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Friday, December 31, 2010

Plantar Fascial Tear: Possible Cause of Unresponsive Plantar Heel Pain

Here is a side view of the heel on a Foot MRI showing the plantar fascia attaching under the heel bone and the fat pad under the heel bone with the achilles tendon attaching into the back of the heel bone (calcaneus).

This is a closer image of the same area with a typical thickness of the plantar fascia (a dark black line attaching into and under the heel). The fat pad is normally very white and thick under the heel bone. The muscles begin to show up to the left of the plantar fascial attachment into the heel and always above the plantar fascia.

After seeing what the normal plantar fascia should look like here is my patient Kate with her plantar fascia torn at the attachment into the heel. If you try to follow the black line from the arch where the fascia looks normal towards the heel (to the right), you can see that there is disruption of the black line. The thin black line attaching into the heel is replaced with grayish thick scar tissue. The scar tissue and plantar heel swelling extends downward through the fat layer (where it does not belong) to the plantar skin (at the bottom of your foot. Just looking at this MRI image and you can tell Kate is in alot of pain.

Here is another closer look at the damage produced by this tear on an image closer to the skin on the arch side of the foot. You can see the black line gone over a section from just in front of the heel to an inch or so to the left (into the arch).

Kate never felt the tear, and just thought she had very bad plantar fasciitis. You can only really treat this one way initially, 3 monthes in a removable cast to limit the bend at the toes. After the casting, and only when you are comfortable walking, you can begin to wean out of the cast into some form of supportive orthotic devices to support the arch. Most patients need alot of physical therapy with deep tissue work to break down the scar tissue which always over does it. While you are in the cast, you can do pain free activities (biking, ellyptical as it calms down, some swimming, etc), icing, stretching (pain free), and foot strengthening (crucial, but must be pain free).
     Here are a copy of links that tie into to this article.

Removable Boot with EvenUp


  1. Hello...
    I have a question...
    Which kind of cast do you use?
    How many hours a day do you indicate it?
    Do you remove it to make therapeutic exercises?
    How many time do you indicate the cast?
    In your opinion : Can we you ultrasound as a diagnostic tool? Has it good yield?


    Gerardo Amilivia, MD im PM&R from Uruguay (south america)

    Great effort from you to make this interesting and excellent blog...Go ahead!

  2. Dear Dr Amilivia, Thank you for your kind words. They definitely help me. I have found the removable casts as shown in the blog to be just fine, however, within two weeks of casting and icing 3 times a day, the patient should be relatively assymptomatic (pain scale 1 to 2). If they still have significant symptoms, level 4 or more on the pain scale after 2 weeks, you should consider complete immobilization for a month, then back to the removable cast. Overall, the casting, to create a painfree environment is done for 3 months, although the 4th month can be a weaning out of the cast month.
    For this injury, I like the cast full time, unless sleeping, icing, showering.
    Yes, the cast is removed to do pain free only exercises. This is an explosion area in medicince (the restrengthening of injured body parts),which is started at the time of the injury almost, but must be painfree in the injured area.
    I do not have experience with ultrasound, but it sounds very useful in diagnosis. Probably depends on the skill of the technician.
    Thank you for your questions. It is good to have a friend in Uruguay. Rich Blake

  3. Thanks for the answers
    One more question:
    In the case of a patient who work in a company that requires formal dress, how do you juggling the use of the cast ?
    Do you use it all day? (including job activities)

    best wishes

    Gerardo Amilivia from Uruguay

  4. Dear Dr Amilivia, The goal of the cast is to avoid toe bend which constantly pulls on the plantar fascia. And the cast has so much extra space that added padding to soften the heel if needed can be placed. This being said the goal of treatment for plantar fascial tears is 3 months of pain free existence. If that can be created, and guaranteed, in another type of shoe, like a stiff soled dress shoe, I say go for it. But the cast is complete immobilization and alot of people feel so much more secure and anxiety free. If the patient does very little walking during a work day, I am sure they could have a good chance that they could definitely go part of each work day without the boot. They have to be very honest, as soon as pain develops, put the cast/boot back on. I hope this helps. Rich

  5. very informative. gr8 job. i do have a question, however, if the only method of diagnosis available is x-ray, would this be enough to form a diagnosis? what other methods of diagnosis do u suggest or clinical measures to take?
    lizzy, medical student

  6. Lizzy, Thanks for the question. I will post on the blog tonight October 7th, 2011. Rich Blake

  7. When the patient is in the acute stage from the pain of a fascia tear, is it advisable to use or avoid sleeping with a night splint?

  8. i have a ruptured heel fat pad. will it heal? and how long will it take?


Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.