Plantar fascia rupture: Diagnosis and treatment

Plantar Fascia Rupture: Diagnosis and Treatment Two patients with spontaneous medial plantar fascia rupture due to a definite injury with no prior symptoms, were referred to our institution. Clinically, there was a tender lump in the sole, and magnetic resonance imaging confirmed the diagnosis. Nonoperative treatment was sufficient in curing the acute total rupture. Endoscopic release was used on the partially ruptured plantar fascia, but it is probably more optimal in the acute phase. The literature provides no comparative data on operative or nonoperative treatment efficacy for this rare condition. (The Journal of Foot and Ankle Surgery 36(2):112-114,1997) Key words: plantar fascia rupture, soft tissue trauma, foot

Christer Rolf, MO, Ph0 1 Peter Guntner, M02

Jan Ericsater, M03 Ibrahim Turan, MO, Ph01

The athlete's foot is under repetitive stress, and injuries to this location are common (1, 2). There are no epidemiologic data available on acute or chronic plantar disorders, except from retrospective calculations of consecutive patients whose symptoms referred to plantar fascia pain accounting for 7% (2). We present two cases of spontaneous medial plantar fascia rupture, focusing on the diagnosis and treatment of this uncommon condition (3, 4).

fascia, which later was confirmed by magnetic resonance imaging (MRI) (Fig. 2). Treatment was given with shoe arch supports and physiotherapy, including stretching and strength training of the plantar flexor muscles. Six months after the injury the patient was free of symptoms. He is still asymptomatic 15 months postoperative.

Case 1

A 31-year-old healthy plumber with no history of disease, no injury to the lower extremity, or prior symptoms of the foot, experienced a sudden sharp pain and a loud snapping sound in the left sole as he landed on his forefoot while playing badminton. He came to the emergency room at midnight, because he noted bluish coloring and a tender lump in the sole. He walked with a limp. The surgeon on call, who was unable to make a diagnosis, referred the patient to a foot surgeon the following day. On this occasion (Fig. 1) the patient's pain was localized to the midportion of the plantar fascia, and standing on his toes aggravated the pain. The preliminary diagnosis was a total rupture of the medial plantar From the Section of Sports Medicine and Foot Surgery, Departments of Orthopedic Surgery and Clinical Radiology, Huddinge University Hospital, S-14186, Huddinge, and Department of Orthopedic Surgery, Vallingby Medical Center, Stockholm, Sweden. 1 Address correspondence to: Department of Orthopedic Surgery, Huddinge University Hospital, S-14186, Huddinge, Sweden. 2 Department of Clinical Radiology. 3 Department of Orthopedic Surgery, Vallingby Medical Center, Stockholm, Sweden. The Journal of Foot and Ankle Surgery 1067-2516/97/3602-0112$3.00/0 Copyright © 1997 by the American College of Foot and Ankle Surgeons

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Case 2

A 45-year-old female play-school teacher had a history of bilateral carpal tunnel surgery due to clinically suspected compression of the median nerves, and had reported "bad" results from both operations. She also reported long-term nonoperative treatment for persistent lower back and neck pain. No earlier symptoms from the lower extremities were noted. She came to the emergency room complaining of persisting pain in her left sole, starting with an ankle sprain that had occurred 5 weeks earlier while she was on holiday in France. She had recovered partially, but 4 weeks later, while walking over her lawn, she suddenly experienced a sharp pain and a clicking sound in her left sole. Upon examination the patient exhibited a decreased and painful plantar flexion of the ankle joint, and tenderness along the plantar fascia. She had no symptoms or signs from the ankle joint. She was treated with a below-knee plaster cast for 2 weeks. An MRI verified a partial rupture of the medial plantar fascia (Fig. 3). After the immobilization period she was given shoe arch support and physiotherapy, including stretching and proprioceptive exercises. She was given, and occasionally used, crutches when she experienced too much pain to walk without them. Six months after the initial ankle sprain she still complained of persisting pain. Release of the remaining medial plantar fascia insertion was performed from a

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FIGURE 1 Typical clinical signs of subcutaneous bleeding and a lump in the sole of a male plumber with an acute total medial plantar fascia rupture.

minor lateral incision under endoscopic vizualization from the medial side. Upon evaluation within the following year, she was improved but complained of minor, persisting pain, sometimes disabling her from normal walking, although this was absent at the most recent follow-up, 22 months postoperative. Discussion

In the cases presented, the level of athletic activity was not extensive. The patients performed sports occasionally, but only at a recreational level, similar to the patients treated by Lester and Buchanan (5). However, in contrast to the latter group, our patients' history did not reveal any previous symptoms prior to injury or any earlier local cortisone injections (6, 7) leading to the suspicion of a plantar fascia rupture. To our knowledge, there is only one reported case of a spontaneous plantar fascia rupture with no prior fasciitis (8). The history of sudden pain in the sole during activity, a clinical finding of a tender lump, or, as in one of our cases, subcutaneous bleeding, should suggest this diag-

FIGURE 2 Angulated axial magnetic resonance image (TRfTE 2800/19) of the acute medial plantar fascia rupture with loss of low signal in the fascia, and irregular signal in the short flexor muscle substance suggesting a hematoma.

