Plantar fasciitis

This common condition is mainly self-limiting, says Dr Gurjit Bhogal.

History and examination alone are usually sufficient to make a diagnosis of plantar fasciitis (Photograph: SPL)
History and examination alone are usually sufficient to make a diagnosis of plantar fasciitis (Photograph: SPL)

Plantar fasciitis commonly affects sedentary individuals, recreational exercisers and elite athletes alike. 15% of all foot complaints presenting to GPs are diagnosed as plantar fasciitis and it is estimated to cause 10% of all injuries that are due to running.1

The highest incidence occurs in those aged 40-60 years,2 and the associated pain can impact significantly on work and social activities. Most cases are self-limiting - 80% will resolve within a year.1

Treating chronic cases, however, is difficult and the evidence base for treatments is limited. This article is an overview of non-surgical management of plantar fasciitis.

1. Aetiology

The plantar fascia has a key role in the integrity of the medial longitudinal arch of the foot, thereby playing a vital part in supporting the foot during weight-bearing activities. Plantar fasciitis occurs if the fascia becomes chronically overloaded.

The name implies an inflammatory pathology; however, tissues removed after surgery in patients with recalcitrant symptoms have shown no acute inflammatory cells. Histology shows a degenerative, not an inflammatory process, similar to conditions such as Achilles or patellar tendinopathy.3

The stretching of the degenerative, overloaded plantar fascia is the cause of the pain during walking or running.

2. Risk factors and presentation

Risk factors include obesity, prolonged standing, reduced ankle dorsiflexion and pes planus/cavus.4 The condition of footwear, a recent increase in weight-bearing activity, and hard surfaces or ground have also been implicated.

Typically, patients complain of gradual onset inferior-medial heel pain on weight-bearing; paraesthesia is not a usual feature. The pain is classically worst after rest, especially in the morning. This may be so severe that initially, the patient is unable to bear weight on the affected foot, but as the patient continues to walk, it eases.

A dull ache often persists and can limit activity, especially exercise. Palpation usually reveals an area of maximal tenderness near the medial attachment of the fascia to the calcaneum.

3. Diagnosis

It is generally acknowledged that history and examination alone are sufficient to diagnose plantar fasciitis. Investigations, bloods and imaging are only requested if the clinical presentation is not typical.

The history should cover red flag symptoms, including night pain and fever, to help exclude cancer and infection. Bilateral symptoms should raise suspicion of spondyloarthropathies and further questioning of joint, urinary, ocular and skin symptoms should occur.

If the history includes symptoms of paraesthesia, careful examination of the lumbar spine and lower limb neurology will help exclude S1 radiculopathy or local nerve entrapments (such as tarsal tunnel syndrome, also called posterior tibial nerve entrapment) as causes.1

4. Initial management

Plantar fasciitis is a self-limiting condition that GPs can manage. The initial advice is relative rest, use of NSAIDs and stretching of the calf muscle and plantar fascia.

Initial treatment aims to reduce the load through the fascia and allow the area to regenerate. A reduction in activities that exacerbate the symptoms is sensible. Data suggest that a combination of calf stretches and plantar fascia stretching by massage is effective.5 The patient can use a chilled soft drink can or a golf ball to provide an adequate stretch through massage.

The role of NSAIDs is questionable because the pathology is degenerative and their use seems to be exclusively pain-relieving. Analgesia such as paracetamol may be more appropriate. If used consistently, a Strassburg sock, worn overnight, keeps the ankle in relative dorsiflexion and reduces morning pain.

If these initial interventions fail, the medial longitudinal arch can be targeted - if the arch is supported with suitable footwear or orthotics, the pressure through the fascia may be off-loaded.

Exercises to strengthen the intrinsic muscles of the foot improve the function of the arch and reduce stress on the fascia. Examples of exercises include the patient picking up a towel from the floor by curling their toes to grip it while their heel remains grounded. Referral to a physiotherapist will allow further instruction on stretching and strengthening exercises.

5. Recalcitrant cases

Recalcitrant cases might require an intervention to reduce pain more potently or to stimulate the degenerative fascia to regenerate. The most common intervention is the painful injection of corticosteroid with local anaesthetic to the area of greatest tenderness.

This is an effective analgesic in the short term, but carries a risk of plantar fascia rupture. The long-term effectiveness, however, is similar to placebo.6 Fascia rupture is associated with a few months of increased foot pain, but patients are usually pain-free thereafter.

Regenerative procedures include dry needling, use of autologous blood injections, extracorporeal shockwave therapy or platelet-rich plasma injections. These procedures bring growth factors to, or stimulate inflammation at, the degenerative fascia, which theoretically promotes regeneration. However, they all have inconclusive evidence to support them and are infrequently used.

  • Dr Bhogal is a locum GP in Worcestershire and a registrar in sports medicine, Centre for Sports Medicine, Queen's Medical Centre, Nottingham

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References
1. Buchbinder R. Plantar fasciitis. N Engl J Med 2004; 350(21): 2159-66.

2. Dyck DD, Boyajian-O'Neill LA. Plantar fasciitis. Clin J Sport Med 2004; 14(5): 305-9.

3. Khan KM, Cook JL, Bonar F et al. Histopathology of common tendinopathies. Update and implications for clinical management. Sports Med 1999; 27(6): 393-408.

4. Riddle DL, Pulisic M, Pidcoe P et al. Risk factors for plantar fasciitis: a matched case-control study. J Bone Joint Surg Am 2003; 85-A(5): 872-7.

5. DiGiovanni BF, Nawoczenski DA, Lintal ME et al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. J Bone Joint Surg Am 2003; 85-A(7): 1270-7.

6. Crawford F, Atkins D, Young P et al. Steroid injection for heel pain: evidence of short-term effectiveness. Rheumatology (Oxford) 1999; 38(10): 974-7.

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