Injection Technique for Plantar Fasciitis

Indications and Clinical Considerations

Plantar fasciitis is characterized by pain and tenderness over the plantar surface of the calcaneus. Occurring twice as often in women, plantar fasciitis is thought to be caused by an inflammation of the plantar fascia. This inflammation can occur alone or be part of a systemic inflammatory condition, such as rheumatoid arthritis, Reiter syndrome, or gout. Obesity also seems to predispose a patient 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. Although plantar fasciitis is usually a straightforward diagnosis, occasionally other pathologic processes of the foot can mimic this condition ( Box 189.1 ).

The pain of plantar fasciitis is most severe on first walking after having not borne weight and is made worse by prolonged standing or walking ( Fig. 189.1 ). Characteristic radiographic changes are lacking in plantar fasciitis, but radionuclide bone scanning may show increased uptake at the point of attachment of the plantar fascia to the medial calcaneal tuberosity.

On physical examination, the patient exhibits point tenderness over the plantar medial calcaneal tuberosity ( Fig. 189.2 ). The patient also may have tenderness along the plantar fascia as it moves anteriorly. Pain is increased by dorsiflexing the toes, which pulls the plantar fascia taut, and then palpating along the fascia from the heel to the forefoot.

Plain radiographs are indicated for all patients with pain thought to be emanating from plantar fasciitis to rule out occult bony disease and tumor. On the basis of the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, prostate-specific antigen, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging and ultrasound imaging of the foot are indicated if plantar fasciitis, occult mass, or tumor is suggested ( Figs. 189.3 and 189.4 ). Radionuclide bone scanning may be useful to rule out stress fractures not seen on plain radiographs. The injection technique described later serves as both a diagnostic and a therapeutic maneuver.

Clinically Relevant Anatomy

The plantar fascia is made up of thick connective tissue that is tightly attached to the plantar skin. It attaches to the medial calcaneal tuberosity and then runs forward, dividing into 5 bands, 1 going to each toe ( Fig. 189.5 ).