CKS Clinical solutions - Plantar fasciitis

A 52-year-old school dinner lady consults complaining of right heel pain for the past four months.

The heel may be tender on examination
The heel may be tender on examination

The case
A 52-year-old school dinner lady consults complaining of right heel pain for the past four months.

It is particularly painful first thing in the morning and at the end of her working day. After taking a history and examining her, you diagnose plantar fasciitis.

What is plantar fasciitis?
Plantar fasciitis is persistent pain associated with chronic degenerative processes affecting the origin of the plantar fascia and surrounding peri-fascial surfaces.

It affects one in 10 people, being most common in patients aged 40-60, and is twice as common in women as in men.

How do I make a diagnosis?
There is a history of intense pain during the first steps after waking or after a period of inactivity. Typically, pain reduces with moderate activity, but worsens later in the day or after long periods of standing or walking. Onset is gradual.

On examination, there is tenderness of the plantar heel area, and there may be limited ankle dorsiflexion, pain on extension of the first metatarsophalangeal joint (a positive 'Windlass' test) and a limp.

Four out of five patients with heel pain will have plantar fasciitis. If clinical signs are absent or inconsistent, consider an alternative diagnosis.

What is the treatment?
Offer reassurance that most make a full recovery within one year. Advise patients to wear shoes with good arch support and cushioned heels, to avoid standing or walking for long periods (if possible), and to lose weight if overweight. Recommend stretching exercises (see CKS website).

Insoles and orthoses can be purchased, with the aim of correcting foot pronation. Ice and simple analgesia can help.

When should I refer?
Refer to a podiatrist (or physio-therapist) if symptoms have not improved with conservative measures after three months.

If interventions have proved inadequate, consider offering a corticosteroid injection after discussing the benefits and possible harms, including plantar fat-pad degeneration and plantar fascia rupture. Injection may be offered sooner than three months if symptoms are having a severe impact on quality of life.

Do not repeat if symptoms do not improve after the first dose; consider an alternative diagnosis. Wait a minimum of six weeks between injections. Refer back to the podiatrist if symptoms persist despite three or more injections.

Evidence
CKS has based these recommendations on published guidelines1-3 and a narrative review,4 although the available trial evidence for interventions is poor.

Stretching exercises are recommended by most experts, although there is a lack of quality evidence from randomised controlled trials to support their use. There is limited evidence that prefabricated orthoses are equivalent in efficacy to custom-made,5 but lack of placebo-controlled trials means overall effectiveness is uncertain.

The evidence to support the use of injected corticosteroids is generally poor5 as placebo-controlled trials have not been conducted.

Reliable, evidence-based answers to real-life clinical questions, from the NHS Clinical Knowledge Summaries in association with GP.  See www.cks.nhs.uk

References

1. ARC. Plantar fasciitis and heel pain. Arthritis Research Campaign, 2004. www.arc.org.uk

2. McPoil T G, Martin R L, Cornwall MW et al. J Orthop Sports Phys Ther 2008; 38: A1-A18.

3. Foye P M, Stitik T P. Plantar fasciitis. eMedicine. Medscape, 2008. www.emedicine.com

4. Neufeld S K. J Am Acad Orthop Surg 2008; 16: 338-46.

5. Crawford F, Thomson C. Cochrane Database Syst Rev 2003; (3): CD000416.

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