Description

  • Overuse injury of the plantar fascia caused by repetitive microtrauma from prolonged walking or running

Also called

  • Heel spur

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 found at age 40-60 years; younger in runners

Risk factors

  • Obesity
  • Occupations that require prolonged standing (especially on cement or other hard surfaces)
  • Pes planus (flat foot)
  • Reduced ankle dorsiflexion
  • Inferior calcaneal exostoses (heel spurs)
  • Runners, athletes, dancers

History

  • Inferior heel pain occasionally with radiation forward into sole or arch
  • Pain with first few steps after period of non-weight bearing (such as getting out of bed in the morning) due to plantar fascia tightening overnight while foot relaxed in equinus position
  • Precipitating and relieving activities

         — Exacerbated after prolonged weight-bearing, walking, or standing

         –Relieved by rest

  • Ask about

         –Any specific trauma, strain, overuse, new job, new exercise regimen

Continue Reading

         –Types of shoes worn (look for poor arch support)

         –Any recent change in footwear

  • Paresthesia or weakness suggests alternative diagnosis

Physical exam

  • Sites of tenderness—anywhere along plantar fascia insertion, especially bottom and medial side of heel

         –If most posterior—painful heel pad

         –If more medial (along with lancinating-type pain)—suggests entrapment of medial calcaneal nerve

         –If no tenderness—may be degenerative joint disease of subtalar joint

         –Bilateral squeeze of calcaneus can be useful in identifying stress fracture (rare), but if done inferiorly, the soft tissue under heel will be painful in plantar fasciitis.

  • Note range of motion—often pain increased by for­cibly dorsiflexing toes and forefoot; check passive ankle dorsiflexion with knee flexed (normal 20°)
  • Observe while standing or walking for loss of longitudinal arch and excessive pronation—calcaneal eversion, loss of longitudinal arch, loss of transverse arch, valgus of forefoot
  • Look at shoe—localized wear (medial areas), poor fit, unusual shape, poor athletic support, thin sole
  • Check neurovascular status

Making the diagnosis

  • Clinical diagnosis is based on history and physical exam.

         –Condition is gradual in onset, often related to change in activity or footwear.

         –Pain is often severe in the morning or with first few steps after period of non-weight-bearing.

         –Pain after prolonged weight-bearing and relieved by rest

         –Tenderness of inferior and medial side of heel at site of plantar fascia insertion

Testing to consider

  • X-ray may be useful to rule out other causes of heel pain (fracture or bony lesions) but are not routinely needed.
  • X-ray identification of calcaneal spur is not helpful for diagnosis or exclusion of plantar fasciitis.
  • Bone scan may differentiate plantar fasciitis from calcaneal stress fracture.
  • Ultrasound and MRI are not routinely useful, but high-resolution ultrasound may help determine if patients will benefit from corticosteroid injection or extracorporeal shock-wave therapy.

Treatment

  • No evidence to define standard of care or treatment of choice, based on replicated randomized trials
  • General advice

         –Select shock-absorbent shoes with snug, stiff heel counter and good arch support.

         –Runners should avoid uphill paths and speed work.

         –Weight loss if obese

  • Initial specific therapy options

         –Ice applications for 20 minutes regularly or as needed, avoid warm soaks if they increase pain

         –Calf and Achilles tendon stretching (ankle dorsiflexion exercises)

         –Plantar fascia stretching

         –Nonsteroidal anti-inflammatory drugs might provide small reduction in pain and disability.

         –Prefabricated shoe inserts (heel pad or heel cup)

         –Mechanical treatments to correct any hyperpronation

  • Medial heel wedges
  • Nonprescription arch supports
  • Treatments to consider in refractory cases

         –Taping followed by custom orthotics

         –Corticosteroid injections are associated with reduced pain but increased risk for plantar fascia rupture.

         –Night splints were ineffective after three months in one large randomized trial, but effective in two smaller randomized trials.

         –Extracorporeal shock-wave therapy has mixed results in randomized trials.

         –Iontophoresis is associated with possible benefit.

         –Acupuncture might reduce pain in plantar fasciitis.

         –Botulinum toxin injections may reduce pain.

         –Intracorporeal pneumatic shock therapy

         –A short leg cast and crutches may provide temporary relief in severe cases, but plantar fasciitis is rarely that severe.

  • Surgical release—generally only used as a last resort when other methods ineffective after at least six months

Prognosis

  • Prognosis is generally good, but resolution may take many months.
  • 82% resolution rate after conservative treatment of plantar heel pain

Prevention

  • Customized semi-rigid foot orthotics may be beneficial in preventing plantar fasciitis.

Dr. Ehrlich is a family physician and Deputy Editor for DynaMed, a database of comprehensive updated summaries covering more than 3,200 clinical topics.

This article originally appeared on Cancer Therapy Advisor

From the June 01, 2011 Issue of Clinical Advisor

Topics:

Orthopedics Pain Sports Medicine