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Plantar Fasciitis Thomas Trojian, MD, MMB, and Alicia K Plantar Fasciitis Thomas Trojian, MD, MMB, and Alicia K. Tucker, MD, Drexel University College of Medicine, Philadelphia, Pennsylvania Plantar fasciitis is a common problem that one in 10 people will experience in their lifetime. Plantar fasciopathy is an appro- priate descriptor because the condition is not inflammatory. Risk factors include limited ankle dorsiflexion, increased body mass index, and standing for prolonged periods of time. Plantar fasciitis is common in runners but can also affect sedentary people. With proper treatment, 80% of patients with plantar fasciitis improve within 12 months. Plantar fasciitis is predominantly a clinical diagnosis. Symp- toms are stabbing, nonradiating pain first thing in the morning in the proximal medioplantar surface of the foot; the pain becomes worse at the end of the day. Physical examination findings are often limited to tenderness to palpation of the proximal plantar fascial insertion at the anteromedial calcaneus. Ultrasonogra- phy is a reasonable and inexpensive diagnostic tool for patients with pain that persists beyond three months despite treatment. Treatment should start with stretching of the plantar fascia, ice massage, and nonsteroidal anti-inflamma- tory drugs. Many standard treatments such as night splints and orthoses have not shown benefit over placebo. Recalcitrant plantar fasciitis can be treated with injections, extracorporeal shock wave therapy, or surgical procedures, although evidence is lacking. Endoscopic fasciotomy may be required in patients who continue to have pain that limits activity and function despite exhausting nonoperative treatment options. (Am Fam Physician. 2019; 99(12):744-750. Copyright © 2019 American Academy of Family Physicians.) Illustration by Todd Buck Plantar fasciitis (also called plantar fasciopathy, reflect- than 27 kg per m2 (odds ratio = 3.7), and spending most ing the absence of inflammation) is a common problem of the workday on one’s feet 4,5 (Table 1 6). One study found accounting for approximately 1 million patient visits per that reduced ankle dorsiflexion is the greatest risk factor in year, with about 60% of these to primary care physicians.1 nonathletes.4 Limited ankle dorsiflexion causes the foot to It is the most common cause of heel pain in adults, with a overpronate, causing more load to be placed on the plan- lifetime incidence of about 10%2 and an increased incidence tar fascia. The condition also occurs in more active people in women 40 to 60 years of age.1 Plantar fasciitis is associ- such as runners and military personnel, but increased body ated with a variety of sports but is mostly reported in recre- mass index is more weakly associated with plantar fasciitis ational and elite runners (incidence of 5% to 10%).3 in these populations.5 Runners and those who spend pro- longed time on their feet are more likely to develop the con- Risk Factors dition because the plantar fascia stretches and contracts (in Risk factors for developing plantar fasciitis in nonathletes what is called a typical elastic stretch–shortening cycle), and include limited ankle dorsiflexion, body mass index greater the repetitive strain can cause an overuse injury.5 Etiology CME This clinical content conforms to AAFP criteria for The plantar fascia originates from the posteromedial cal- continuing medical education (CME). See CME Quiz on page 735. caneal tuberosity and inserts into each metatarsal head to Author disclosure: No relevant financial affiliations. form the longitudinal arch of the foot. Plantar fasciitis is a biomechanical overuse condition resulting in degenera- Patient information: A handout on this topic, written by the authors of this article, is available at https:// www.aafp.org/ tive changes at its attachment to the calcaneus. Histologic afp/2019/0615/p744-s1.html. examination of samples taken from patients undergoing plantar fascia release surgery shows myxoid degeneration Downloaded744 from the American Family Physician website at www.aafp.org/afp. Copyright © 2019 American Academy of Family Physicians. For the ◆private, noncom- mercialAmerican use of one Family individual Physician user of the website. All other rightswww.aafp.org/afp reserved. Contact [email protected] for copyrightVolume questions 99, and/or Number permission 12 June requests. 15, 2019 PLANTAR FASCIITIS TABLE 1 FIGURE 1 Risk Factors for Plantar Fasciitis Body mass index > 27 kg per m2 Excessive running Intrinsic foot and calf muscle tightness Leg length discrepancy Occupations requiring prolonged standing or walking Pes cavus (high arch) Pes planus (excessive foot pronation) Reduced ankle dorsiflexion Sedentary lifestyle Adapted with permission from Goff JD, Crawford R. Diagnosis and treatment of plantar fasciitis. Am Fam Physician. 