPN. (Repreduced with per- ‘mission from the Cleveland Cine Foundation, Cleveland, OF). Frstbranch ot Pe lateral plantar norve Panta fc Anducto fist muse le wth detailed dose up ofthe tia neve and ts ances Note the elton ecto hac mc. Reproduced with permasion or te Cree Sng Esig in an amalgle gait ait changes can produce paint Etter or contralateral. lower back. Central heel pain syndrome patients because of heel pad at. 4s present to some degree in most elderly henenee wey can be accelerated in patients with pili a disorders or those treated with corticosteroid inectons in that area. The clinical presemation piclly ance central plantar heel pain associated with barefoot walk, ing or the use of hard-soled shoes. Unlike patents with plantar fascits, the pain does not impeove after the first few steps, but is usually relieved by tes or with the use of well-padded shoes. Entrapment of the FBLPN also causes inferior heel pain.’ The nerve becomes entcapped between the stout deep fascia of the abductor hallucis muscle and the me- dial head of the quadratus plantac. muscle Athetes ‘who spend a significant amount of time on thet toes (sprincers, dancers, gymnasts, and skaters) are. more prone to this type of nerve entrapment because they have a well-developed abductor halacis muscle, Unlike plantar fasciitis, this condition may resule in paresthe Sias although the occurrence of abnormal sensations is variable. With isolated entrapment of the FBLPN, startup pain is unusual however, if simultaneous ine volvement of the fasciae occu the clinical scenario can mimic plantar fasciitis. Physical Examination The Key to the examination of the painful plantar hee! is determining the location of maximal endemess (Fig ure 3). Each diagnosis has a specific location of max tal tenderness. Percussion and compression should be performed over the medial and lateral caleaneal tubs Tosties, proximal and distal plantar fascia, proximal abductor hallucis muscle, plantar hel fat pad, tarsal tunnel, and any surgical sear near the heel. The precise location of maximal tenderness will often provide the diagnosis. Plantar fascitis is uswaly indicated by pain with deep palpation at the origin of the plantar fascia on the plantar medial calcaneus tuberosity. Pain appre lated more medially and cranially to this point, ever ibsequent compensatory ul symptoms in the ips extremity of the low ‘may develop in elderly ‘ophy. Heel pad atrophy the origi cis muscle, may indicate origin of the abductor ha ¢trapment of the FBLPN. Pain with palpation i he central plantar heel is often associated with a thinning, ofthe far pad and is consistent with fat pad atzophy The ‘windlass mechanism. shouldbe tenon through dorsiflexion of the metatarsophalangeal Joh" is maneuver ea deve det or mass tN a tar fascia midsubstance, Achilles tendon comeactare commonly associated with plantar fasciitis and should Cvaluated. by measuring ankle dorsiflexion with the ree in flexion and extension. A positive Tinel sgh along an incision is consistent with a ‘surgically injur nerve. Weight-bearing align tremity should be observ ot and he oe American Academy of Orthopaedic Sure ~— (Chapter 26: Plantae Heel Pain Proximal plantar asc Comprossion o rt ranch of tho atoral Pantar mene Central noel pan (itpas crops) EERE] Common locations of tende"nes n patients with plantar heel pain. (Reproduce with perm from the Cleveland Chic Fourcavion Cleve, land, On) patient is standing. A thorough neurologic and vascular ‘examination should be performed. Range of motion of the ankle and subtalar joint should be measured to evaluate intra-articular pathology. Unilateral heel symproms are most common; bilateral involvement ‘may indicate a systemic cheumarologic condition. Imaging A thorough history and physical examination is usually sulficient to properly identify the etiology of plantar hel pains however, imaging can be helpful in ruling out or confirming a diagnosis. Weight-bearing radiographs re typically normal in patients with plantar heel pain Syndromes but may show arthritis, neoplasm, trauma, infection, oF prior surgery. The lateral image will occa” sionally show a plantar heel spue, although its clinical felevance is unkown, “Teehnetium bone scans have a 60% to 98% sensitiv. ity and up t0 an 86% specificity in diagnosing plantar fascitis, and may be helpful in detecting a caleaneus stress fracture or neoplasm. A heel with plantar fasci- ins shows increased uptake atthe origin of the fascia, Whereas a stess fracture shows increased uptake throughout a. much larger portion of the calcaneus MRI may show thickening of the plantar fascia. The ah vege Uae: Foot and AnkleSection 6: Special Probl the Foot and Ankle Achilles stretching exercie. (Reproduced with pr. ‘mission from DiGiovann’ Bf Nevrocrersk| DA, Uta Et at Msue-specite plantar fascoe Stretching exercne enhancer outcomes inp Fandomized study. 