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Plantar Fasciitis as an Overuse Injury

1 in 10 individuals may develop this painful foot condition in their lifetime. Inside differential diagnoses and pain management strategies.

This overview is part of a Chronic Overuse Injuries Primer. View the introduction.
 

History/Pathogenesis

Plantar fasciitis is a common overuse injury that is primarily caused as a result of repetitive strain, leading to micro tears of the plantar fascia, and eventually degenerative irritation of the fascia and/or other relevant perifascial structures at the medial calcaneal origin. Other than degenerative observations, histological findings such as collagen disarray and absence of traditional inflammation have been documented. Pain is often reported as progressive and originating at the medial calcaneal origin (inferior and medial heel) but has been reported to radiate proximally in more serious cases.

Pain is typically the worst first thing in the morning and, though light activity often provides temporary relief, pain typically progressively increases throughout the day. Symptoms are often exacerbated by increasing activity and long periods of standing.1-4

Prevalence/Epidemiology

Plantar fasciitis is the most common cause of heel pain in adults, consisting of 11% to 15% of foot symptoms requiring professional care. Though the exact incidence is unknown, it is estimated that there are approximately 1 million patients seen annually for plantar fasciitis and that 1 in 10 people will develop the condition during their lifetime. Reports show up to 83% of patients were active working adults between the ages of 25 and 65 years old (peak between ages 40 and 60 years old).3-12

Image: iStock (Henadzi Pechan)1 in 10 people will develop plantar fasciitis in their lifetime.

Signs/Symptoms

Tenderness noted at the anteromedial calcaneal margin and tightness of the Achilles tendon, with burning pain at the anteromedial aspect of the heel. Worsens with activity (walking or running) but tends to be worse with the first few steps in the morning, immediately after getting out of bed. Pain intensity increases with prolonged weight bearing, especially if walking barefoot or in dress shoes, such as heels or those with rigid soles.

High Risk Activities for Plantar Fasciitis

  • Activities involving repetitive impact such as running (specifically toe running), commonly associated with improper biomechanics or footwear.
  • Plantar fasciitis is frequently seen in occupations that require prolonged standing.

Associated Risk Factors

  • Obesity is present in up to 70% of plantar fasciitis cases.
  • Age, more likely to develop with increased age
  • Pes planus (low arch) can cause increased strain at origin of plantar fascia.
  • Pes cavus (high arch) can cause excessive strain on heel because foot doesn’t effectively evert or absorb shock.
  • Heel spurs
  • Limited ankle dorsiflexion
  • Deficient flexibility in plantar flexor muscle group (gastrocnemius, soleus, and/or other posterior leg muscles) can alter the normal biomechanics.4,13-18

Physical Exam

The clinician should look for the following: pain localized to the anteromedial aspect of the calcaneus; and tightness to the gastrocnemius/soleus complex. Patient-reported outcome measures (PROMs) display hypermobility to the subtalar joint, the midfoot complex, and the first ray. Additionally, gait evaluation reveals overpronation at the midfoot with excessive calcaneal eversion at heel lift and pain on passive toe extension with the foot in dorsiflexion.

Diagnostic Tests

If indicated, evaluate with baseline x-rays, MRI, musculoskeletal diagnostic U/S testing, or bone scan testing, or EMG/NCS testing.

Differential Diagnosis

  • Posterior tibial ligament injury
  • Tarsal tunnel syndrome
  • Occult lesion
  • Stress fracture
  • Prevention:
  • Footwear—shoes with adequate support; avoid worn out shoes.
  • Minimize high-impact activities
  • Emphasize biomechanical factors associated with walking
  • Minimize instances of long hours spent standing
  • Stretch calf muscles regularly

Acute Treatment

The clinician should advise relative rest; new shoes to control excessive motion if present; analgesia through appropriate doses of NSAIDs with physical modalities such as ice, ultrasound, iontophoresis, phonophoresis, topical anesthetic skin refrigerant, and electrical stimulation; calf stretching (early morning and throughout the day); manual therapy techniques/deep soft tissue work to the gastrocnemius and soleus along with deep transverse friction massage to the arch and insertion point; soft gel heel cups; and arch taping during athletic activities.

Long-Term Treatment/Rehab

Plantar fasciitis is typically a self-limiting condition that is usually resolved with conservative therapy guided by pain level. Cross-fiber/deep tissue massage and sound assisted soft tissue mobilization (SASTM), at therapist discretion, has shown to help with fascial adhesions, and therefore pain levels and mobility. Therapy should include stretching and strengthening of musculature and associated anatomical structures with the goal of increasing function and decreasing the potential for recurrence.

Corticosteroid injection therapy has been shown to be ineffective for long-term treatment but effective for short periods (< 4 weeks). Custom orthotic intervention and/or night splinting in combination with therapeutic treatment may be beneficial.

However, if the condition is not resolved within 6 to 12 months of conservative treatment, alternative methods such as local platelet-rich plasma injections, extracorporeal shock wave therapy, or surgery (last option) may be considered. Regenerative medicine techniques are now on the forefront of research and for potential treatments for chronic overuse musculoskeletal/sports injuries. These techniques, such as platelet-rich plasma and stem cell injection options, should be considered on a case-by-case setting for plantar fasciitis.

Practical Takeaways

  • Plantar fasciitis is a common overuse injury that is primarily caused as a result of repetitive strain, leading to micro tears of the plantar fascia, and eventually degenerative irritation of the fascia and/or other relevant perifascial structures at the medial calcaneal origin.
  • Plantar fasciitis is the most common cause of heel pain in adults, consisting of 11% to 15% of foot symptoms requiring professional care.
  • Symptoms of plantar fasciitis include tenderness noted at the anteromedial calcaneal margin and tightness of the Achilles tendon, with burning pain at the anteromedial aspect of the heel.
  • Acute treatment can include relative rest; new shoes to control excessive motion if present; analgesia through appropriate doses of NSAIDs with physical modalities such as ice, ultrasound, iontophoresis, phonophoresis, topical anesthetic skin refrigerant, and electrical stimulation; calf stretching (early morning and throughout the day); manual therapy techniques/deep soft tissue work to the gastrocnemius and soleus along with deep transverse friction massage to the arch and insertion point; soft gel heel cups; arch taping during athletic activities.1-4,19-20
Additional chronic overuse injuries in this primer:
Last updated on: May 29, 2020
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Lumbar Facet Joint Pain and Chronic Overuse, Pain Management
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