2011; 84(6): 676. with fragmentation and degeneration of the plantar fascia and bone marrow vascular ectasia. These findings sup- port that the condition is a degenerative fasciosis without inflammation, not a fasciitis.7 Therefore, plantar fasciopathy is a more accurate descriptor. Diagnosis Plantar fasciitis can be diagnosed clinically by findings from the patient history and physical examination. The patient will have sharp pain in the anteromedial aspect of the heel8 (Figure 16). Pain will begin with ambulation after a period of inactivity, then will improve or resolve as the activity progresses. However, the pain will return at the end of the day. The classic presentation is pain with the first step of the morning. Paresthesia is uncommon. The patient may have had a recent increase in weight-bearing activity.9 On physical examination, the patient will be tender to Medioplantar region of the heel where most pain is elicited when pressure is applied during physical palpation on the proximal plantar fascial insertion at the examination or with walking in patients with plantar anteromedial calcaneus. The windlass test may also be help- fasciitis. ful (https:// www.youtube.com/watch?v=fg0PtnoAzSs). A Reprinted with permission from Goff JD, Crawford R. Diagnosis positive result is heel pain reproduced by forced dorsiflex- and treatment of plantar fasciitis. Am Fam Physician. 2011; 84(6): 677. ion of the toes at the metatarsophalangeal joints with the ankle stabilized.10 According to one study, the windlass test has 100% specificity and 32% sensitivity (positive likelihood initial study.12 Magnetic resonance imaging has been proven ratio = 1.47).10 helpful in the diagnosis of plantar fasciitis. Ultrasonography is effective for differentiating the normal plantar fascia from Imaging tissue involved with plantar fasciitis, and it is less expensive.12 In most cases, clinical findings are sufficient to diagnose Plain radiography can evaluate for bony lesions. A heel plantar fasciitis. However, imaging may help determine spur may be visible on lateral heel radiographs, but this is whether an alternate diagnosis (Table 2 6) is present in not pathognomonic of plantar fasciitis because it is a com- patients with pain that lasts longer than three months and mon incidental finding in asymptomatic patients(Figure 2).6 does not respond to therapy.11 Guidelines from the Ameri- Although people with chronic heel pain are more likely to can College of Radiology state that although radiography is have a bone spur,13 the spur will remain after symptoms typically not sensitive for plantar fasciitis, it should be the resolve. Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2019 American Academy of Family Physicians. For the private, noncom- ◆ 745 mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. June 15, 2019 Volume 99, Number 12 www.aafp.org/afp American Family Physician PLANTAR FASCIITIS TABLE 2 Differential Diagnosis of Plantar Heel Pain Etiology Symptoms Ultrasonography is an inexpensive, Neurologic causes accurate, and reliable alternative to Baxter neuritis Burning over the medial heel magnetic resonance imaging for eval- Medial calcaneal nerve Burning over the inferomedial aspect of the uation of heel pain.14 Ultrasound find- entrapment calcaneus ings consistent with plantar fasciitis Tarsal tunnel syndrome Paresthesia in the plantar aspect of the foot include greater plantar fascia thickness Skeletal causes compared with controls,13 plantar fas- Acute calcaneal fracture Inability to bear weight secondary to a high-energy cia thickness greater than 4.0 mm (odds event ratio = 105.11; 95% CI, 3.09 to 3,577.28; Bone tumor Deep bone pain, night pain 13 P = .01), and reduced echogenicity of Calcaneal apophysitis Heel pain in girls eight to 13 years of age or boys 10 3 the plantar fascia. If ultrasonography (Sever disease) to 15 years of age is not available in the clinic, the patient Calcaneal stress fracture Slow-onset heel pain secondary to repetitive loading can be referred for further imaging. Spondyloarthropathies Heel pain at Achilles tendon insertion Magnetic resonance imaging can be useful to rule out other conditions, such Soft tissue causes as plantar fascia tears or calcaneal stress Achilles tendinitis Posterior ankle pain at medial malleolus level fracture. It can show increased plantar Fat pad contusion Centralized heel pain fascia thickness and signal intensity.3 Flexor hallucis longus Pain with resisted flexion of the great toe tenosynovitis Nonoperative Treatment Plantar fascia rupture A pop followed by sudden onset of pain Plantar fibroma Nodule in the plantar surface of
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