Plantar fasciitis is a clinical syndrome characterized by pain and tenderness over the plantar surface of the calcaneus made immediately worse by dorsiflexion of the toes. Occurring twice as often in women, plantar fasciitis is thought to be caused by an inflammation of the plantar fascia. Inflammation of the plantar fascia can occur alone or be part of a systemic inflammatory condition, such as rheumatoid arthritis, Reiter syndrome, or gout. Obesity also seems to predispose to the development of plantar fasciitis, as does going barefoot or wearing house slippers for prolonged periods. High-impact aerobic exercise also has been implicated.

Pain on palpation of the insertion of the plantar fascia on the plantar medial calcaneal tuberosity is a consistent finding in patients with plantar fasciitis as is exacerbation of pain with active resisted dorsiflexion of the toes (Fig. 169.1). Patients suffering from plantar fasciitis will also exhibit pain on deep palpation of the plantar fascia, especially when the toes are dorsiflexed pulling the plantar fascia taunt. The pain of plantar fasciitis is most severe on taking the first few steps after having not borne weight and is made worse by prolonged standing or walking.

Plain radiographs are indicated in all patients who present with heel and foot pain (Fig. 169.2). Based on the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging and/or ultrasound imaging of the ankle is indicated if plantar fasciitis, rupture, or joint instability is suggested (Figs. 169.3 and 169.4). Radionuclide bone scanning is useful to identify stress fractures of the calcaneus and foot not seen on plain radiographs and may aid in the diagnosis as there may be increased uptake of radionuclide at the insertion of the plantar fascia at the calcaneus. The injection technique described later serves as both a diagnostic and a therapeutic maneuver.

The plantar fascia is made up of thick, longitudinally oriented connective tissue that is tightly attached to the plantar skin. It attaches to the medial calcaneal tuberosity and then runs forward, dividing into five bands, one going to each toe (Fig. 169.5). The plantar fascia provides dynamic support in the arch of the foot, tightening as the foot bears weight.

The benefits, risks, and alternative treatments are explained to the patient, and informed consent is obtained. The patient is then placed in the prone position with the patient’s ankle hanging off the edge of the table (Fig. 169.6). With the patient in the above position, a high-frequency linear ultrasound transducer is placed in a longitudinal plane with the inferior portion of the ultrasound transducer over plantar surface of the foot with the superior end of the transducer on the anterior portion of the calcaneus, and an ultrasound survey scan is taken (Fig. 169.7). The calcaneus and linear plantar fascia are identified at its insertion on the calcaneus (Fig. 169.8). When the insertion of the plantar fascia is identified, the skin overlying the area of the heel and beneath the ultrasound transducer is prepped with antiseptic solution. A sterile syringe containing 3.0 mL of 0.25% preservative-free bupivacaine and 40 mg of methylprednisolone is attached to a 1½-inch, 22-gauge needle using strict aseptic technique. The needle is placed through the skin ˜1 cm above the superior border of the ultrasound transducer and is then advanced using an in-plane approach with the needle trajectory adjusted under real-time ultrasound guidance so that the needle tip rests against the site of tendinous insertion (Fig. 169.9). When the tip of needle is thought to be in satisfactory position, a small amount of solution is injected to insure that the needle tip is not in the substance of the fascia. After confirmation that the needle tip is outside the tendon, after careful aspiration, the contents of the syringe are slowly injected. There should be minimal resistance to injection. The patient may note an exacerbation of his or her pain during the injection.