Plantar fasciitis is certainly one of the most common conditions we see in podiatric practice and more than 90 percent of patients are cured with conservative treatment.1 It sounds relatively simple. Well, in order to consistently facilitate successful outcomes, not only must one have a strong anatomical understanding of the plantar fascia, there must also be a strong command of the various causes of the condition, key diagnostic indicators and when to apply various treatment solutions in the armamentarium. The current thinking is that plantar fasciitis is a chronic degenerative/reparative process secondary to stress overload with an insidious onset of weeks to months.2 Histologic studies confirm this etiology, with findings of fascia microtears, collagen necrosis, chondroid metaplasia and angiofibroblastic hyperplasia. This could explain why the syndrome is found in both overweight and active individuals.2 Overuse and over-training can contribute to the cause of plantar fasciitis.3,4 Any motion of the foot that puts excessive pull on the plantar fascia at the calcaneus will be a factor in the development of plantar fasciitis.5 Inflammation of the plantar fascia is more often seen in females and people of middle age.6 Contracture of the intrinsics, especially the flexor digitorum brevis, can be a predisposing factor for this condition.6 Often, you will find that those with plantar fasciitis have a history of exercising or working on hard, unyielding surfaces or are on their feet for prolonged periods of time.3,7 Improper conditioning can also be a factor as tight Achilles/hamstring tendons or ankle equinus may cause excessive pull on the plantar fascia.3 Improper shoes that bend in the wrong place, are too wide, have soft heel counters and/or do not have enough support can cause plantar fasciitis.3 Excessive shoe wear is also a common culprit in causing this condition.3 There are two typical kinds of patients that present with heel pain syndrome. You may see a fair number of middle-aged, overweight patients who work in jobs that require prolonged standing on hard unyielding surfaces.8 You will also see long-distance runners presenting with heel pain and they will usually report a recent change in their training routine, such as a rapid increase in mileage, running up steep hills, using athletic shoes from last season or using the shoes for longer than six months or 400 miles.9,10 The condition can have structural causes as well. Having a pes planus or pes cavus foot can be the root cause of heel pain.11 Indeed, the following foot types are associated with plantar fasciitis: uncompensated rearfoot varus, partially compensated rearfoot varus, partially compensated forefoot varus, compensated forefoot varus, forefoot supinatus, flexible forefoot valgus, rigid forefoot valgus, compensated congenital gastrocnemius equines or compensated transverse plane deformity.11 Limb length discrepancy may also cause plantar fasciitis in the long limb.12 A Primer On The Differential Diagnosis The differential diagnosis for plantar fasciitis is large and varied. The various possibilities include: faulty foot structure, fascial strain or rupture, stress fracture, subcalcaneal bursitis, tarsal tunnel syndrome, nerve entrapment radiculopathy and peripheral nerve compression “double crush,” neuroma, fat pad atrophy, systemic arthritis (such as gout), rheumatoid arthritis and the various seronegative arthridities, tendonitis of the first layer of the plantar musculature or quadratus plantae, infection, plantar fibromatosis or Dupuytren’s contracture and posterior heel pathology.4,8,11-13 Evaluating plantar fasciitis is fairly straightforward most of the time. Patients present with post-static dyskinesia or pain in the heel after rising from prolonged sitting or lying. They usually have this pain after getting out of bed in the morning.3 Runners may experience heel pain at the beginning of the run with the pain decreasing during the run and increasing after the run.3 Usually, these patients will describe a progressive and gradual onset of pain with no history of injury or trauma.4,8 However, patients may relate a history of long periods of weightbearing or heavy labor, often on hard surfaces.8 What You May Note During The Physical Exam Upon the physical examination, you will find that pain is usually localized to the plantar medial aspect of