AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Background

Plantar fasciitis is a common foot disorder encountered in the outpatient clinic.^{1, 2, 3, 4, 5} The typical presentation is sharp pain localized along the middle to posterior aspect of the sole of the foot. Plantar fasciitis is often, but not always, associated with a heel spur (exostosis). Most patients with this condition have satisfactory outcomes with nonsurgical treatment.⁶

See also the following related eMedicine topics:
Plantar Fasciitis [Emergency Medicine]
Plantar Fasciitis [Orthopedic Surgery]
Plantar Fasciitis [Sports Medicine]
Plantar Heel Pain

Pathophysiology

Excessive stretch of plantar fascia can result in microtrauma (microtears) of the plantar fascia at its insertion on the medial calcaneal tuberosity or along the course of the fascia. This microtrauma, if repetitive, can result in chronic inflammation and degeneration of the plantar fascia fibers. Repetitive microtrauma at the plantar fascia may cause significant plantar pain, particularly with the first few steps after sleep or other periods of inactivity.

Frequency

United States

Plantar fasciitis is a common problem; however, the exact incidence and prevalence have not been determined.

Mortality/Morbidity

No mortality is associated with this condition, but patients may experience progressive plantar pain, leading to limping (antalgic gait) and restriction of activities, such as walking and running.

Sex

Women are affected by plantar fasciitis twice as often as men.

Age

The exact incidence and prevalence by age of plantar fasciitis is unknown, but the condition is seen in adults essentially of all ages. An increased incidence exists in patients with certain spondyloarthropathies (eg, ankylosing spondylitis), which often present in patients aged 20-40 years.

See also the following related Medscape topic:
CME Tackling the Controversies of Biologic Therapy in Rheumatoid Arthritis and Spondyloarthropathy: Application of Emerging Clinical Data Into Daily Treatment Decisions

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

History

• The chief complaint is plantar pain, generally localized to an area 1-2 cm distal to the medial calcaneal tuberosity.
• Inquire about the onset of the symptoms, as well as about any precipitating factors.
• • Ask the patient what makes the pain worse and what makes it better.
  • Most patients report that the pain usually is most severe during the first few steps after prolonged inactivity, such as sleeping or sitting.
• Patients may report that symptoms typically are relieved by unloading the affected foot (via sitting, elevation, or other means).
• Patients who are generally on their feet all day report that the symptoms may actually worsen by the end of the day.
• Important elements in the history of this condition include various activities, such as recreational running, as well as changes in footwear and previous trauma to the foot (eg, falls, motor vehicle accidents, work-related injuries).
• If this condition occurred in the course of the patient's employment, then it may be considered a worker's compensation issue. The physician should obtain a thorough history of the onset of the pain, any previous diagnostic assessment and/or treatments, and current functional capacities. This history is important for potential medicolegal purposes, such as impairment ratings.

Physical

• Inspection of the foot is the first step in the physical examination. Note any obvious deformities, skin changes, or congenital conditions (eg, pes planus [flatfoot]). Patients with plantar fasciitis often present with tightness of the Achilles tendon.
• The most important physical finding is reproduction of pain by palpating the plantar surface over the medial calcaneal tuberosity and along the course of the plantar fascia. Passive dorsiflexion of the toes usually does not aggravate the symptoms of plantar fasciitis, but it may do so in severe cases.
• To ensure that the patient is not presenting with retrocalcaneal bursitis or Achilles tendonitis, the clinician also should palpate the posterior aspect of the heel and ankle to look for tenderness.
• To rule out an S1 radiculopathy, perform the straight leg raise test, Achilles tendon reflex, and calf strength assessment with toe walking or 1-legged heel raises. All test results are within the reference range in the patient with plantar fasciitis.
• Tarsal tunnel syndrome can be ruled out by percussing over the tarsal tunnel behind the medial malleolus. This test produces no pain in the patient with plantar fasciitis.
• Reproduction of pain in the forefoot by compressing together the metatarsal heads of the second and third or the third and fourth toes suggests the presence of a Morton neuroma and is not a typical finding in plantar fasciitis. Morton neuroma is due to the entrapment of the common digital nerve between the metatarsal heads.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Other Problems to Be Considered

