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Treatment of Plantar Fasciitis CRAIG C COVER ARTICLE PRACTICAL THERAPEUTICS Treatment of Plantar Fasciitis CRAIG C. YOUNG, M.D., Medical College of Wisconsin, Milwaukee, Wisconsin DARIN S. RUTHERFORD, M.D., Mercy Sports Medicine, Janesville, Wisconsin MARK W. NIEDFELDT, M.D., Medical College of Wisconsin, Milwaukee, Wisconsin Plantar fasciitis is a common cause of heel pain in adults. The disorder classically pre- sents with pain that is particularly severe with the first few steps taken in the morn- O A patient informa- ing. In general, plantar fasciitis is a self-limited condition. However, symptoms usually tion handout on plan- tar fasciitis, written by resolve more quickly when the interval between the onset of symptoms and the onset the authors of this of treatment is shorter. Many treatment options exist, including rest, stretching, article, is provided on strengthening, change of shoes, arch supports, orthotics, night splints, anti-inflamma- page 477. tory agents and surgery. Usually, plantar fasciitis can be treated successfully by tailor- ing treatment to an individual’s risk factors and preferences. (Am Fam Physician 2001; 63:467-74,477-8.) lantar fasciitis is a common foot arch. The function of the plantar cause of heel pain in adults. fascia is to provide static support of the The pain is usually caused by longitudinal arch and dynamic shock collagen degeneration (which absorption. Individuals with pes planus is sometimes misnamed (low arches or flat feet) or pes cavus P“chronic inflammation”) at the origin of (high arches) are at increased risk for the plantar fascia at the medial tubercle developing plantar fasciitis. of the calcaneus. This degeneration is Other anatomic risks include over- similar to the chronic necrosis of ten- pronation, discrepancy in leg length, donosis, which features loss of collagen excessive lateral tibial torsion and exces- continuity, increases in ground sub- sive femoral anteversion. Functional risk stance (matrix of connective tissue) and factors include tightness and weakness vascularity, and the presence of fibro- in the gastrocnemius, soleus, Achilles blasts rather than the inflammatory tendon and intrinsic foot muscles. How- cells usually seen with the acute inflam- ever, overuse rather than anatomy is the mation of tendonitis.1 The cause of the most common cause of plantar fasciitis degeneration is repetitive microtears of in athletes. A history of an increase in the plantar fascia that overcome the weight-bearing activities is common, body’s ability to repair itself. especially those involving running, The classic sign of plantar fasciitis is which causes microtrauma to the plan- that the worst pain occurs with the first tar fascia and exceeds the body’s capacity Members of various few steps in the morning, but not every to recover. Plantar fasciitis also occurs in family practice depart- patient will have this symptom. Patients elderly adults. In these patients, the ments develop articles often notice pain at the beginning of problem is usually more biomechanical, for “Practical Therapeu- activity that lessens or resolves as they often related to poor intrinsic muscle tics.” This article is one warm up. The pain may also occur with strength and poor force attenuation sec- in a series coordinated by the Department of prolonged standing and is sometimes ondary to acquired flat feet and com- Family and Community accompanied by stiffness. In more pounded by a decrease in the body’s Medicine at the Med- severe cases, the pain will also worsen healing capacity. ical College of Wiscon- toward the end of the day. On examination, the patient usually sin, Milwaukee. Guest The plantar fascia is a thickened has a point of maximal tenderness at the editors of the series are Linda N. Meurer, M.D., fibrous aponeurosis that originates from anteromedial region of the calcaneus. M.P.H., and Douglas the medial tubercle of the calcaneus and The patient may also have pain along the Bower, M.D. runs forward to form the longitudinal proximal plantar fascia. The pain may be FEBRUARY 1, 2001 / VOLUME 63, NUMBER 3 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 467 in patients who are not responding to appro- The pain of plantar fasciitis is caused by collagen degenera- priate treatment. tion associated with repetitive microtears of the plantar fascia. Treatment In general, plantar fasciitis is a self-limiting condition. Unfortunately, the time until reso- exacerbated by passive dorsiflexion of the toes lution is often six to 18 months, which can or by having the patient stand on the tips of lead to frustration for patients and physi- the toes. cians. Rest was cited by 25 percent of patients Diagnostic testing is rarely indicated for the with plantar fasciitis in one study as the treat- initial evaluation and treatment of plantar ment that worked best.3 Athletes, active adults fasciitis. Plantar fasciitis is often called “heel and persons whose occupations require lots spurs,” although this terminology is some- of walking may not be compliant if instructed what of