Aetiology
- Repetitive impact activity
- May be related to spondyloarthropathy (enthesiopathy)
- Obesity
Pathoanatomy
- Pain at plantar fascia origin on medial calcaneal tubercle
- Degenerative microtears of plantar fascia
- Reactive enthesiopathy with spur formation
- Spurs are related but not causative
- Many people with spurs are asymptomatic
Differential Diagnosis
Entrapment of Baxter’s Nerve
- 1st branch of lateral plantar nerve, just beyond the tarsal tunnel
- Runs beneath Abductor Hallucis, supplies Quadratus Plantae
- Causes medial heel pain with rest or shooting pains
Calcaneal Stress Fracture
- Due to repetitive high-impact activity (e.g., military recruits)
- Bone scan or MRI diagnostic
- Suspect if history fits & does not settle with non-operative measures
Clinical Features
- Pain with first few steps in the morning
- Activity-related pain
- Settles at rest
- Neurologic symptoms → suspect other causes
- Tight Achilles tendon is common
- Windlass Test
- Dorsiflexion of toes causes pain
- Often overweight patients
- Tibialis Posterior (TP) insufficiency may co-exist
Management
Non-Surgical
- Almost always effective enough to avoid surgery
- Weight loss
- Activity modification
- Shoewear modification
- Heel pads with cut-outs, silicone insoles, etc.
- Plantar fascia stretching programme
- Similar to Achilles stretches
- Steroid injections
- May be useful but beware of plantar fascia rupture
Surgical Management
- Only if non-surgical methods fail
- Release of medial 1/3 plantar fascia origin + Abductor Hallucis fascia release
- +/- Excision of prominent spurs if indicated
- Avoid complete release to prevent:
- Arch collapse
- Lateral column overload
- Baxter’s nerve compression is uncommon but may explain failure of non-surgical treatment
- May as well release during surgery
- Surgical outcomes are unpredictable
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