Plantar fasciitis: A review

Geraldine N. Urse, DO, FACOFP, Doctors Hospital Family Practice, 2030 Stringtown Road, Suite 300, Grove City, OH 43123.

E-mail address: gurse@ohiohealth.com.

KEYWORDS:

Plantar fasciitis; Heel pain

Plantar fasciitis (PF) is a common problem presenting to the family practice office. It is seen in approxi- mately 10% of the population and is more common in women than men. It presents with pain on the plantar surface of the foot overlying the calcaneus. The pain is most intense in the morning with the first step and after periods of inactivity. The differential diagnosis for heel pain includes other entities such as tarsal tunnel syndrome. Heel spurs are found in approximately 50% of the patients with plantar fasciitis; however, they are also found in patients without the condition and are noncontributory. Risk factors for the development of PF include lifestyle and obesity. Diagnosis of the condition is primarily clinical in nature and treatment modalities are varied. Osteopathic manipulative medicine is indicated in the treatment of the tender points associated with PF. Custom orthotics, taping, casting, and splinting are also discussed as management techniques for the condition. Surgical intervention is best left to recalcitrant patients. Future developments and ongoing studies in the management of PF include platelet-rich plasma injections and prolotherapy.

© 2012 Elsevier Inc. All rights reserved.

‌Pathophysiology

The plantar fascia is a wide, fibrous band of connective tissue constructed of multiple longitudinally oriented bands

Corresponding author: Geraldine N. Urse, DO, FACOFP, Doctors Hospital Family Practice, 2030 Stringtown Road, Suite 300, Grove City, OH 43123.

E-mail address: gurse@ohiohealth.com.

originating on the medial process of the calcaneal tuberosity and inserting at the base of the toes. The fascia is multilay- ered and has a thickness of approximately 3 mm. Three distinct components of this band are described: the central component, which is the largest and most prominent; the lateral component; and the medial component.

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Table 1 Differential diagnosis of heel pain

Plantar fasciitis

Tarsal tunnel syndrome Osteomyelitis

Occult fracture of the calcaneus Achilles tendinitis

Calcaneal apophysitis

is that the constant pull of a tight fascia caused by a flattened arch causes the bone to grow or remodel in the direction of the pull. The spur itself regardless of size does not appear to be related to the development of inflammation of the plantar fascia. Injury to the origin of the plantar fascia, whether acute or chronic, caused by the overload stress and micro- trauma lead to the development of the plantar inflammation and pain.3

ing over-pronation during ambulation, leg length discrepan- cies, tibial torsion, or femoral anteversion. Even though these anatomical changes may contribute to the develop- ment of PF, it is more often as a result of overuse.

‌Presentation of PF

The pain of PF is most intense with the first step of the morning or after periods of inactivity. Activities such as walking on the toes, climbing stairs, and walking barefoot tend to increase the pain. The pain subsides with continued ambulation but tends to return promptly once the activity has ended and the fascia returns to its resting tension. As with all functional complaints, a comprehensive struc- tural examination must be completed to identify any correctable somatic dysfunctions that may contribute to the chief complaint.

‌Differential diagnosis of heel pain

‌Diagnosis

‌Treatment

Stretching exercises specifically for the plantar fascia, as well as the Achilles tendon and hamstring muscles, have

Figure 1 Plantar fascia stretching.

‌Figure 2 The Heinking technique for counterstrain in treating plantar fasciitis.

physician seated on the foot of the table. The patient’s ipsilateral knee is flexed and the plantar tender point iden- tified where the fascia inserts onto the calcaneus. One thumb is used to monitor the tender point, whereas the opposite hand plantar flexes the toes and ankle curving around the tender point. Additional adjustment to the tension may be accomplished by supination or pronation of the foot until there is symptomatic relief of the tenderness underlying the monitoring thumb. This position of ease is held for approx- imately 90 seconds or until there is softening of the tissues below the monitoring thumb. The foot is then returned to the neutral position without moving the monitoring thumb. Re- assessment of the tenderness should be completed at the end of the treatment.5,8