a misnomer because 15 to 25 percent to stop all activity. Many sports medicine of the general population without symptoms physicians have found that outlining a plan of have heel spurs and many symptomatic indi- “relative rest” that substitutes alternative viduals do not.2 Heel spurs are bony osteo- forms of activity for activities that aggravate phytes that can be visualized on the anterior the symptoms will increase the chance of calcaneus on radiography. However, diagnos- compliance with the treatment plan.4 tic testing is indicated in cases of atypical It is equally important to correct the prob- plantar fasciitis, in patients with heel pain lems that place individuals at risk for plantar that is suspicious for other causes (Table 1) or fasciitis, such as increased amount of weight- TABLE 1 Differential Diagnosis of Heel Pain Disease or injury Differentiating clinical features Neurologic causes (entrapment syndromes) Radiating burning pain, numbness and tingling, especially at night Tarsal tunnel syndrome Diffuse symptoms over plantar surface Medial calcaneal branch of the Medial and plantar heel symptoms posterior tibial nerve entrapment Abductor digiti quinti nerve entrapment Burning pain in heel pad area Skeletal causes Bony point tenderness Calcaneal stress fracture activity Pain with weight-bearing; worsens with prolonged weight-bearing Paget’s disease Bowed tibias, kyphosis, headaches Tumor Deep bone pain; constitutional symptoms late in the course Calcaneal apophysitis (Sever’s disease) Posterior heel pain in adolescents Soft tissue causes Fat pad syndrome Atrophy of heel pad Heel bruise History of acute impact injury Bursitis Usually retrocalcaneal; swelling and erythema of posterior heel Plantar fascia rupture Sudden acute, knife-like pain, ecchymosis Tendonitis Pain with resisted motions Plantar fasciitis See text. 468 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 63, NUMBER 3 / FEBRUARY 1, 2001 Plantar Fasciitis bearing activity, increased intensity of activ- such as tightness of the gastrocsoleus complex ity, hard walking/running surfaces and worn and weakness of the intrinsic foot muscles. shoes. Early recognition and treatment usu- Increasing flexibility of the calf muscles is par- ally lead to a shorter course of treatment as ticularly important. Frequently used stretching well as increased probability of success with techniques include wall stretches (Figure 1) conservative treatment measures.3,5,6 and curb or stair stretches (Figure 2). Other effective techniques include use of a STRETCHING AND STRENGTHENING slant board (Figure 3) or placing a two-inch 3 Stretching and strengthening programs play four-inch piece of wood (Figure 4) in areas an important role in the treatment of plantar where the patient stands for a prolonged time fasciitis and can correct functional risk factors (e.g., workplaces, kitchen or stoves) to use in FIGURE 1. Wall exercises for calf stretching. (Left) Gastrocnemius stretch. (Right) Soleus stretch. FIGURE 2. Stair stretch. FIGURE 3. Slant board. FEBRUARY 1, 2001 / VOLUME 63, NUMBER 3 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 469 FIGURE 4. Use of two-inch 3 four-inch piece of FIGURE 5. Dynamic stretching with a 15-oz wood for stretching. can. stretching the calf. Dynamic stretches such as rolling the foot arch over a 15-oz size can or a tennis ball are also useful (Figure 5). Cross- friction massage above the plantar fascia (Fig- ure 6) and towel stretching (Figure 7) may be done before getting out of bed and serve to stretch the plantar fascia. In one study,3 83 percent of patients involved in stretching programs were success- fully treated, and 29 percent of patients in the study cited stretching as the treatment that had helped the most compared with use of orthotics, nonsteroidal anti-inflammatory The Authors FIGURE 6. Cross-friction massage above the CRAIG C. YOUNG, M.D., is an associate professor of orthopedic surgery and commu- plantar fascia. nity and family medicine and the medical director of sports medicine for the Medical College of Wisconsin, Milwaukee. He received his medical degree from the University of California, San Diego, School of Medicine and completed a family medicine resi- dency at the University of California, Los Angeles, UCLA School of Medicine and a pri- mary care sports medicine fellowship at the Cleveland Clinic Hospital, Cleveland, Ohio. DARIN S. RUTHERFORD, M.D., is in private practice at Mercy Sports Medicine in Janesville, Wis. He received his medical degree from the University of Iowa College of Medicine, Iowa City, and completed his family medicine residency at the Medical Col- lege of Wisconsin St. Mary’s program and a primary care sports medicine fellowship at the Medical College of Wisconsin. MARK W. NIEDFELDT, M.D., is an assistant professor of community and family medi- cine and orthopedic surgery for the Medical College of Wisconsin. He received his medical degree from the Medical College of Wisconsin and completed his family med- icine residency at the Medical College of Wisconsin St.
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