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plantar fasciitis

Etiology: 1) biomechanical disorders a) cavus foot b) planovalgus foot c) tight gastrocnemius-Achilles complex 2) obesity especially a problem for people who stand for long periods of time 3) improper footwear 4) heel fat pad atrophy in individuals > 50 years of age 5) overtraining: repetitive impact of heel strike [3] 6) plantar spurs 7) rheumatoid disease [10] Epidemiology: - most common cause of heel pain in the elderly [2] Pathology: 1) stretching of plantar fascia at its site of calcaneal attachment (medial tuberosity) [2] - during periods of rest, the plantar fascia shortens, resulting in a sudden stretch with the first step manifested as pain that usually diminishes with further steps [3] - an associated factor is ankle equinus, reduction in dorsiflexion of ankle - decreased ankle dorsiflexion causes increased stress on the plantar fascia during walking [3] 2) inflammation, weakening & tearing of fibers [3] 3) heel spur may occur as secondary process Clinical manifestations: 1) inferior heal pain 2) gradual onset 3) burning or aching sensation 4) activities exacerbating plantar fasciitis a) climbing hills or stairs b) standing on toes 5) nocturnal cramps in the toe plantar flexors 6) the foot feels weak 7) pain with the 1st step* 8) point tenderness over the origin of the plantar fascia at the medial process of the calcaneal tubercle 9) passive toe dorsiflexion reproduces the pain* a) palpate plantar surface of foot to ellicit pain points b) posterior heel pain suggests another diagnosis [10] c) dorsiflexion of ankle may be reduced but not painful [3] 10) absence of other signs of inflammation (swelling, erythema, heat) * Not likely a feature of other disorders in differential diagnosis Radiology: 1) plain radiographs of foot & calcaneus: a) indications: 1] symptoms developed acutely (calcaneus fracture suspected) 2] clinical manifestations are atypical 3] the patient is still growing b) heel spur may be present c) weight-bearing films not helpful 2) bone scan can help distinguish plantar fasciitis from calcaneal stress fracture 3) ultrasound may be useful [17] Differential diagnosis: 1) stress fracture of calcaneus a) acute in onset b) tenderness on medial & lateral aspect of heel c) generally visible on plain radiography d) no improvement withh ambulation 2) tarsal tunnel syndrome a) burning pain extending into plantar aspect of toes b) may have positive Tinel's sign at tarsal tunnel 3) Sever's disease 4) neoplasm a) pain often worse or unchanged during rest b) unlikely to improve with treatment of fasciitis 5) arthritis a) gout, rheumatoid arthritis, ankylosing spondylitis, Reiter's syndrome b) joint & bursa swelling is common 6) arterial insufficiency 7) heel pad syndrome 8) Achilles tendonitis (posterior tibial tendonitis) - symptoms worsen with prolonged ambulation 9) tears of the plantar fascia - may be visualized by ultrasonography or magnetic resonance imaging - far less common than plantar fasciitis [3] Management: 1) ice for 20 minutes several times/day especially after weight-bearing activities 2) non-steroidal anti-inflammatory drugs (NSAIDs) for 2-3 weeks 3) relative rest 4) stretching exercises for plantar fascia & Achilles tendon 5) physical therapy 6) heel pad or wedge [3] 7) arch support for pes planus [s9] 8) taping 9) orthotics of limited benefit [6] - custom-made 'total-contact insoles' (insoles molded to the patient's foot) may be of some benefit [14] - foot orthotics offer no advantage over other conservative treatments [16] 10) glucocortiocoid injection a) dexamethasone 4 mg [11] b) benefit at 4 weeks, but not at 8-12 weeks (ultrasound-guided) [11] NNT = 3 c) potential for fat pad atrophy & rupture of plantar fascia 11) night splints to maintain foot in a neutral or less plantar flexed position 12) avoid walking barefoot or in slippers [10] 13) surgery a) failure of 6 months of conservative management b) disability in activities of daily living c) exacerbating activities are considered very important to the patient 14) extracorporeal shock wave therapy [4,5,14] 15) prognosis: 80% resolve spontaneously within 1 year [10]

Related

plantar fascia stretching exercises for plantar fascia

General

fasciitis repetitive strain disorder; repetitive motion disorder; cumulative trauma disorder; overuse syndrome

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 752,814-817
  2. Clyman M. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  3. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004; - Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010 - Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  4. Journal Watch 22(9):73, 2002 Rompe JD et al Evaluation of low-energy extracorporeal shock-wave application for treatment of chronic plantar fasciitis. J Bone Joint Surg Am 84:335, 2002 PMID: 11886900
  5. Rompe JD et al Shock wave application for chronic plantar fasciitis in running athletes. A prospective, randomized, placebo- controlled trial. Am J Sports Med. 31(2): 268-75 , 2003 PMID: 12642264
  6. Landorf KB et al, Effectiveness of foot orthoses to treat plantar fasciitis: A randomized trial. Arch Intern Med 2006; 166:1305 PMID: 16801514
  7. DiGiovanni BF et al, Plantar fascia-specific stretching exercise improves outcome in patients with chronic plantar fasciitis: A prospective trial with two-year follow-up. J Bone Joint Surg Am 2006, 88:1775 PMID: 16882901
  8. Cole C et al, Plantar Fasciitis: Evidence-based review of Diagnosis and Therapy American Family Physician 2005, 72:2237 PMID: 16342847 http://www.aafp.org/afp/20051201/2237.html
  9. Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 17,19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2021
  10. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
  11. McMillan AM et al Ultrasound guided corticosteroid injection for plantar fasciitis: randomised controlled trial BMJ 2012;344:e3260 PMID: 22619193 http://www.bmj.com/content/344/bmj.e3260
  12. Young C. In the clinic. Plantar fasciitis. Ann Intern Med. 2012 Jan 3;156(1 Pt 1): PMID: 22213510
  13. Goff JD1, Crawford R. Diagnosis and treatment of plantar fasciitis. Am Fam Physician. 2011 Sep 15;84(6):676-82. PMID: 21916393
  14. Gollwitzer H et al. Clinically relevant effectiveness of focused extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: A randomized, controlled multicenter study. J Bone Joint Surg Am 2015 May 6; 97:701 PMID: 25948515 http://jbjs.org/content/97/9/701 - Oliveira HAV et al. Effectiveness of total contact insoles in patients with plantar fasciitis. J Rheumatol 2015 May; 42:870 PMID: 25774062 http://www.jrheum.org/content/42/5/870
  15. Muth CC Plantar Fasciitis JAMA. 2017;318(4):400 PMID: 28742914 http://jamanetwork.com/journals/jama/fullarticle/2645108
  16. Rasenberg N, Riel H, Rathleff MS et al Efficacy of foot orthoses for the treatment of plantar heel pain: a systematic review and meta-analysis. British J Sports Med. 2018 PMID: 29555795 http://bjsm.bmj.com/content/early/2018/02/23/bjsports-2017-097892
  17. Argerakis NG, Positano RG, Positano RC et al. Ultrasound diagnosis and evaluation of plantar heel pain. J Am Podiatr Med Assoc. 2015;105(2):135-140 PMID: 25815653 https://japmaonline.org/view/journals/apms/105/2/0003-0538-105.2.135.xml