the foot.14 The patients will usually have a deep tender pain and for some, the pain will radiate into the arch. Few patients will complain of numbness or tingling in the sole of the foot.13 However, there is usually pain along the plantar fascia, especially at its connection to the heel bone.3 In addition to possible swelling and warmth, you may notice increasing pain with ankle joint dorsiflexion as the plantar fascia stretches.3 Check for decreased ankle dorsiflexion.13 The patient may experience increased pain with toe extension.4 When evaluating the gastroc-soleus complex (Achilles tendon), you will invariably notice a loss of motion with passive dorsiflexion. One should perform this test with the knee extended (gastroc-soleus) and with the knee flexed to 90 degrees (soleus only). Less than 9 degrees of dorsiflexion is consistent with Achilles tendon contracture.10 You should also check the plantar fascia for tears or lumps as well as thickness and shifting.3,14 Also observe for obesity and gross orthopedic deformity.15 One of the more important tests is to compress the heel bone from side to side to rule out stress fracture.3 The classic test involves cupping both hands around the posterior heel and applying side compression to the walls of the calcaneus with the palms of your hands. This helps to recreate the patient’s pain.10 Patients with stress fractures usually present with edema along the medial and lateral calcaneal walls.13 Ascertain the quality of motion of the ankle, subtalar, midtarsal and first metatarsophalangeal joints.14 If you note stiffness in multiple joints, the diagnosis may be rheumatic in origin.10 Proceed to evaluate the patient’s foot structure and assess his or her muscle strength and tone.14 What The Diagnostic Imaging And Other Tests May Reveal Obtain X-rays to assess biomechanical considerations and rule out unusual problems like cysts, spondylopathy, stress fracture and/or coalitions.3 The presence of a positive technetium scan may indicate more intense pain refractory to treatment.16 Test for Tinel’s or Valleix’s sign at the posterior tibial nerve and perform a straight leg test to rule out radiculopathy and test deep tendon reflexes.14 The calcaneus at the plantar medial tubercle is tender with palpation.13 Consider the following laboratory tests for suspected conditions. One should obtain a SED rate for collagen vascular disease, a CBC for infection, uric acid for gout, a rheumatoid profile for rheumatoid arthritis or other collagen vascular disease and a HLA-B27 for seronegative arthridities.14 One should employ ultrasonography when plantar fascia symptoms persist or when the patient’s clinical presentation is atypical.17 During the ultrasonographic examination, patients can tell you directly whether they still have pain when you palpate the plantar fascia bands.18 Vohra found that the the medial band was involved in 100 percent of plantar fasciitis cases, the central band in 68 percent and the lateral band in 26 percent.18 How And When To Treat Patients Conservatively Normally, you would perform conservative treatment six months before considering surgical intervention. One study found that 89.5 percent of patients achieved resolution of their heel pain within approximately five months.19 Another study found that patients with a higher risk of continued pain were either overweight, had bilateral symptoms or had a prolonged duration of symptoms (greater than six months) prior to seeking medical attention.20 Initial treatment, consisting of RICE (rest, ice, compression, elevation), is directed toward reducing the inflammation of the heel.3 One may use supportive taping with medial arch support to help identify biomechanical causes of heel pain.3,14 Patient compliance factors into the equation. Encourage them to stop walking barefoot as doing so can reduce pain.21 Also be sure to emphasize stretching exercises of the plantar fascia and Achilles/hamstring muscles/tendons.3 If weight is a contributing factor, consider referring the patient to a bariatrics specialist.21,22 Antiinflammatory pills and nonsteroidal or oral corticosteroids will reduce inflammation.3,15 One may also utilize trigger point injections of local short-acting cortisone and hyaluronidase.15 Some mix a short-acting with a long-acting glucocorticoid for injection and some use their injection with ultrasound. Some