nosis, which may be confirmed by MRI. The choice of treatment should be based on the severity of symptoms and disability. In the acute total medial rupture, treatment with shoe arch supports seems sufficient, at least in nonathletes. If this treatment is not successful, an operation with excision of scar tissues interrupting contact with the calcaneal insertion may be performed. In the chronic stage of a partial rupture, the prognosis of nonoperative treatment may be worse. It should be stressed that in this rare condition, there are no prospective comparative data between operative and conservative treatment in the literature. Baxter and Thigpen (9) stress that a complete release of the plantar fascia may be harmful in a competitive athlete and prolongs recovery time; however, this statement is not supported by McElgun and Cavaliere (10) and Leach, Jones, and Silva (3). Christel et al. (4) reported 19 cases of surgically treated ruptures, of which 18 cases occurred during sports activities. In 17 cases MRI showed the lesion of the plantar fascia. Surgical treatment was performed with excision of excessive scar tissue and release of the plantar fascia with successful results. All patients were VOLUME 36, NUMBER 2, 1997

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fibromatosis, and a rupture of the plantar fascia was discovered intraoperatively. There is a risk of focal necrosis of collagenous tissue from cortisone injections, predisposing tendon and fascia rupture, as shown in rabbits (6). It may also be debated whether there is any rationale for treatment of a partial or complete rupture of the plantar fascia with cortisone. Conversely, in plantar fasciitis, cortisone injections are frequently used, and the literature lacks reports of degenerative ruptures following this treatment (13). Additional basic studies are needed to examine the relationship of cortisone injections to degeneration and ruptures. Conclusion

FIGURE 3 Sagittal (TRITE 780/20) magnetic resonance image of the medial/plantar fascia rupture suggested by the thickening and partial loss of low signal in the proximal part of the plantar fascia, as well as a partial disruption of continuity in the fascia.

relieved of pain, and had an average follow-up time of 18 months. They recommended, similar to Leach et al. (3), excision of all macroscopically pathologic tissues to avoid reestablishment of continuity with the calcaneus and persistence of scar tissue, that may be considered as a cause of pain. This may well be the case in our female patient, in whom endoscopy allowed visualization only to release the insertion of the medial plantar fascia, as recommended by Lester and Buchanan (5) and Snider, Clancy, and McBeath (11). Poux et al. (12) reported the largest series of 30 patients, of whom 10 were treated operatively. Unfortunately, no randomization of treatment was performed. Diagnosis is a key factor. One of our patients gave a history of ankle sprain 5 weeks earlier and a reinjury 4 weeks later, which in both cases might have produced partial ruptures, because no complaints or clinical signs referred to the ankle joint. Clinical examination is based on knowledge of this rare condition, which is not always obvious. Pai (13) reported a degenerative rupture in a 72-year-old man after he received a cortisone injection to treat a suspected condition of plantar fasciitis. This treatment provided extended relief of symptoms. Six months after this injection the patient lost his footing on the steps and fell on the back of his foot. He experienced pain similar to what he had previously reported, and was provided another cortisone injection. Fourteen months later he was referred to surgery with the diagnosis of plantar

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A total or partial plantar fascia rupture should be suspected when a patient, referring to a definite injury, presents a tender lump in the sole. MRI confirms this diagnosis. In the acute total rupture, conservative treatment with arch supports works well. Surgical treatment with release and excision of scar tissues has previously resulted in successful pain relief in the chronic partial rupture. An endoscopic procedure may not be optimal in the chronic stage. The literature provides no comparative data on operative or conservative treatment. References 1. Rodineau, J. Vulnerabilite du pied au cours des activities sportives. J. Traumato!. Sport 8:1-3, 1991. 2. James, S., Bates, B., Osternig, L. Injuries to runners. Am. J. Sports Med. 6:40-50, 1978. 3. Leach, R, Jones, R, Silva, T. Rupture of the plantar fascia in athletes. J. Bone Joint Surg. 60A:537-539, 1978. 4. Christel, P., Rigal, E, Poux, D., Roger, B., Witvoet, J. Surgical treatment of rupture of the plantar fascia. Rev. Chir. Orthop. 79:218-225, 1993. 5. Lester, D., Buchanan, J. Surgical treatment of plantar fasciitis. Clin. Orthop. 186:202-204, 1984. 6. Balasubramanian, P., Prathab, K. The effects of injection of hydrocortisone into rabbit calcaneal tendons. J. Bone Joint Surg. 54B:729-734,1972. 7. Phelps, D., Sonstegard, D., Mathews, L. Corticosteroid injection effects on the biomechanical properties of rabbit patellar tendons. Clin. Orthop. 100:345-348, 1974. 8. Herrik, R, Herrik, F. Rupture of the plantar fascia in middle aged tennis player. A case report. Am. J. Sports Med. 11:95-96, 1983. 9. Baxter, D., Thigpen, C. Heel pain: operative results. Foot Ankle 5:16-21, 1984. 10. McElgun, T., Cavaliere, R Sequential bilateral rupture of plantar fascia in a tennis player. Sports Med. 84:137-141, 1994. 11. Snider, M., Clancy, W., McBeath, A. Plantar fascia release for chronic plantar fasciitis in runners. Am. J. Sports Med. 11:215219,1983. 12. Poux, D., Christel,P., Demarais, Y., Parier, J., Roger, B., Viel, E. Les ruptures de laponevrose plantaire. J. Traumato!. Sport 6:77-87, 1989. 13. Pai, V. Rupture of the Plantar Fascia. J. Foot Ankle Surg. 35:39-40, 1996.

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