Plantar Fasciitis

This page is currently under construction as part of an EIM project. Please do not edit, but please come back in the near future to check out new information!!

Original Editor - Brooke Kennedy

Lead Editors - Your name will be added here if you are a lead editor on this page.  Read more.

Clinically Relevant Anatomy

Plantar fascitis is a degenerative process that may or may not have inflammatory changes to the plantar fascia.  The plantar fascia originates on the medial tubercle of the calcaneous and fans out to the flextor tendon sheaths to form the longitudinal arch.  It's main purpose is to provide support and act as a shock absorber.

Mechanism of Injury / Pathological Process

The most common of injury is overuse such as running, jobs with prolonged standing, etc which allow for repetative micro trauma to the fascia.  B Young et al reported in 2004 that some other causes may include biomechanical derangements, inflammatory arthritis, stress fractures, and nerve.  According to the research, some common risk factors include obesity, an occupation with prolonged standing, heel spurs, pes planus, and decreased dorsiflexion.

Clinical Presentation

• Heel pain with first steps in the morning or after long periods of non-weight bearing
• Tenderness to the anterior medial heel
• limited dorsiflexion and tight achilles tendon
• a limp may be present or may have a preference to toe walking
• pain is usually worse when barefoot on hard surfaces and with stair climbing
• many patients may have had a sudden increase in their activity level prior to the onset of symptoms

Diagnostic Procedures

Currently there are no special tests or test item clusters for diagnosing plantar fascitis.  A diagnosis is generally made with regard to the symptoms present such as described above.  X-rays and ultrasonagraphy are also being used to help assess degenerative changes and x-rays help detect heel spurs which may or may not be present.  Ultrasonography is used to measure plantar fascia thickness, which is reported to be thicker in patients diagnosed with plantar fascitis according to a study by Wall. 

Outcome Measures

The FAAM, or Foot and Ankle Ability Measure, is a good outcome measure to give to patients that are diagnosed with plantar fascitis. 

A few studies have also used the Foot Function Index but only the the pain subscale.  It is a validated measure, and the first 7 items of the pain subscale are used as the primary numeric outcome measure. Items are scored from 0 (no pain) to 10 (worst pain imaginable) depending on the mark on the visual analog scale.  The sum of the 7 items is then expressed as a percentage of maximum possible score, ranging in an overall percentage

Management / Interventions

The most common treatments include stretching of the gastroc/soleus/plantar fascia, orthotics, taping, ultrasound, iontophoresis, night splints, joint mobilization, and surgery. 

Differential Diagnosis

add text here relating to the differential diagnosis of this condition

Key Evidence

According to a prospective, randomized controlled trial by DiGiovanni, stretching can be an appropriate treatment for plantar fascitis as long as it is specific stretching. He compared patients who received either a plantar-fascia tissue-stretching program compared to patients who received an achilles tendon stretching program. The plantar fascia stretching consisted of one stretch to be performed before taking their first step in the morning. The patient crossed the affected leg over the contralateral leg and used the fingers across to the base of the toes to apply pressure into toe extension until a stretch was felt along the plantar fascia. In the achilles-tendon stretching group, the stretch was performed in a standing position and to be performed immediately after getting out of bed in the morning. A shoe insert was placed under the affected foot, and the affected leg was placed behind the contralateral leg with the toes pointed forward. The front knee was then bent, keeping the back knee straight and heel on the ground. Both stretches for both groups were to be held 10 secondes for 10 repetitions, 3 times a day. The results indicated that both groups improved but the planta fascia specific stretching was superior. The protocol was linked to the use of dorsiflexion night splints that incorporate toe dorsiflexion, but reported the stretching program had advantages over night splints. 

In a case series by B Young et al, they described an impairment-based physcial therapy treatment approach for 4 patients with plantar heel pain. All patients received manual therapy, consisting of posterior talocrural joint mobs and subtalar joint distraction manipulation, in combination with calf-stretching, plantar fascia stretching, and self-anterior-posterior ankle mobilization as a home program.  They demonstrated complete pain relief and full return to activities with an average of 2-6 treatments per case. 

Pfeffer G, Bacchetti P, Deland J et al. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int. 1999 Apr;20(4):214-21.

Abstract
Fifteen centers for orthopaedic treatment of the foot and ankle participated in a prospective randomized trial to compare several nonoperative treatments for proximal plantar fasciitis (heel pain syndrome). Included were 236 patients (160 women and 76 men) who were 16 years of age or older. Most reported duration of symptoms of 6 months or less. Patients with systemic disease, significant musculoskeletal complaints, sciatica, or local nerve entrapment were excluded. We randomized patients prospectively into five different treatment groups. All groups performed Achilles tendon- and plantar fascia-stretching in a similar manner. One group was treated with stretching only. The other four groups stretched and used one of four different shoe inserts, including a silicone heel pad, a felt pad, a rubber heel cup, or a custom-made polypropylene orthotic device. Patients were reevaluated after 8 weeks of treatment. The percentages improved in each group were: (1) silicone insert, 95%; (2) rubber insert, 88%; (3) felt insert, 81%; (4)stretching only, 72%; and (5) custom orthosis, 68%. Combining all the patients who used a prefabricated insert, we found that their improvement rates were higher than those assigned to stretching only (P = 0.022) and those who stretched and used a custom orthosis (P = 0.0074). We conclude that, when used in conjunction with a stretching program, a prefabricated shoe insert is more likely to produce improvement in symptoms as part of the initial treatment of proximal plantar fasciitis than a custom polypropylene orthotic device.

