Plantar Fasciitis

Risk: The condition is most common in runners and other athletes and those with jobs that require prolonged walking or standing on hard surfaces. Obesity, pronation of the feet, flat feet (pes planus), heel spurs, leg length discrepancy, and reduced range of motion in the ankle are other risk factors. Suddenly switching from high-heeled to lower-heeled shoes, as well as wearing ill-fitting shoes, may precipitate the condition. Although the exact cause is unknown, repetitive microtrauma may play a role.

Incidence and Prevalence: Plantar fasciitis occurs in about 10% of the general population and represents 10–15% of foot problems requiring professional care (Singh). Women are twice as likely as men to get plantar fasciitis (Foye).

History: The individual usually complains of intense, sharp pain in the bottom of the heel or in the arch. Characteristically, the pain is worst with the first few steps in the morning or after periods of rest. Pain decreases with ambulation throughout the day. At the end of the day, the pain may change to a dull ache that improves with rest. Pain is worsened by walking barefoot, especially on hard surfaces, and improves when shoes are worn. Careful questioning may reveal that the onset of pain was associated with a new activity or a change in activity level, change in the type of exercise surface, or new footwear.

Physical exam: Typical physical exam findings include tenderness when touching (palpating) the bottom of the heel and mild swelling (edema). Bending the foot toward the shin (ankle dorsiflexion) may increase the pain, especially if the toes are simultaneously hyperextended. Standing on tiptoe or walking on one’s toes reproduces the pain in many individuals.

Tests: The diagnosis of plantar fasciitis is based on history and physical examination. If plantar fasciitis presents in both feet (bilateral), blood tests may be obtained to detect any underlying conditions, such as systemic inflammatory diseases.

Laboratory tests may include a complete blood count (CBC), general tests for inflammation (erythrocyte sedimentation rate, C-reactive protein), and specific tests for different types of arthritis (rheumatoid factor, human leukocyte antigen typing). Although imaging studies are rarely indicated for making the diagnosis, x-rays can help to rule out stress fractures.

Because plantar fasciitis is a self-limiting disease, it usually resolves within a nine-month period, with residual symptoms in about 10% of all cases (Chen). The condition becomes chronic if pain persists for longer than 6 months. A variety of treatments are commonly implemented to treat plantar fasciitis with many of these treatments unsubstantiated by sound scientific evidence. Common treatments include exercise, ultrasound, night splints, and custom and standard orthotics. Injections are also used as treatment (Crawford, "Steroid Injection").

Exercises emphasizing stretching of the Achilles tendon are commonly prescribed. For greater benefit, a plantar fascia tissue stretching program should be utilized (DiGiovanni). Orthotics are commonly used to provide external support to the foot in an anatomically proper alignment. Some evidence exists supporting the use of prefabricated supports over custom orthotics, while no clear evidence indicates the benefit of custom devices. A combination of stretching and shoe inserts has yielded the most favorable results (Pfeffer). Cushioned insoles with active bipolar magnets have not been shown to have any therapeutic value (Winemiller).

To date, no randomized controlled trials exist to support the use of ultrasound or resting night splints as part of the rehabilitation for plantar fasciitis (Probe). Limited evidence supports the use of corticosteroid injections for pain reduction up to 1 month; however the benefits were not lasting (Crawford, "Interventions").