Acute traumatic rupture of the plantar fascia
Calcaneal neuritis
Calcaneal stress fracture
Lumbosacral radiculopathy of S1 nerve root

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Lab Studies

• No specific laboratory studies are needed to confirm the diagnosis of plantar fasciitis unless there is a bilateral presentation that appears in association with some seronegative spondyloarthropathies. Then the standard hematologic and chemistry studies may include, but are not limited to, a complete blood cell count, an erythrocyte sedimentation rate, complete metabolic panel, rapid plasma reagin, and rheumatoid factor study.

Imaging Studies

• Radiographic imaging of the foot generally confirms the clinical examination and may reveal a heel spur that is the result of this condition and not a cause. The heel spur is best seen on the lateral view, located at the antero-inferior aspect of the calcaneus. Radiographic films of the foot should be obtained prior to corticosteroid injection or for any patient who continues to have symptoms despite 1-2 months of conservative, nonsurgical treatment. Standing lateral radiographs may help in the assessment for stress fractures of the calcaneus (a rare condition) in patients with pain at rest.
• Three-phase bone scanning is helpful for patients in whom there is a suggestion of a stress fracture of the calcaneus in spite of negative findings with plain radiography. In plantar fasciitis, a bone scan often shows increased uptake over the medial calcaneal tuberosity due to the local inflammation. This should not be confused with a stress fracture that shows increased uptake elsewhere in the calcaneus.
• If stress fracture remains a significant consideration despite negative radiographic findings, further imaging studies could include a computed tomography (CT) scan.
• Plantar fasciitis can be identified using ultrasonography by visualizing a thickened heel aponeurosis.^{7, 8}

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Rehabilitation Program

Physical Therapy

The mainstay physical therapy treatment for plantar fasciitis is stretching.⁹ There are a number of ways to stretch the plantar fascia and the Achilles tendon.

• For patients who report that the most severe symptoms occur with the first steps after awakening, stretches should be performed before the patient even gets out of bed. This can be accomplished by keeping a long towel at the bedside. When the patient wakes up, he/she can stretch the plantar fascia by using the towel to cause passive dorsiflexion of the ankle, with each hand pulling one end of the towel, using the midportion of the towel to pull on the plantar aspect of the forefoot region.
• Other techniques for stretching the Achilles tendon include passive stretch while standing and nighttime ankle foot orthoses to keep the feet in neutral at night (thus stretching the Achilles tendon).
• The plantar fascia also can be stretched by having the patient, while seated, roll a soda can between the sole and the floor. Using a cold can of soda may give further symptomatic relief through local cooling.
• Passive stretching of the plantar fascia also can be achieved by using one hand at the plantar aspect of the forefoot region, then dorsiflexing the foot.
• A study found non–weight-bearing stretching exercises specific to the plantar fascia to be superior to the standard program of weight-bearing, Achilles tendon–stretching exercises in patients with chronic plantar fasciitis.¹⁰

Massage of the plantar fascia, accomplished by running the thumb or fingers lengthwise along the fascia, can be beneficial for patients with plantar fasciitis. The physical therapist may complete this technique within therapy sessions and may instruct the patient or family members on how to continue the massage independently at home.

Application of ice is an important part of the treatment process to reduce pain and inflammation. Ice should be applied after exercise and may be performed either as an ice massage for 5 minutes or by applying an ice pack for 15-20 minutes. The physical therapist also may recommend other modalities, such as ultrasonography, phonophoresis, or iontophoresis, to assist further with pain relief and reduction of inflammation.

Sometimes, taping of the plantar fascia by an athletic trainer or physical therapist can help to decrease stress on the fascia, enabling the patient to better tolerate activity. Taping techniques are used to distribute force away from the stressed and irritated fascia and to provide some relief from discomfort caused by weight-bearing activities.

If the patient needs to decrease his/her activity level due to this condition, remember to suggest alternative means of maintaining strength and cardiovascular fitness (eg, swimming, water aerobics, other aquatic exercises). Generally, in patients with plantar fasciitis due to work-related causes, the physical therapist can perform work-hardening activities with physician supervision.

