Plantar Faciitis
Plantar Faciitis is considered the primary foot condition treated by health care providers. It has been estimated that, 2 million Americans are affected by Plantar Faciitis each year (Cleland et al 2009)
Recent histological research by Lemont et al suggests that plantar fasciitis is more of a degenerative process without inflammatory cells and that the term fasciosis may be more appropriate.
The specific causes of plantar fasciitis are not well understood. Riddel et al (2003) found that the risk of plantar faciitis increases as ankle dorsiflexion decreases. Other factors related to increased risk were a body mass index of greater than 30kg/m2 and spending the majority of the workday on one’s feet. A review of risk factors by Irving et al (2006) of chronic plantar heel pain also found a strong association with increased body mass index, as well as a calcaneal spur in the non-athletic population. There was a reported weak association with increased age, decreased ankle dorsiflexion, decrease first MTP extension and prolonged standing. Inconclusive evidence was reported with respect to static and dynamic foot postures.
Typically, an individual with plantar fasciitis will report pain along the medial border of the plantar fascia near its origin at the medial tuberosity of the calcaneus. The individual may describe the pain as worse in the morning with the first few steps or after sitting for a prolonged period. The pain is less during normal daily activities but will tend to increase with participation in more intense sport or activity.
The following differential diagnosis should be considered with respect to plantar heel pain: calcaneal stress fracture, bone bruise, fat pad atrophy, tarsal tunnel syndrome, tumors, PagetDisease, Sever’s Disease, and S1 radiculopathy.
Lateral non weight bearing x rays views to assess plantar fascia and fat pad thickness have been found to have a 85% sensitivity and 95% specificity in a study to distinguish between subjects with plantar faciitis. Interestingly, the authors concluded that calcaneal spurs were not a key x-ray feature in plantar fasciitis (Osborne et al 2006).
Clinical Practice Guidelines (2008) make the following treatment recommendations:
Anti- inflammatory agents No randomized clinical trials to support the use of NSAIDS in treating plantar fasciitis were reported. Considering the recent suggestion of a degenerative non- inflammatory process there seems to be little indication for anti -inflammatory agents in treating plantar fasciitis. Injection of steroids into the plantar fascia has produced mixed results. There are noted concerns of fascia rupture and fat pad degeneration following steroid injection.
Orthotics: Effective to provide short- term improvement (1 – 3 months) in pain and function, however no difference was found at the one year mark.. Pre- fabricated and custom orthotics seem to be equally effective.
Stretching – Both calf muscle and plantar fascia stretching are recommended to improve both pain and flexibility.
Taping – Low dye taping is recommended to offer short -term improvement in pain (7-10 days).
Night splints – Splints worn at night to prevent shortening of the plantar fascia are helpful for short- term pain relief and improvement in function for those individuals who have had plantar fasciitis for greater than 6 months.
Manual Therapy –Clinical practice guidelines support the use of manual therapy to treat plantar fasciitis based on theoretical and foundational evidence. A recent randomized clinical trial by Cleland(2009) compared manual treatment and exercise to electrophysical agents and exercise. The manual techniques in each case were chosen based on objective measures and included joint mobilization of the talocrural, subtalar, forefoot, midfoot or hip joints, neural mobilizations of the tibial or plantar nerve and soft tissue mobilization of the triceps surae or the plantar fascial origin. Both interventions demonstrated benefit but manual therapy and exercise were found to have superior results at both the short term (4 weeks) and long term follow up (6 months).
References
Irving DB, Cook JL, Menz HB. Factors associated with chronic plantar heel pain: a systematic review. J Sci Med Sport. 2006;9:11-22
Osborne HR, Breidahl WH, Allison GT. Critical differences in lateral X-rays with and without a diagnosis of plantar fasciitis. J Sci Med Sport. 2006;9:231-237.
Riddle DL, Pulisic M, PidcoeP, Johnson RE. Risk factors for plantar fasciitis: a matched case-control study. J Bone Joint Surg Am. 2003;85-A:872-877.
McPoil TG, Martin RL. Heel pain – plantar fasciitis: Clinical practice guidelines. J Orthop Sports Phys Ther. 2008;38(4):11-18.
Cleland JA, Abbott JH, Kidd MO, Stockwell S, Cheney S, Gerrard DF, Flynn TW. Manual physiotherapy and exercise verses electrophysical agents and exercise in the management of plantar heel pain: a multicenter randomized clinical trial. J Orthop Sports Phys Ther 2009;39(8):573-585.