Applied Evidence

Plantar fasciitis: How best to treat?

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In addition to stretching exercises and orthotics, consider steroid injections as part of your first-line treatment options. For recalcitrant pain, a newer injectable reparative treatment is showing promise.


 

References

Practice recommendations

› Use plantar fascia specific stretching to decrease pain in patients with plantar fasciitis. A

› Consider recommending prefabricated orthoses, including night splints, to decrease pain. A

› Consider using extracorporeal shock wave therapy for plantar fascial pain. A

Strength of recommendation (SOR)

A. Good-quality patient-oriented evidence
B. Inconsistent or limited-quality patient-oriented evidence
C. Consensus, usual practice, opinion, disease-oriented evidence, case series

CASE A 43-year-old obese woman seeks advice for left heel pain she has had for 2 months. Before the onset of pain, her activity level had increased as part of a weight loss program. Her pain is at its worst in the morning, with her first few steps; it decreases with continued walking and intensifies again after being on her feet all day. There is no history of trauma, and she reports no paresthesias or radiation of the pain. Her medical history is otherwise unremarkable. She has used ibuprofen sparingly, with limited relief.

If you were this patient’s physician, how would you proceed with her care?

Plantar fasciitis (PF) is a common cause of heel pain that affects up to 10% of the US population and accounts for approximately 600,000 outpatient visits annually.1 The plantar fascia is a dense, fibrous membrane spanning the length of the foot. It originates at the medial calcaneal tubercle, attaches to the phalanges, and provides stability and arch support to the foot. The etiology of PF is unknown, but predisposing factors include overtraining, obesity, pes planus, decreased ankle dorsiflexion, and inappropriate footwear.2 Limited dorsiflexion due to tightness of the Achilles tendon strains the plantar fascia and can lead to PF. Histology shows minimal inflammatory changes, and some experts advocate the term plantar fasciosis to counter the misperception that it is primarily an inflammatory condition.3

A patient’s history and physical exam findings are the basis for confirming or dismissing a diagnosis of PF. Radiologic studies, used judiciously, can rule out important alternative diagnoses that should not be overlooked. Multiple treatment options range from conservative to surgical interventions, although studies of the effectiveness of each modality have had conflicting results. Clinical practice guidelines generally advocate a stepwise approach to treatment.

Diagnosis

The differential diagnosis of PF (TABLE) includes significant disorders such as calcaneal stress fracture, entrapment neuropathies (eg, tarsal tunnel syndrome), calcaneal tumor, Paget’s disease, and systemic arthritidies.4,5

What to look for in the history and physical exam
Severe heel pain upon initial weight bearing in the morning or after prolonged periods of inactivity is pathognomonic for PF.2 Initially the pain presents diffusely, but over time it localizes to the area of the medial calcaneal tubercle. Pain typically subsides with activity but may return with prolonged weight bearing, as it did with the patient in the opening case.

Test range of motion of the foot and ankle. Although this is not needed for diagnosing PF, some patients will exhibit limited ankle dorsiflexion, a predisposing factor for PF.4,6 Look for heel pad swelling, inflammation, or atrophy, and palpate the heel, plantar fascia, and calcaneal tubercle. Lastly, evaluate for gait abnormalities and the presence of sensory deficits or hypesthesias.4

The most common exam finding in PF is pain at the medial calcaneal tubercle, which may be exacerbated with passive ankle dorsiflexion or first digit extension.2,4 If paresthesias occur with percussion inferior to the medial malleolus, suspect possible nerve entrapment or tarsal tunnel syndrome. Tenderness with heel compression (squeeze test) may indicate a calcaneal fracture or apophysitis.

Imaging is useful to rule out alternative disorders
Radiologic studies generally do not contribute to the diagnosis or management of PF, but they can assist in ruling out alternative causes of heel pain or in reevaluation if symptoms of PF persist after 3 to 6 months of treatment.

Plain films lack the sensitivity to detect plantar fasciitis. While a plantar calcaneal spur is often seen on radiography, it does not confirm the diagnosis, correlate with severity of symptoms, or predict prognosis.4 Despite this deficiency, plain radiography remains the initial choice of imaging modalities, particularly to rule out other conditions.

Ultrasound accurately diagnoses plantar fasciitis. Plantar fascia thickness of more than 4.0 mm is diagnostic of PF.7 Additionally, a decrease in plantar fascia thickness correlates with a decrease in pain levels, and thus ultrasound can aid in monitoring treatment progress.8 If results of plain films and ultrasound are inconclusive and clinical concern for an alternative diagnosis warrants additional expense, consider arranging for magnetic resonance imaging.9

Noninvasive treatments

Conservative therapies remain the preferred approach to treating PF, successfully managing 85% to 90% of cases.10,11 A 2010 clinical practice guideline from the American College of Foot and Ankle Surgeons recommends conservative treatments such as nonsteroidal inflammatory drugs (NSAIDs), stretching, and prefabricated orthotics for the initial management of plantar heel pain.4 Emphasize to patients that it may take 6 to 12 months for symptoms to resolve.4

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