A Closer Look At A New Algorithm For Treating Plantar Fasciitis

Author(s): 
By Babak Baravarian, DPM, and Bora Rhim, DPM

In the United States, at least 10 percent of the population experiences heel pain secondary to plantar fasciitis. Reportedly, 600,000 outpatient visits to medical professionals a year are due to plantar fasciitis.1 According to a 2003 study, plantar fasciitis frequently occurs in people who are on their feet most of the day, those who are obese and those who have limited ankle dorsiflexion.2

However, it is important to recognize that all heel pain symptoms do not stem from plantar fasciitis. There are many different etiologies for heel pain and making the correct diagnosis becomes crucial in determining the right treatment course for the patient.

Usually, when one obtains a proper history and conducts the physical exam, it is easy to distinguish a case of plantar fasciitis among patients with heel pain. The pain is mostly caused by acute or chronic injury to the origin of the plantar fascia from cumulative overload stress. The pain is usually medial and inferior to the heel, starts in the morning with the initial step and the patient experiences extreme tenderness with palpation. Patients may describe throbbing pain that occurs after periods of inactivity.

In the physical examination, one should assess dorsiflexory range of motion of the ankle, palpate the medial inferior of the heel and evaluate the angle and base of gait.

Since neurologic, soft tissue, skeletal and systemic conditions can cause heel pain, it is necessary to have high index of suspicion when seeing patients with heel pain. There are many different etiologies of heel pain. Accordingly, the differential diagnosis for heel pain includes:

• local inflammatory plantar heel
• pain/mechanical heel pain
• plantar fasciitis
• plantar heel pain
• nerve entrapment syndromes
• calcaneal branch neurodynia
• tarsal tunnel syndrome
• Baxter’s neuritis
• lumbar spine disorders
• calcaneal bone cyst
• aneurysmal bone cyst
• unicameral bone cyst
• interosseous lipoma
• calcaneal stress fractures
• systemic inflammatory plantar heel pain
• rheumatoid arthritis
• seronegative spondyloarthropathy
• ankylosing spondylitis
• psoriatic arthritis
• Reiter’s syndrome

What About Diagnostic Imaging?
Diagnostic imaging is very helpful in diagnosing plantar fasciitis. Imaging is also strongly recommended if one suspects other diagnoses. Ultrasound is a helpful modality in determining the thickness of the plantar fascia. According to one ultrasound study, the plantar fascia was significantly thicker in the heels of symptomatic patients with plantar fasciitis (3.2-6.8 mm with a mean of 5.2 mm) in comparison to their asymptomatic heels (2.0-4.0 mm with a mean of 2.9 mm), and in comparison to the heels of the patients in the control group (1.6-3.8 mm with a mean of 2.6 mm).3

On the lateral radiograph, calcifications in the soft tissue on the anterior calcaneus may be present. However, 50 percent of symptomatic patients and up to 19 percent of asymptomatic patients have heel spurs.4 The presence of a heel spur is not a definitive diagnosis of plantar fasciitis and this is a very important fact to emphasize to patients. A bone scan can show increased uptake in the body of the calcaneus in cases of stress fracture. Magnetic resonance imaging (MRI) can show thickening of the plantar fascia, soft tissue lesions within the body of the calcaneus or a space-occupying lesion in the medial ankle that may cause tarsal tunnel syndrome.

Other Pertinent Pointers
Treating patients with plantar fasciitis is rewarding because most patients’ symptoms improve with conservative treatment alone. In a recently published study, after four years, 80 percent of patients with plantar fasciitis had complete resolution of pain with conservative treatment alone.5 Usually when the plantar fasciitis symptoms have persisted for greater than six months to one year, conservative care is less successful due to the increase in scar tissue and a loss of blood flow to the fascia region. This results in a new diagnosis called plantar fasciosis.

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