1 Bone Joist Surg Am 2003;88:1270:1277) fascia in patients with plantar fasciitis has been mea- sured at 6 to 8 mm, whereas the fascia measures less than 4 mm in asympromatic individuals.” MRI also is, useful in dececting a stress fracture of the calcaneus. Ul- trasonography has received increased attention for its diagnostic capabilities and its role in guiding the loca- tion of extracorporeal shock wave therapy (ESWT) With ultrasound, the fascia can easily be differentiated from the superficial fat pad and the underlying calea neus. The normal thickness of the planar fascia is 210 44mm, whereas a thickness from 5 to 7 mim is found in patients with plantar fasciitis. Pee Although mechanical overload is freque as a primary factor, the etiology of plantar fasciitis is believed to be multifactorial. nteinsic factors such as older age, abnormal foot posture, an elevated body ‘mass index, and a tight Achilles eendon, as well as ex trinsic factors such as the use of improper footwear, the type and intensity of daily activity, and incidence of iso lated or repetitive trauma have been proposed as risk factors for plantar fasciitis. No single risk factor has been reliably identified across multiple studies. Static and dynamic cadaver studies have linked Achilles ten- don tension and plantar fascia loading to plantar fasci- ccase-controlled study of 50 patients in tar fasciitis was clinically diag. \ctors commonly believed to “hoa un nn rt al ote dnoer” Two contol te ch pret on the ce of i dy Showed tat individuals who "efter woray bad iia ts compared wah hoe Sbjct wee arand gender Sd tering es Sheena kof pata a rand for lng prods Te risk of plantar Te 28 Sateases athe amoueof ankle dorsi aan es rash body mass index increases. Fach ia tes was determined 0 bea ode ete PEE er for plantar fl with reduced vei donlxton being the most important Plantar facts is believed to be a slfimiting cond tion in most patients. Nonsurgieal treatment is success ini 90% of patents Howes, complete esto sin often takes several months and sometimes more than I year Initiation of treatment within the ise {weeks afer symptoms appear may speed recovery, a though this has yet ro be proven. An important ee tment of succesol management is patient education, ‘which includes establishing realistic patient exces tions, Patients who expect rapid resolution of pain ill usualy be Sangoma and stated these expt tions can have negative impact on compliance with treatment and on the relationship sich the physicion. Many previo clnial studies evaluating the eifiscs of nonsurgial treatment licked high-level eden however, the quality of tecent research has improve Data from several high-quality randomized, comerolsa studies are available to assess the efficacy of specie treseent options Stretching Exercises theories have feos Pans a tendon and pan facia seek ar ry fen ca Ege 4) wah lear tones se ure 5) in patients with chronic plantar fasciitis." All favens tthe uy sed reel (Ns >) therapy, and viewed an educational video on froup showed sigan improvement cotaeeT ca the Aches tendon stein ee ee Achilles tendon gro aa ta tach fascia suetching ty year bok ca ‘cre nt between the group, Resa id ot ine a contol groupe ake Ras ee rennet es other ree dy eva fetvenes of itis; the clinical significance of this relationship contin- tues to draw investigative interest A recent, ‘atnopatis Koowledge Uplate oor and Rae ‘American Academy of Orthopaedic Sunpeeing in ia eine of ge sham control geoup." Panna whether they were in the treaties goup. The treatment prose fa recived sham ulsasoral included were blinded as to roup oF the sham formed calf stretching alone. After 