Plantar fasciitis

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Dr. Omori is assistant professor of family medicine and community health, University of Hawaii, Honolulu. Dr. Withy is associate professor of complementary and alternative medicine, also at the University of Hawaii, and a peer reviewer for DynaMed (www.dynamicmedical.com), a database of comprehensive updated summaries covering nearly 2,000 clinical topics.

Description
• Overuse injury of the plantar fascia
• Also called heel spur (actually an inferior calcaneal exostosis associated with plantar fasciitis)

ICD-9 codes
• 726.79 other enthesopathy of ankle and tarsus
• 726.8 other peripheral enthesopathies
• 728.71 plantar fascial fibromatosis

Epidemiology
• 11%-15% of all foot symptoms requiring professional care among adults
• Highest incidence at age 40-60 years, younger in runners
• Common in military personnel and workers who stand a lot

Etiology
• Repetitive microtrauma

Risk factors
• Obesity
• Prolonged standing (especially when surface is hard)
• Pes planus (excessive pronation of foot)
• Reduced ankle dorsiflexion
• Heel spurs
• Increased risk in runners, athletes, dancers

Complications
• Generally no long-term complications

History
• Timing: Pain is often severe in the morning
• Location: Inferior heel pain occasionally with radiation forward into sole or arch
• Ask about trauma, overuse, new job, new exercise regimen, types of shoes worn.
• Precipitating activities:
— Prolonged weight-bearing, walking, or standing
— Often significant pain with first step of the morning or after inactivity
• Relieved by rest
• Paresthesia or weakness
suggests alternative diagnosis.

What to look for
• Tenderness along plantar fascia insertion, especially bottom and medial side of heel
• Increased pain on forcible dorsiflexion of toes and forefoot
• Loss of longitudinal arch and excessive pronation while standing and walking
• Examine shoe for localized wear (medial areas), poor fit, unusual shape, poor athletic support, thin sole.
• If acute inflammation, consider Reiter’s syndrome, rarely gout.
• Check neurovascular status.

Imaging
• X-rays may be useful to rule out other causes of heel pain (fracture or bony lesions) but are not routinely needed.
• Bone scan may differentiate plantar fasciitis from calcaneal stress fracture.
• Ultrasound and MRI not routinely useful

Prognosis
• Usually spontaneous resolution, can take many months
• 82% resolution rate after conservative treatment of plantar heel pain

Treatment
• No data define standard of care or treatment of choice.
• Select shock-absorbing shoes with snug, stiff heel counter and good arch support.
• Runners should avoid uphill climbs and speed work.
• Apply ice for 20 minutes regularly or as needed; avoid warm soaks if they increase pain.
• Weight loss if obese
• Plantar fascia-stretching found to be more effective than Achilles tendon-stretching in a randomized trial
— Plantar fascia tissue-stretches: While seated with affected leg crossed over unaffected leg, place fingers on affected side over base of toes and foot distal to metatarsophalangeal joints, and pull toes back until stretch is felt in arch of foot.
— Achilles tendon stretches: While standing with affected leg placed posteriorly and kept straight with heel planted, lean against wall and flex unaffected knee.
• Prefabricated shock-absorbing shoe inserts appear more effective than custom orthotics or no shoe inserts in a randomized trial.
• Arch supports found to be as effective as custom orthotics or night splints in a randomized trial.
• Soft viscoelastic heel pads will cushion but not effectively prevent fat pad from flattening; hard rubber heel cups hold fibrofatty pad and preserve its natural cushion.
• Taping is associated with short-term benefit but has frequent side effects.
— Low-dye taping appears to reduce pain (nonrandomized comparison).
— Calcaneal taping may reduce pain more than stretching at one week.
• Counterstrain (osteopathic manipulative techniques) may reduce pain.
• Magnetic insoles not found to be effective.
• Treatments to consider in refractory cases
— Taping followed by use of custom orthotics more effective than anti-inflammatory medication or viscoelastic heel pads
— Nonsteroidal anti-inflammatory drugs may provide small reduction in pain and disability.
— Corticosteroid injection in addition to local anesthetic injection may reduce pain but is associated with increased risk of plantar fascia rupture.
— Night splints ineffective in a large randomized trial but may be highly effective in a small randomized trial
— Extracorporeal shock wave therapy has mixed results in randomized trials.
— Iontophoresis associated with possible benefit in two small randomized trials
— Botulinum toxin (Botox, Dysport) may reduce pain, based on one randomized trial with high dropout rate.
• Surgical release (small medial incision under general anesthesia with incision of fascia at base of calcaneus) is considered a last resort (no randomized trials identified)—used only when other methods ineffective after at least six months

Prevention
• Limited evidence regarding interventions for preventing lower-limb soft-tissue injuries in runners
• Stretching for injury prevention is controversial.
— Hamstring-stretching exercises four times daily reduced risk of overuse leg injuries in military recruits.
— Pre-exercise stretching did not significantly reduce training injuries in randomized trial.
• Shock-absorbing insoles do not appear to reduce lower-limb injuries.

For references, see www.dynamicmedical.com.

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