Medical Issues/Complications

• The main rehabilitation medicine issue in plantar fasciitis is that chronic plantar pain leads to increased limping; this can produce an antalgic gait pattern that may hinder and possibly decrease mobility to levels that are unacceptable for the performance of activities of daily living (ADLs), including work and recreation.
• Medical complications of plantar fasciitis are limited to aggressive medical interventions when conventional therapy, nonsteroidal medications, and modalities (eg, heat, cold, ultrasonography) have failed to achieve resolution of the symptoms. Corticosteroid injection into the superficial fat pad may cause fat pad necrosis, due to loss of the shock absorption normally provided by the superficial fat pad, with subsequent pain during the early part of stance phase with ambulation. This development could create a significant disability in the event of a worker's compensation case.

Surgical Intervention

• Surgical intervention, which rarely is required, involves a resection to release the plantar fascia from its bony attachment at the calcaneus.
• A study by Bazaz and Ferkel found that endoscopic plantar fascia release provided significantly improved outcomes for patients, specifically those with less severe symptoms.¹¹

Consultations

• Many authors advise against considering surgical referral/intervention until a minimum of 6-9 months of comprehensive nonsurgical treatment has been completed.

Other Treatment

• Shoe inserts and heel pads - A heel pad typically is considered part of the initial treatment. These prefabricated orthotic devices, which are available at most pharmacies and surgical supply stores, are relatively inexpensive. The heel insert can be made of silicone, rubber, gel, or felt.
• Orthotic arch supports - These have also been advocated to improve symptoms. The orthotic device can support the bony arch and decrease the stress on the plantar fascia.
• Corticosteroid injection - This can be considered for plantar fasciitis in the relatively small percentage of patients who do not respond to an appropriate plantar stretching program and/or appropriate shoe inserts or orthoses.^{12, 13}
• • A randomized, controlled study demonstrated that intralesional corticosteroid injection is more efficacious and more cost-effective than low-energy extracorporeal shockwave therapy in the treatment of plantar fasciitis that has persisted for more than 6 weeks.¹⁴
  • Corticosteroid injection can be performed for plantar fasciitis, typically using a 22-gauge, 1.5-in (3.8-cm) needle to inject a mixture of 4 mL of local anesthetic (eg, lidocaine) and 1 mL (40 mg) of corticosteroid (eg, methylprednisolone [Depo-Medrol]).
  • Palpate the most anterior aspect of the medial plantar calcaneal tubercle and insert the needle at this site. Advance the needle until it reaches the most anterior (distal) aspect of the plantar medial calcaneal tuberosity. When the proximal (anterior) edge of the heel spur has been identified, advance the needle immediately anterior to this spot. Avoid injecting within the superficial layers of the subcutaneous tissue, because corticosteroid injection into the superficial fat pad can cause fat necrosis and atrophy, resulting in a loss in the shock absorption of the plantar heel.
  • In a preliminary report, a posterior tibial nerve block prior to steroid injection was shown to decrease the pain from injection and to improve compliance with treatment, without any complications.¹⁵
  • Bleeding or bruising generally is expected only in patients who have bleeding disorders or are taking anticoagulants.
  • Infection at the injection site is rare, but possible. In addition to the sterile technique for the procedure itself, patients need to maintain good foot hygiene after the injection.
  • In diabetic patients, transient elevation of blood glucose levels may occur after corticosteroid injection.
  • Allergic reactions to the injected medications are rare, but possible.
  • Intravascular injection could potentially cause cardiac dysfunction, due to the inherent toxicity of local anesthetic agents.
  • Peripheral nerve dysfunction is possible if the local anesthetic is injected either close to or within the medial plantar nerve or the calcaneal branch of the tibial nerve.
  • Trials of ultrasonographically-guided steroid injection have shown its potential efficacy. It has been shown to produce a good clinical response when palpation-guided injection is unsuccessful.¹⁶ Accurate injection under ultrasonographic guidance may also minimize adverse effects from the injection.¹⁷
  • A study of 25 patients who received corticosteroid injection for plantar fasciitis showed that patients received symptomatic relief as measured by tenderness threshold and a visual analog scale (VAS) (P <0.001).¹⁷ The study showed that this symptomatic benefit was obtained whether the injection was performed with image guidance (ultrasonography) or with palpation alone. However, patients injected using image guidance showed a lower rate of recurrence of heel pain. Thus, although injection with or without image guidance is helpful, image guidance does appear to provide additional benefit.
• Shockwave therapy - A meta-analysis seemed to show that shockwave therapy could be a safe and effective nonsurgical treatment for plantar fasciitis.¹⁸ Further research into this area seems warranted.
• Botulinum toxin type A injection - Botulinum toxin type A injection seems to produce significant improvements in pain relief and overall foot function according to a short-term, randomized, controlled, double-blinded study.¹⁹
• Cryosurgery - A prospective study suggests that cryosurgery is an effective treatment for plantar fasciitis after failed conservative management, without resorting to open, invasive surgery.²⁰