2 weeks, no difference was found ee between a safe and yn the teeat- the ewo groups. Although stretching ro relatively easy treatment option, svete ment of plantar facitis is undetermined Night Dorsiflexion Splints ‘Atight Achilles tendon is implicated ‘ology of plantar fasitis A night spine hol heal a maximum donee anf 0 to prevent contracture of the plantar imog net fastosnemiussoles compen, The eden Sd Sart-up pain is considered «divest benef ch sonnct splinting. A prospective erosover study showed sat icant improvement when sing a night splint as come pared with no treatment." Alter the crssovey oh Pappiliueecd smitiane inpovencarah maintained after 6 months. A randomized, controlled study compared the use of NSAIDs, Achilles tendon stretching, and footwear modification wth and with ue thee of igh sin. No irene wee nd between the two groups. The evidence support ing the ose of night splints in ecating plantar fasts is mixed. as one possible eti- Orthoses Heel cups, prefabricated insoles, and custom orthotics are used to treat plantar fasciitis. The goal of these de~ tices isto elevate and cushion the heel, provide medial arch support, or both. A multicenter study found pre- fabricated orthotic devices to be superior #0 custom- made orthotic devices in treating plantar fasciitis in pa- tients who stand more than 8 hours per day. Howeves ‘outside this subgroup, no difference was detected. more recent randomized study compared the use of a custom-made orthosis to a night dorsiflexion splint ‘The authors found no difference in pain or funetion be- tween the groups: however a much higher ae of om pliance was reported for patients using the orthosis Eompared with those treated with the nigh splint. Nei ther study used a sham control group. "A recent randomized controlled study compared @ sham orthosis thin, soft foam), a prefabricated ortho; 3 hicks fim foam) and tsi semi orthosis in a population of parents who did not receive ty other eaten (euch as NSAIDs and sting exercises)" At 3- and 12-month followup all three groups had improvement in pain and function. 3 months, the groups wsing the prcfabricaed and Ws tomized orthoses had significane improvement 9 tion compared with the sham group, but no diferce™ in pain level, By 12 months, no difference Wait” or pain was reported among the groups. The St term use of custom or prefabricated orthoses Trercan Academy of Orthopaedic Swe Mantar fascia spect stretching exercte.(Repro- tlced with permison ram Btuvanm 86 Noweczensti DA Lint! ME ea: Tue specific plantar esastrething exercise enhances et Specie fandomisnd cy | Sane he Sry Kn 08512701977). ported by high-quality clinical evidence, but the long: term benefits of these devices have not been established. Anti-inflammatory Agents and Other Modalities Antiinflammarory agents are often used in clinical practice but limited data are available to evaluate their efficacy in treating plantar fasciitis. A recent double , prospective, placebo-controlled study evaluated a nonsurgical protocol (heel cord stretching, heel cups, right splinting) with or without the administration of Dal celecoxib.” Over time, pain and disability scores improved significantly in both groups. Although the NSAID group showed a ttend for improved function ‘and pain scores, there was no statistical significance be- tween the placebo and NSAID groups at 1-, 2- oF 6-month follow ‘Corticosteroid injection, usually mixed with local anesthetic, is another common treatment for plantar fasciitis, To avoid injection into the plantar fat pad and. Subsequent atrophy, a medial approach is advocated. ‘The needle tip should be placed at the medial origin of, the plantar fascia, One study found significantly im- “Orhopastis Knowledge Uae For and Aekle 4lems of the Foot and Ankle proved pain at 1 n Gemonth follow-up local anesthetic alone.’ mth, no difference at 3+ and 0 compared with the use of a This apparent short-term bene fit must be weighed against the potential complications of plantar fat pad atrophy and plantar fascia. rup ‘Topically applied steroid, propelled into the tissues with a small electric charge (iontophoresis), may pro Vide a safer alternative. The authors of one study found significant improvement in pain control and function at the time of treatment compared with a placebo group.