Foot / Ankle
Plantar Fasciitis
족저 근막염
Chronic degenerative changes of the plantar fascia causing heel pain — excruciating pain on first morning steps
- How common
- Very common
- Typical age
- Ages 30–60
What is it?
Repetitive microtrauma and degenerative changes at plantar fascia origin on medial calcaneal tuberosity (similar to angiofibroblastic tendinosis)
Commonly affected: Plantar fascia (at medial calcaneal tuberosity origin), calcaneus
How it develops
- Repetitive OverloadPlantar fascia tension with weight bearing and dorsiflexion — concentrated at medial calcaneal tuberosity origin
- MicrotearsRepetitive overload causes microtears at plantar fascia origin
- Degenerative FasciosisFailed normal healing → degenerative changes without angiogenesis (fasciosis)
- Nocturnal ShorteningPlantar fascia contracts in plantarflexed sleep position → sudden tension with first steps
Symptoms
- Morning Heel PainSevere heel pain on first morning steps — most characteristic symptom
- Medial Calcaneal TendernessDirect tenderness over medial calcaneal tuberosity (anteromedial heel) — most important physical finding
- Post-activity WorseningPain returns after prolonged walking or standing ('warm-up phenomenon' reversal)
- Dorsiflexion RestrictionAnkle dorsiflexion restriction from gastrocnemius/soleus tightness — adds load to plantar fascia
How it is examined
- Medial Calcaneal Tuberosity TendernessDirect pressure over medial calcaneal tuberosity reproduces pain → most specific finding for PF
- Windlass TestDorsiflexing toes (especially hallux) increases plantar fascia tension → reproduces heel pain
- Ankle Dorsiflexion TestMeasure ankle dorsiflexion with knee extended/flexed — differentiates gastrocnemius vs soleus tightness
- Foot Arch AssessmentAssess pes planus or pes cavus — risk factor evaluation
Imaging
Assess calcaneal spur and exclude other bony pathology
- Calcaneal spur (heel spur) — seen in 50%, not necessarily symptomatic
- Plantar fasciitis itself not visible on X-ray
- Stress fracture exclusion
Confirm plantar fascia thickness and degeneration — consider when conservative treatment fails
- Plantar fascia thickening (>4mm, especially at calcaneal origin)
- T2 hyperintense degenerative changes
- Medial calcaneal tuberosity bone marrow edema
Non-surgical care
- StretchingGastrocnemius/plantar fascia stretching — especially before first steps at bedside. Most important treatment
- Night SplintNighttime dorsiflexion splint (5-10°) — prevents plantar fascia shortening during sleep
- OrthoticsMedial arch support insole, cushioned heel cup
- Steroid InjectionSteroid injection at plantar fascia origin — short-term effect. Repeated injections risk fascia rupture
- ESWTESWT when conservative treatment fails at 3-6 months — stimulates regeneration, 70-80% effective
Conservative options are generally tried first. Medications listed here can have side effects — discuss them with your prescriber.
When surgery is considered
Failed conservative treatment >6-12 months
Procedures that may be discussed
- Plantar fascia release — medial 1/3 incision
- Endoscopic plantar fascia release
- Heel spur excision (if present)
Outlook
>90% improve with conservative treatment within 12-18 months. Adding ESWT accelerates recovery