Multiple styles of prefabricated nighttime splints are available that hold the foot in dorsiflexion during sleep. Overnight dorsiflexion prevents shortening of the fascia, thus decreasing the pain of stretching when weight-loaded with the first morning steps. Custom dorsiflexion splints made in the office can also provide relief when used con- sistently at night and have shown to be more efficacious

little or no benefit.14,15

‌Summary

Plantar fasciitis is a painful and debilitating condition for the majority of people in whom it develops. An understand-

ing of the anatomy and mechanism of weight-loading of the plantar fascia can aid in understanding the pathophysiol- ogy of this condition. Osteopathic manipulative thera- pies, as well as multiple conservative measures, are avail- able and have demonstrated some benefit in the management of PF. More intensive treatments such as injections and surgery carry concomitant risks; however, they may provide an option for patients who fail conser- vative management.

‌References

1. ‌Cole C, Seto C, Gazewood J: Plantar fasciitis: evidence-based review of diagnosis and therapy. Am Fam Physician 72:2237-2242, 2005‌

2. ‌American College of Foot and Ankle Surgeons: The diagnosis and treatment of heel pain. J Foot Ankle Surg 40:329-340, 2001

3. Buchbinder R: Clinical practice. Plantar fasciitis. N Engl J Med 350: 2159-2166, 2004

4. ‌Carlson R, Fleming L, Hutton W: The biomechanical relationship between the tendoachilles, plantar fascia and metatarsophalangeal joint dorsiflexion angle. Foot Ankle Int 21:18-25, 2000

5. ‌Nelson K (editor)Somatic Dysfunction in Osteopathic Family Medi- cine. Baltimore, MD: Lippincott Williams & Wilkins, 2007

6. ‌DiGiovanni BF, Nawoczenski DA, Lintal ME, et al: Tissue-specific plantar fascia stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg [Am] 85-A:1270-1277, 2003

7. Wynne MM, Burns JM, Eland DC, et al: Effect of counterstrain on stretch reflexes, Hoffmann reflexes, and clinical outcomes in subjects with plantar fasciitis. JAOA 106;547-556, 2006

8. ‌Jones LH: Strain and Counterstrain. Newark, OH: American Acad- emy of Osteopathy, 1981

9. ‌Norris DM, Eickmeier DM, Werber BR: Effectiveness of extracorpo- real shockwave treatment in 353 patients with chronic plantar fasciitis. J Am Podiatr Med Assoc 95:517-524, 2002

10. Osborne HR, Allison GT: Treatment of plantar fasciitis by low dye taping and iontophoresis: short term results of a double blinded, randomised, placebo controlled clinical trial of dexamethasone and acetic acid. Br J Sports Med 40:545-549, 2006

11. ‌Pfeffer G, Bacchetti P, Deland J, et al: Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int 20:214-221, 1999

12. ‌Tsai WC, Hsu CC, Chen C, et al: Plantar fasciitis treated with local steroid injection: comparison between sonographic and palpation guid- ance. J Clin Ultrasound 34:12-16, 2006

13. ‌Folman Y, Bartal G, Breitgand A, et al: American College of Foot and Ankle Surgeons: Treatment of recalcitrant plantar fasciitis by sono- graphically-guided needle fasciotomy. Foot and Ankle Surgery 11: 211-214, 2005

14. Buchbinder R, Ptasznik R, Gordon J, et al: Ultrasound-guided extra- corporeal shock wave therapy for plantar fasciitis: a randomized con- trolled trial. JAMA 288:1364-1372, 2002

15. ‌Footlaw.com: Endoscopic plantar fasciotomies/heel pain. Available at:

    http://footlaw.com/news/heel-pain.html. Accessed May 20, 2011.

16. ‌ClinicalTrials.gov: Prolotherapy for the treatment of plantar fasciitis. Available at: http://clinicaltrials.gov/ct2/show/NCT01326351. Ac- cessed May 20, 2011.

17. ‌Sampson S, Gerhardt M, Mandelbaum B: Platelet rich plasma injection grafts for musculoskeletal injuries: a review. Musculoskelet Med 1:165-174, 2008

18. ClinicalTrials.gov: Platelet rich plasma to treat plantar fasciitis. Avail- able at: http://clinicaltrials.gov/ct2/show/NCT00758641. Accessed May 20, 2011.