* At I-month follow-up, no significant difference vas re ported between the no groups. Although it may not alter the natural history of the disease, iontophoresis may be helpful in allowing athletes to retuen ro play more quickly Patients with central heel pain secondary to fat atro- phy can be treated nonsurgically, Interventions mainly involve alteration in footwear, with options inclading gel heel cups, prefabricated shock-absorbing shoe serts, and custom-made orthoric devices. Combined with activity modification, these devices can reduce the impact and pain associated with this condition, Nonsurgical management of entrapment of the FBLPN typically involves activity modification, the use ‘of heel cups, NSAIDs, and corticosteroid injections; however, the clinical response to these treatments is un clear. When patients do nor adequately respond to nonsur- seal erearments, additional medical studies may be pet- formed to rule out less common etiologies of heel pain Rheumatoid arthritis and other inflammatory condi tions are associated with heel pain. These conditions cean be diagnosed with laboratory studies, including 2 ‘complete blood cell count with differential white blood cell count, and evaluation of erythrocyte sedimentatios rate, rheumatoid factor, antinuclear antibodies, and hu- man leukocyte antigen B27 and uric acid levels, Ifthe findings are positive, consultation with a rheumacology specialist is recommended. Extracorporeal Shock Wave Therapy Proponents of ESWT, also referred to as orthottipsy, claim it offers an effective means of treatment of chronic plantar fasciitis in patieats who have been un- teaponsveco other nonsurpeal teatments. The mech anism of action of orthotripsy is similar co lithotripsy for treating kidney stones. Acoustic waves dissipate me- chanical energy at the interface of two substances of differing acoustic impedance. An electrohydraulic,elec- tromagnetic, or piezoelectric generator can be used to produce the shock waves. Currently all three wave pro: duction techniques are available for clinical use. ESWT is classified as ether high- or low-energy therapy based ‘on the magnitude of the shock wave generated by the device. High-energy ESWT requires local or general an cesthesia and is administered in a single session, whereas low-energy treatment does not require anesthesia ad is usually administered in three weekly sessions. uf oo yo ES ae tera randomized, controled acu maven fing results." A recent Fy of ESWT for plan a em review ofall fandom, ee mated trials published from 1966 10 2004 eval sieht. Sits (897 pats ae eat et analyse 0 allow poling ofthe sage incawon eters, Otcomen showed Seuiant tw ePsigieance (P= O08), the sae epi tar 2 oka, the observed Se ere gan 0.50 cm on a 10m vital a rarer FSWT remains a viable option for treating chronic plone lc when oer nonsurgieal measures have plata fee" rinees sept of good omnes ae aly sue are needed to make this thee tora seas uci neanaearopon ESWT has been actively In most patients, planar fasciitis resolves with non: glcal treatment. For patients who do not achieve pain felieafter atleast 6 co 12 months of conservative man Sgcment, surgical treatment may be considered. Surg cal treatment options for reealctrant plantar fasciss include isolated paral or complete release of the plan tar fascia, a fascial release combined with resection of Calcaneal spur excision of abmormal dssue, oF nerve de. compression. These procedures can be performed ether ‘open or using an endoscopic approach, Most studies ot the surgical treatment of planar fasciitis have been cove series evaluating a single surgical technique or ret. spective comparisons of two different th nigues.