Pain on the Plantar Surface of the Foot

Abstract

Background: Plantar fasciitis (PF) is characterized by pain on weight-bearing in the medial plantar area of the heel, metatarsalgia (MTG) by pain on the plantar surface of the forefoot radiating into the toes. Reliable figures on lifetime prevalence in Germany are lacking.

Methods: This review is based on pertinent publications retrieved from a selective search in PubMed, on guidelines from Germany and abroad, and on the authors' clinical experience.

Results: Plantar fasciitis is generally diagnosed from the history and physical examination, without any ancillary studies. In 90-95% of cases, conservative treatment (e.g., stretching exercises, fascia training, ultrasound therapy, glucocorticoid injections, radiotherapy, shoe inserts, and shock-wave therapy) brings about total, or at least adequate, relief of pain within one year. Intractable pain is an indication for surgical treatment by plantar fasciotomy and/or calf muscle release. In metatarsalgia, a directed diagnostic work-up to find the cause is mandatory, including a search for excessive mechanical stress due to abnormal foot posture, neuropathic pain, rheumatoid arthritis, aseptic bony necrosis, or malignant disease; imaging studies and pedobarography are needed. For causally oriented treatment, a wide range of conservative and surgical measures can be considered.

Conclusion: The reported results of treatments for plantar fasciitis and metatarsalgia are heterogeneous. The efficacy of the individual measures should be studied in randomized controlled trials.

Figure 1

Female patient with severe metatarsalgia in bilateral recurrent hallux valgus and floating toes following bilateral hallux valgus correction and Weil osteotomy: a) plantar view; b) anterior view.

Figure 2

Pedobarographic image with high peak pressures over the metatarsal heads (left); postoperative pressure distribution after hallux valgus correction and distal minimally invasive metatarsal osteotomy (right). (Color key: increased pressure from black to red)

Figure 3

a) Radiograph in dorsoplantar projection showing hallux valgus and increased sclerosis of the head of MT2 in Köhler disease II; b) radiographic follow-up after percutaneous hallux valgus correction with proximal displacement osteotomy of MT1 and Akin osteotomy and displacement osteotomy of MT2

eFigure 1

Lateral radiography with the patient standing upright (a) and a sagittal MRI section (b) demonstrate a marked yet asymptomatic heel spur (arrow)

eFigure 2

MRI shows bone marrow edema and an osteochondral defect of the dorsal MT 2 head with joint effusion and involvement of the base of the proximal phalanx in Köhler disease II