Current Concepts In The Algorithm For Plantar Fasciitis

Patrick DeHeer, DPM, FACFAS, and Kellie Higgins, DPM

Given the common presentation of heel pain, these authors discuss their stepwise approach to treating plantar fasciitis, focusing on pain reduction and controlling biomechanical abnormalities.

Plantar fasciitis has become a commonplace medical condition. In America, close to 11 percent of all foot complaints are attributed to plantar fasciitis and it causes over 2 million Americans to seek medical attention annually.1,2 Plantar fasciitis can be a self-limiting condition with patients usually having resolution of their symptoms within 10 months in most cases.3 However, this is a frustrating period of time to have discomfort, especially in active patients. Accordingly, let us take a closer look at key considerations in approaching and treating a patient with a chief complaint of heel pain.

   The plantar fascia is a thick, fibrous aponeurosis composed of dense connective tissue. It originates from the medial and lateral tubercle of the calcaneus and inserts into the plantar plate. The plantar fascia provides static support and stabilizes the arch of the foot by plantarflexing the metatarsals during the gait cycle.

   Plantar fasciitis is the inflammation and degeneration of the aponeurosis.4 Chronic overuse due to excessive standing, running or abnormal anatomy or biomechanics leads to an inflammatory process. Plantar fasciitis commonly occurs in patients with equinus, patients who are overweight or older, and those who are on their feet for much of the day. It also arises in active patients who have abnormal foot loading. Some structural deformities that lead to plantar fasciitis include pes planus, overpronation, pes cavus and limb length discrepancies. Some functional deformities causing overuse of the plantar aponeurosis include gastroc and/or soleus tightness or weakness and intrinsic foot muscle weakness.5

   The diagnosis of plantar fasciitis often is based on a good history and physical. Patients will usually have a chief complaint of severe heel pain with the first few steps in the morning or after prolonged sitting or resting (post-static dyskinesia). Many will have a dull ache at the end of the day and pain with excessive walking or standing.

   During the physical exam, palpation over the medial calcaneal tubercle will elicit pain. Palpating the medial band of the plantar fascia while passively dorsiflexing the toes (and thereby activating the windlass mechanism) can also cause discomfort. It is important to note the patient’s foot type as well as the quality of shoe gear. During the physical exam, it is also important to assess for any neurological changes and check for a Tinel or Valleix sign.

   While we often do not use imaging in the diagnosis of plantar fasciitis, one may utilize it to evaluate for a plantar calcaneal spur. Radiographs can be valuable to rule out differential diagnoses including a calcaneal stress fracture, neoplasm and arthritis. However, they are not needed solely to diagnose fasciitis. Magnetic resonance imaging (MRI) can rule out nerve entrapments as well as assess the thickening and changes in consistency in the fascia. One may employ ultrasound to assess the fascia as well but this can be more technically difficult.

Keys To Initial Treatment

After diagnosing a patient with plantar fasciitis, the senior author believes the treatment is a two-step process. The first step is to decrease the patient’s pain level by at least 90 percent. Medrol packs and non-steroidal anti-inflammatory drugs (NSAIDs) can help to achieve this by treating the inflammatory component of the condition.

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