*" These types of studies produce low-level evades evel and IV viens) To date, non domized, controlled studies on the surgical manage ment of planar fasciitis have been published. Open release of the plantar fascia is. performed through a medial incision that allows direct iewales tion ofthe fascia, Preservation of the lateral $0% of the nlanta fascia fibers may prevent collapse ofthe lone tudinal arch, One tevhnique tht reese the hte plantar fascia requires no weight bearing for 6 mon, followed by the use of arch suppon Re sean moval of the plantar calcaneal spur introdeecs adel tional surgical trauma and delays recovery without i proving outcomes In patients with isolated plantar fascitis, endoscope release may offet a shone ieee, sy times however, the ability to view surrounding structures is impaiedy and the lateral plane mene snay be at risk for injury. Patents with srmovoms of nerve compeession and plantar fasciitis are nee pero. Prat antes fr enoscopi ese acces rates for surgical treatment of planta fas: ts ave variable, and dhe use of diferent Gare sures prevents direct comparisons Hermon ohn ‘Orthopedic Knowledge Update Foor and Aakle 4 ‘American Academy of Orthopaedi Srgcomsly of endoscopic plantar fa rent in the American Orthy ove st fT ety ankle-hindtoor scor fort Society an © (66 to Hy pat Me ions in this BroUP included one patient winh | ati fi sg onal pain syndrome who required tna pai specials Other potential cons jo pan or emlscopic men of plana fe fee ave ines Mate cy ein marl pain, ad pes wally, FBLPN entrapment has been trea si Moree mote een tay ep diel pati fom plantar fascia and FRLPN en cm and recommended partial plantar fascia re. wre i mip EBLPN neurolysis. Decompression of the SUN is performed through a medial approach when etal and deep fascia ofthe abductor hallucs divided; The partial plantar fasta elase tformed through the distal aspect of the s fe FAn extensive release of the tarsal tunnel an be ‘formed witha plantar fascia release.” thnar bel pain remains a common disorder, most of- teased by plantar fasciitis. Many safe, nonsurgical feaments are available; however, few data show that thse modalities are more effective than sham treat tuat. The natural history of plantar fasciitis results in teokion of symptoms in less than I year in most pa- tex. ESWT may be helpful in patients with chronic liar fscitis whose symptoms have not improved wih other nonsurgical treatments. Surgical treatment {planar fasciitis should be considered only after non- fugzal modalities have failed. If surgery is required, »mre than 50% of the fascia should be released to ‘wi stucrural complications. If entrapment of the is present, concurrent decompression of this tune abo should be performed. Heel pad atrophy is ete nonsurgically with shock-absorbing footwear. ‘reiated References * Meaty DJ, Gorecki GE: The anatomical it caleaneal lesions: A eryomicrotomy ediatry Assoe 1979,69:527-536. bass of i wy. J Am Compacison of he inital teat 1998 ier G, eceher P, Deland J, et al ‘ed prelates eof posal pasar cs Foot Anklet 214-291, Painful eel sydr0™e: DEP or aml It ROPE, SeverudE, Bax ; Hei OF nonoperative treatment Besassarsss. : 8 Neem tn Chaps 26: Pantar Heel Pain sind dons FP: Painful heck: Report of 364 painful 6 Pant hel: Cin Ort Reker Webb M, Cook C Graham C, Mauldin 9 Tot Alen ious ee How Baxter DE, Th » Thigpen CM: Hel pin: Operative resol Foot Ankle 1984;5:16-25, . i : Jarde O, Diebold P, Haver E, Roulu G, Verois k De Eenerative lesions ofthe plantar fas: Sarpeal teat ‘ment by fascietomy and excision ofthe he! spa Ave Por on 38 cases. Acta Onhop Belg 20N3,69-267-274 The authors prevent a review of MR his and Surgical resus of 38 paiens treated with plantar fascia release and cakaneal spur rection. Level of i dence: WV, Leach RE, Seavey MS Salter DK: Results of surgery in athletes with plantar fascitis, Foot Ankle 19867 156-161 Lemont H, Ammirati KM, Usen N: Plantar fascits A degenerative proces fais) without inflammation J Am Podiatr Med Assoc 2003,93:234-2 “The authors review histologic findings f heel spur surgery for chronic plantar fais. Finings include myxoid degeneration with fragmentation and degeneration of the plantar facia and bone marrow ‘ascular ecasia, Histologic findings support the hypoth tsi tha plantar fascits 6a degeneeaive fascoss with fut inflammation, nor a fascts. aya BK: Plantar fits in athletes. J Sport Rehabil 1996,5:305-520. Warren BL: Plantar fascinsin runners: Treatment and prevention. Sports Med 1980;10:338345 Schweitace ME, Kovalvich AM, et al: MR fea, tear, and occult ob with outcome. AJR 701. Grose RP, srt of planar asst: ie Ginoraliicy cole ma Rong (PHT sc Janis LR: Chai paar Lele Ral Cl Por Med eee 85389 Gry Mant ai Ei eee ee the Tpoiaeaiss%6 Leach RE surge avo Relat Res ‘Sports Med 1983: | |