emphasize an Unna boot after giving this injection. Physical therapies include deep massage, ultrasound, iontophoresis, interferential stimulation, whirlpool and ice treatments.3,14 You may utilize various appliances such as heel lifts, heel cups, horseshoe pads and silicone rubber inserts.3,15 Another option is using posterior night splints or the Strassburg Sock.15 Emphasizing Activity Modification And More Supportive Footwear When treating athletes with plantar fasciitis, you should encourage them to train on softer surfaces or shift their training to nonweightbearing sports.15 A modification of activity might consist of biking or swimming. For the serious runner, activity modification means reducing mileage, decreasing velocity, cross training, eliminating speed work and correcting training errors such as failing to stretch before hill workouts.23 Also be sure to have these runners decrease the level of intensity and reduce distance, speed and hills until they are completely healed. It’s also essential to get patients in proper shoes with good heel support and rigid heel counters.23 Shoes with a higher density material on the medial aspect of the rear midsole are anti-pronatory.24 Stiff soles and a firm heel counter help stabilize the foot and provide a secure platform for orthotic devices whereas a 1-inch heel or western-style boots distribute weight to the forefoot.15 Shoes with a rocker bottom and steel shank compensate for ankle equinus.25 Have them replace worn shoes because they do not support or cushion the foot.3 Emphasizing stander’s mats and foot bars may help treat fatigue while temporary orthotics can be employed to reduce tension. Custom orthotics can be useful in assisting with foot function.3 An orthotic with a fascial groove and a cushioned top cover is recommended when you’re dealing with a pes cavus foot or a prominent fascia.4 Finally, when you are dealing with recalcitrant cases, you may want to emphasize nonweightbearing casting.14 After six months of conservative therapy, consider extracorporeal shockwave therapy or surgical treatment. A Treatment Paradigm For Resolving Plantar Fasciitis Patients may have pain after conservative treatment and different levels of pain warrant different remedies. Using a pain scale of one to 10 with 10 being the worst, the author maps out what treatment options you should consider for each visit. Initial visit • X-rays to rule out rearfoot pathology • Strassburg sock • Antiinflammatory pill • Consider a cortisone injection • Taping • RICE after activity • Massage plantar fascia with tennis ball prior to standing • Activity alteration • Stretching • Proper shoe gear • Elimination of barefoot walking • Healthy Weight loss referral PRN • Patient education Second visit (two weeks after treatment) • If pain is greater than or equal to five, continue current therapies and refer the patient to physical therapy • If pain is greater than three, consider a second cortisone injection, stander’s mat and foot bar PRN. Continue and evaluate therapies. • If pain is less than or equal to three, evaluate therapies. • If pain is greater than zero, proceed with a biomechanics evaluation. Use a prefab orthotic or cast for custom orthotics as per your biomechanics exam. Third visit (five weeks after treatment) • If pain is greater than five, continue current therapies and evaluate the effectiveness of continued physical therapy. • If pain is greater than three, offer a third and final cortisone injection, and continue to evaluate current therapies. • If pain is less than or equal to three, evaluate current therapies. • Dispense custom orthotics. • Provide patient education regarding orthotics and shoe therapies. Fourth visit (two months after treatment) • If pain is greater than five, continue current therapies and evaluate the effectiveness of continued physical therapy. • If pain is greater than three, continue current therapies and recommend a night splint. • If pain is less than or equal to three, evaluate current therapies. • Evaluate orthotics and shoe therapies. • Check for compliance with self care instructions. Fifth visit (three months after treatment) • If pain is greater than five, continue current therapies and then consider a transition into a weightbearing, below-the-knee cast. • If pain is greater than three, continue and evaluate therapies, and consider a below-the-knee