Plantar Fasciitis

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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, shockwave therapy, iontophoresis, night splints, joint mobilization, and surgery. 

Differential Diagnosis

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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 Young et al, they described an impairment-based physcial therapy treatment approach for 4 patients with plantar heel pain.

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