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11 Articles in Volume 18, Issue #8
Challenges & Opportunities for Pain Management In Veterans
Chronic Pain and Psychopathology in the Veteran and Disadvantaged Populations
ESIs: Worth the Benefits?
Letters to the Editor: Recovery Centers Reject MAT, Cannabis for Chronic Headaches, Central Pain
Medication Management in the Aging
Pain Management in the Elderly
Pharmacists as Essential Team Members in Pain Management
Photobiomodulation for the Treatment of Fibromyalgia
Plantar Fasciitis: Diagnosis and Management
Slipping Rib Syndrome: A Case Report
What types of risk screening tests are available to clinicians prescribing opioid therapy?

Plantar Fasciitis: Diagnosis and Management

Applying an osteopathic approach.
Page 1 of 2

Plantar fasciitis is one of the most common causes of foot and heel pain in adults. Consisting of pain and tenderness at the sole of the foot, this condition affects approximately 1 in 10 persons at some point in their life. Peak incidence occurs between age 40 to 60 in the general population with an additional younger peak in runners and athletes.1,2 The plantar fascia, or plantar aponeurosis, lies superficially to the muscles of the plantar surface of the foot, attaching to the anterior medial calcaneal tuberosity; it divides distally into five slips attaching at the proximal phalanges, acting as a truss to maintain the longitudinal arch of the foot and to facilitate shock absorption during ambulation and other weight bearing.2-5

Physiological and Biomechanical Foot Changes Leading to Plantar Fasciitis

The prevailing hypotheses regarding the pathophysiology of plantar fasciitis involves biomechanical stress leading to inflammation of the plantar fascia, resulting in tightening of the fascia during non-weight bearing periods.6-8 Biomechanical stressors are common in specific populations, such as:

  • obese individuals
  • individuals who engage in prolonged standing or jumping
  • people with flat feet or high arches
  • anyone with reduced ankle dorsiflexion8,2
  • Consistent joggers/runners, suggesting that repetitive microtrauma may contribute to underlying etiology.2

Dancers, especially those performing aerobic-type movement, also suffer from plantar fasciitis due to stress on the Achilles tendon, which translates through the calcaneus to increase tension (and hamstring tightness may produce decreased knee extension and increased load to the forefoot, resulting in increased plantar fascia stress).2

Physical activities and dysfunction may introduce repetitive microtrauma with high calcaneal pressure; opposing traction of the forefoot and Achilles tendon may lead to microtears in the central bundle of the plantar fascia.9,10 When cumulative cellular damage is exacerbated by a failed healing pattern that leads to zones of both hyper- and hypoplasia,11 normal collagen repair cycles may be disrupted, leading to a continuum of cellular damage similar to that in Achilles tendinosis and lateral epicondylitis.12,13 Microtrauma and disruptions in healing and collagen repair can lead to the development of hyperirritable, tender points in taut fascia that refer pain when palpated or compressed by weight-bearing activities, known as myofascial trigger points.14

Evidence also points to a central nervous system role in chronic tendinopathies with programmed cell death (apoptosis), tissue breakdown, and collagen degeneration at the origin of the plantar fascia at the medial tubercle of the calcaneus, accompanied by a distinct lack of chronic inflammatory cells, suggesting that in the chronic stages, plantar fasciitis is not mediated by inflammatory processes.9,10,15,16 Thus, repetitive microtears overwhelm inherent repair mechanisms, rather than perpetuate chronic inflammation.16 Acute inflammation, as well as chronic stress to the plantar fascia may result in a greater morbidity and presents a difficult choice for individuals who maintain regular exercise or whose employment requires extended standing or reliance on active use of their feet. Successful treatments account for the development of acute inflammatory etiology of plantar fasciitis and anticipate its progression into a chronic, degenerative problem.

Other common causes of plantar fasciitis and plantar foot pain should be considered in the differential diagnosis such as inflammatory disorders (especially, spondyloarthropathies), neurologic conditions (ie, neuropathies, nerve entrapment), skeletal causes (ie, stress fractures, trauma, calcaneal fractures, osteomyelitis and malignancy), and soft tissue causes (eg, heel fat pad inflammation).

(Source: 123RF)

Making a Differential Diagnosis

Patients typically present with complaints of sharp pain localized to the medial aspect of the heel at the calcaneal insertion of the Plantar Fascia. Pain patterns may also involve the arch of the foot, typically during the first few steps in the morning, or after long periods of non-weight bearing.2,6,7,17,18 Regarding the former, after about 10 to 20 steps, the plantar fascia will begin to stretch, allowing for a gradual decrease in the sharp, burning pain. However, symptoms such as a throbbing, dull ache or fatigue-like sensation in the medial arch of the foot commonly recur after prolonged periods of standing (or weight bearing).17-19

The diagnosis of plantar fasciitis is typically made on the basis of a thorough history and physical exam. In assessing the patient, particularly with runners and athletes, careful attention to the six S’s (shoes, surface, speed, stretching, strength, and structure) may assist the clinician in confirming a diagnosis.20 On physical exam, plantar fasciitis will elicit local point tenderness along the bottom of the foot. This is best achieved by dorsiflexing the patient’s toes, pulling the plantar fascia taut, and then palpating along the plantar fascia from the heel to the forefoot.2 Tender points due to microtrauma and disrupted healing confirm such a diagnosis, but also represent markers for treatment focus, such as with osteopathic manipulation or corticosteroid injections.2,21

Laboratory, radiographic, and ultrasonographic studies are generally not necessary to diagnose plantar fasciitis. While not routinely used, ultrasound imaging may show evidence of a thickening of the plantar fascia and associated edema from inflammation. The diagnostic utility of ultrasound for plantar fasciitis has not yet been shown as beneficial for routine use.2,22,23 However, these diagnostic modalities may be useful in considering the full differential diagnosis of foot and heel pain.

Common Approaches for Short- and Long-Term Relief

Multiple treatment modalities for plantar fasciitis are available. The most commonly utilized options include glucocorticoid injections, dry needling, braces, and orthotics. The majority of patient cases respond to conservative, nonsurgical therapies within 6 to 18 months.24-26 However, approximately 5% to 10% of patients may progress to require surgical intervention to achieve sufficient restoration of function and pain relief.26

Last updated on: November 7, 2018
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Effective Protocol for the Management of Plantar Fasciitis