cast. • If pain is less than or equal to three, evaluate current therapies. • If pain is zero, discontinue therapies except orthotics. • Evaluate orthotics and shoe therapies. • Pursue imaging studies and test for arthridities. Sixth visit (3.5 months after treatment) • If pain is greater than five, continue current therapies and consider a nonweightbearing cast. • If pain is greater than three, continue to evaluate current therapies and consider a weightbearing cast. • If pain is less than or equal to three, evaluate current therapies. • If pain is zero, discontinue therapies except orthotics. • Evaluate imaging studies and tests for arthridities and make appropriate referrals. Seventh visit (4.5 months after treatment) • If pain is greater than five, continue current therapies and provide patient education concerning shockwave therapy and surgical options. • If pain is greater than three, continue current therapies. • If pain is less than or equal to three, evaluate current therapies. • If pain is zero, discontinue therapies except orthotics. • Discontinue BK casting if it is ineffective. Eighth visit (six months after treatment) • Evaluate failed conservative care. • Reserve surgical intervention for intractable cases, those cases in which conservative measures have failed for a minimum of six and perhaps as long as 12 months.23 Recommending Stretching And Footwear To Patients According to the literature, up to 90 percent of patients with plantar fasciitis are cured with conservative treatment. Patients can also play an active role in resolving the condition. Be sure to remind patients about the potential benefit of stretching exercises and emphasize other things they can do to resolve the pain. Here are some recommendations you may pass on to patients … • Run your foot up and down the opposite shin while curling your toes about the shin. Repeat this three times in a row, three times a day. Do not stretch to the point of pain. • Stand at arm’s length from a table or wall with your back knee locked and your front knee bent. Gently, without bouncing, lean toward the table or wall until you feel a stretch in the tendons of both legs. Hold the stretch for 30 seconds. Change legs and stretch again. Keep your heels on the floor. Repeat the stretch three times in a row, three times a day. Do not stretch to the point of pain. • Stand on a step and maintain your balance on the balls of your feet with your heels hanging over the step. Gently, without bouncing, lower your heels as far as you can. Feel the stretch in your Achilles tendon. Hold the stretch for 10 seconds. Repeat 20 times. Do not stretch to the point of pain. • With the knee straight and a towel around the forefoot, pull the foot up. Do this in the morning before getting out of bed. Move the foot in circles before arising in the morning or after prolonged rest. • Massage your heel and plantar fascia by rolling a tennis ball under the foot. • When obtaining new shoes, make sure they: are cushioned at the sole of the heel; have a rigid heel counter; fit correctly (not too wide); offer good support; and have a removable insole. Often, an athletic shoe will meet these requirements. Shoes also can have a 1-inch heel and a stiff sole. A high arched foot needs a cushioned shoe. An average arch or mold pronator needs a stability shoe. If your patient is a heavy pronator or has excessive weight, he or she needs a motion control shoe. John Mozena, DPM, is board-certified and is a Fellow of the American College of Foot and Ankle Surgeons. He has a private practice at the Town Center Foot Clinic in Portland, Ore. CE Exam #114 Choose the single best response to each question listed below: 1. Less than ___ degrees of dorsiflexion is consistent with Achilles tendon contracture. a.) 5 b.) 9 c.) 10 d.) 6 2. Which patients have a higher risk of continued heel pain despite conservative treatment efforts? a.) patients who are overweight b.) patients with bilateral symptoms c.) patients with a prolonged duration of symptoms (greater than six months) prior to seeking medical attention d.) all of the above 3. One should employ ultrasonography or a MRI when … a.) plantar fascia symptoms persist b.) ruling out unusual problems such as cysts and spondylopathy c.) the patient’s clinical presentation is atypical d.) a and c 4. In a study, Vohra found that the … a.) medial band was involved