Gudeman SD, Eisele SA, Heidt RS et al. Treatment of plantar fasciitis by iontophoresis of 0.4% dexamethasone: a randomized, double-blind, placebo-controlled study.  American Journal of Sports Medicine.  1997
Abstract
Plantar fasciitis is a common problem in running sports. This study was undertaken to determine whether iontophoresis of dexamethasone in conjunc tion with other traditional modalities provides more im mediate pain relief than traditional modalities alone. Forty affected feet were randomly assigned to one of two groups. Group I feet were treated with traditional modalities and placebo iontophoresis. Group II feet received the traditional modalities plus iontophoresis of dexamethasone. Both groups were treated six times over 2 weeks. The subjects' clinical course was as sessed using the Maryland Foot Score. At the conclu sion of treatment, Group II patients had significantly greater improvement than Group I patients (increase on Maryland Foot Score of 6.8 ± 5.6 for Group II and 3.1 ± 4.1 for Group I). However, at followup 1 month after completion of treatment there was no significant difference between groups (increase of 5.6 ± 8.0 for Group I and 7.4 ± 6.3 for Group II). These results suggest that although traditional modalities alone are ultimately effective, iontophoresis in conjunction with traditional modalities provides immediate reduction in symptoms. Based on these results, iontophoresis of dexamethasone for plantar fasciitis should be considered when more immediate results are needed (i.e., performance athletes and active patients). 

Osborne HR, Allison GT. Treatment of plantar fasciitis by LowDye taping and iontophoresis: short term results of a double blinded, randomised, placebo controlled clinical trial of dexamethasone and acetic acid. Br J Sports Med. 2006 Jun;40(6):545-9; discussion 549. Epub 2006 Feb 17.

OBJECTIVES: To determine if, in the short term, acetic acid and dexamethasone iontophoresis combined with LowDye (low-Dye) taping are effective in treating the symptoms of plantar fasciitis. METHODS: A double blinded, randomised, placebo controlled trial of 31 patients with medial calcaneal origin plantar fasciitis recruited from three sports medicine clinics. All subjects received six treatments of iontophoresis to the site of maximum tenderness on the plantar aspect of the foot over a period of two weeks, continuous LowDye taping during this time, and instructions on stretching exercises for the gastrocnemius/soleus. They received 0.4% dexamethasone, placebo (0.9% NaCl), or 5% acetic acid. Stiffness and pain were recorded at the initial session, the end of six treatments, and the follow up at four weeks. RESULTS: Data for 42 feet from 31 subjects were used in the study. After the treatment phase, all groups showed significant improvements in morning pain, average pain, and morning stiffness. However for morning pain, the acetic acid/taping group showed a significantly greater improvement than the dexamethasone/taping intervention. At the follow up, the treatment effect of acetic acid/taping and dexamethasone/taping remained significant for symptoms of pain. In contrast, only acetic acid maintained treatment effect for stiffness symptoms compared with placebo (p = 0.031) and dexamethasone. CONCLUSIONS: Six treatments of acetic acid iontophoresis combined with taping gave greater relief from stiffness symptoms than, and equivalent relief from pain symptoms to, treatment with dexamethasone/taping. For the best clinical results at four weeks, taping combined with acetic acid is the preferred treatment option compared with taping combined with dexamethasone or saline iontophoresis.

Cole C, Seto C, Gazewood J. Plantar fasciitis: evidence-based review of diagnosis and therapy.  Am Fam Physician. 2005 Dec 1;72(11):2237-42.
Plantar fasciitis causes heel pain in active as well as sedentary adults of all ages. The condition is more likely to occur in persons who are obese or in those who are on their feet most of the day. A diagnosis of plantar fasciitis is based on the patient's history and physical findings. The accuracy of radiologic studies in diagnosing plantar heel pain is unknown. Most interventions used to manage plantar fasciitis have not been studied adequately; however, shoe inserts, stretching exercises, steroid injection, and custom-made night splints may be beneficial. Extracorporeal shock wave therapy may effectively treat runners with chronic heel pain but is ineffective in other patients. Limited evidence suggests that casting or surgery may be beneficial when conservative measures fail.

Resources

add appropriate resources here

Case Studies

add links to case studies here (case studies should be added on new pages using the case study template)

Recent Related Research (from Pubmed)

Failed to load RSS feed from http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1houoX_LGC305ro2l-cEh_uDPlVE-LuIbL2pcsEP2W6Il42kL|charset=UTF-8|short|max=10: Error parsing XML for RSS

References

References will automatically be added here, see adding references tutorial.