An Evidence-Based Medicine Approach To Plantar Fasciitis

Allen Jacobs, DPM, FACFAS

   Although both excessive pronation and supination are suggested causes of plantar heel pain, Riberio and coworkers demonstrated that there was no difference in hindfoot alignment in runners with or without plantar fasciitis although runners with plantar fasciitis tended to have higher arches.12 Studies have demonstrated decreased ankle joint dorsiflexion to be present in many patients with plantar fasciitis.13,14 This reinforces the role of dorsiflexion exercises, night splints or gastrocnemius recession in the treatment of plantar fasciitis. Multiple studies have demonstrated the successful use of night splints for the treatment of plantar fasciitis and reduction of ankle equinus.15,16 Similarly, stretching of the gastrocnemius and the plantar fascia can reduce pain and activity restriction.17,18

Key Diagnostic Insights

In addition to ensuring a thorough patient history and clinical examination, one may utilize a variety of diagnostic imaging techniques for the evaluation of plantar fasciitis. These include radiographs, ultrasound, magnetic resonance imaging (MRI), scintigraphy and elastography.

   In several studies, researchers have found that increased plantar fascia thickening with diffuse hypoechogenicity is associated with symptomatic plantar fasciitis, particularly when the plantar fascia is greater than 4.0 mm.19,20 Studies of intra-observer reliability utilizing ultrasound for the diagnosis of plantar fasciitis, even by experienced sonographers, have suggested that reliability increases when clinicians use an average of three separate measurements rather than one.21 Researchers have also noted that changes in thickness greater than 0.6 mm represent true thickening of the plantar fascia.21

   Clinicians may also use magnetic resonance imaging to evaluate recalcitrant heel pain. One study characterized atypical heel pain as being associated with bone marrow edema of the calcaneus and MRI confirmed the diagnosis of plantar fasciitis in 76 percent of patients.22 Another study demonstrated the presence of bone marrow edema and fascial tears utilizing MRI although the authors noted no difference in clinical response from patients with plantar fasciitis.23

   Scintigraphy can help predict patient response to the treatment of plantar fasciitis. Noting three patterns of uptake in plantar fasciitis, Frater and colleagues found that treatment response was most predictable with focal uptake versus diffuse uptake along the plantar fascia or uptake along the proximal plantar fascia.24 This indicates a less typical presentation of plantar fasciitis and a decreased response to treatment.

   The measurement of plantar fascia elasticity utilizing elastography is reportedly 95 percent sensitive/100 percent specific for the diagnosis of plantar fasciitis in comparison to ultrasound with a 65.8 percent sensitivity and 75 percent specificity.25

A Guide To The Non-Operative Management Of Plantar Fasciitis

It has long been established and generally accepted that plantar fasciitis responds well to non-operative management. Utilizing anti-inflammatory medication, heel cushions, stretching, relative rest and injection therapy, Davis and coworkers demonstrated an 89.5 percent resolution of heel pain over 10.9 months.26

   Although clinicians frequently utilize therapeutic ultrasound in the treatment of plantar fasciitis, it is somewhat controversial. Researchers have found that ultrasound is associated with a 30 percent reduction in treated patients versus a 25 percent reduction in sham ultrasound patients.27 In another study, stretching plus sham ultrasound yielded better results (54.6 percent improvement) than did stretching plus ultrasound (46.5 percent improvement).28

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