in 68 percent of plantar fasciitis cases b.) lateral band was involved in 20 percent of plantar fasciitis cases c.) central band was involved in 68 percent of plantar fasciitis cases d.) none of the above 5. When recommending activity modification for serious runners with plantar fasciitis, which recommendation would you not give them? a.) increase mileage gradually b.) eliminate speed work c.) decrease the level of intensity d.) emphasize cross training 6. Which of the following foot types are associated with plantar fasciitis? a.) uncompensated rearfoot varus b.) forefoot supinatus c.) compensated forefoot varus d.) all of the above 7. Patients with plantar fasciitis may be advised to get new shoes. Which shoe is best for the high arched foot? a.) stability shoe b.) motion control shoe c.) cushioned shoe d.) none of the above 8. Compressing the heel bone from side to side helps you rule out … a.) a stress fracture b.) plantar fasciitis c.) radiculopathy d.) none of the above 9. Initial treatment for heel pain … a.) consists of rest, ice, compression and elevation b.) is directed toward reducing inflammation c.) would include shockwave therapy among other options d.) a and b Instructions for Submitting Exams Fill out the postage-paid card that appears on the following page or log on to www.podiatrytoday.com and respond electronically. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam. Responses will be accepted up to 12 months from the publication date.
References1. Myerson MS. Foot and Ankle Disorders. Philadelphia, WB Saunders Co., 2000, p 838.2. http://www.medscape.com/viewarticle/408477_3.3. Bernard MA, et. al. Review Text in Podiatric Orthopedics and Primary Podiatric Medicine, Fresno, American College of Foot & Ankle Orthopedics & Medicine, 1997, p 233,234.4. Olaff LM. Musculoskeletal Disorders of the Lower Extremities. Philadelphia, WB Saunders Co. 1994, p 240,241.5. Dorland I. Dorland’s Illustrated Medical Dictionary 27th Edition. Philadelphia, WB Saunders, pg 835. 6. Barry LD, et. al. A Retrospective Study of Standing Gastrocnemius-Soleus Stretching versus Night Splinting in the Treatment of Plantar Fasciitis. The Journal of Foot & Ankle Surgery, 41(4): 225, 20027. Strash WW, et. al. Extrcorpeal shockwave therapy for chronic proximal plantar fasciitis. Clinics in Podiatric Medicine and Surgery,19(4):470, 20028. McGlamry, E. Dalton, Comprehensive Textbook of Foot Surgery 2nd Ed. Baltimore, Williams & Wilkins, 1992, p 434.9. Abdo R. http://zipmall.com/mpm-art-heel-fascitis.htm.10. http://www.medscape.com/viewarticle/408477_4.11. Valmassy RL. Clinical biomechanics of the lower extremity. St. Louis, Mosby-Year Book Inc., 1996, p 76. 12. Banks AS, et. al. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Philadelphia, Lippincott Williams & Wilken 2001, 468.13. Banks AS, et. al. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery, Philadelphia, Lippincott Williams & Wilken 2001, 469. 14. Marcinko DE. Medical and Surgical Therapeutics of the Foot and Ankle, Baltimore, Williams & Wilkins, 1992, p 466-469.15. Banks AS, et. al. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery, Philadelphia, Lippincott Williams & Wilken 2001, 471. 16. Banks AS, et. al. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery, Philadelphia, Lippincott Williams & Wilken 2001, 470.17. Vohra PK, et. al. Ultrasonographic Evaluation of Plantar Fascia Bands. JAPMA, 92, 447.18. Vohra PK, et. al. Ultrasonographic Evaluation of Plantar Fascia Bands. JAPMA, 92, 444, 2002.19. Davis PF, et. al. Painful Heel Syndrome: Results of Nonoperative Treatment, Foot & Ankle International, 15(10), p531-535, 1994.20. Wolgin M, et. al. Conservative Treatment of Plantar Heel Pain: Long-Term Follow-Up. Foot & Ankle International, (15)3: 102, 1994.21. Barry LD, et. al. A Retrospective Study of Standing Gastrocnemius-Soleus Stretching versus Night Splinting in the Treatment of Plantar Fasciitis. The Journal of Foot & Ankle Surgery, 41(4): 222, 2002.22. Dorland I. Dorland’s Illustrated Medical Dictionary 27th Edition. Philadelphia, WB Saunders, pg 191. 23. http://www.medscape.com/viewarticle/408477_524. Ross M. Use of the Tissue Stress Model as a Paradigm for Developing an Examination and Management Plan for a Patient with Plantar Fasciitis. JAPMA, 92(9): 504, 2002.25. Myerson MS. Foot and Ankle Disorders. Philadelphia, WB Saunders Co., 2000, p 839.