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medications are used primarily to decrease pain and inflammation. The most commonly used medications are oral nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections employed in conjunction with physical therapy.

Drug Category: Nonsteroidal anti-inflammatory drugs

These agents can help to decrease pain and inflammation. Various oral NSAIDs can be used, as there are no particular drugs of choice. Choice of NSAID is largely a matter of convenience (how frequently doses must be taken to achieve adequate analgesic and anti-inflammatory effects) and cost.

Drug Category: Corticosteroids

In contrast to the widespread systemic distribution of an oral anti-inflammatory drug, a local corticosteroid injection can achieve focal placement of a potent anti-inflammatory agent at the site of maximal tenderness or inflammation. When corticosteroid injections are used, there are a variety of corticosteroid preparations to choose from. Commonly, the corticosteroid is mixed with a local anesthetic agent prior to injection. Again, there are various local anesthetic agents from which to choose.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Further Outpatient Care

• The patient should return for a re-evaluation no more than approximately 1 month after initial evaluation and implementation of a rehabilitation program.
• Patients requiring more aggressive treatment due to severe disruption of their athletic, occupational, or recreational activities may need to be seen more frequently, mainly for re-assurance and to chart progress with therapeutic interventions.
• At the time of follow-up, assess the therapeutic response to the corticosteroid injection and evaluate for any complications.
• The patient should be instructed to contact the physician before the scheduled follow-up appointment if there is significant progression of the symptoms or if there are any local signs of infection at the injection site.

Deterrence

• Education is the single most important means of deterrence and prevention of plantar fasciitis. Sports-minded patients (especially runners) should be advised on the appropriateness of their shoes. Padding, sole stiffness, and appropriate arch support all can help to alleviate symptoms. The patient may need to decrease his/her running temporarily and resume at the discretion of the physician and physical therapist. In cases of occupationally related plantar fasciitis, evaluation of the worker's shoes and work environment is essential to preventing a recurrence of this musculoskeletal condition.

Complications

• Please see Medical Issues/Complications for a discussion of complications, such as plantar fat pad atrophy secondary to corticosteroid injection.

Prognosis

• Most patients with plantar fasciitis are treated successfully with aggressive nonsurgical treatment.

Patient Education

• The patient should understand proper performance of a home exercise program involving stretching the plantar fascia.
• The patient should be educated to watch for any signs or symptoms of local infection at the injection site, while maintaining good skin hygiene.
• Diabetic patients should be informed that they may experience a transient increase in blood glucose levels and should be instructed to monitor their blood sugar carefully for the week following the corticosteroid injection.
• Patients should be informed that the symptomatic improvement from the corticosteroid usually does not begin to take effect until a few days after the injection. They may experience a transient, mild increase in symptoms when the effect of the short-term local anesthetic has ended but the long-term corticosteroid effect has not yet begun.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical/Legal Pitfalls

• Improper placement of a corticosteroid injection for plantar fasciitis can result in necrosis and atrophy of the plantar fat pad at the heel. This complication may result in significant pain and a decreased activity level for the patient.

Special Concerns

• Pregnancy - Corticosteroid injection can be performed during pregnancy, although safety for use during pregnancy has not been established. Oral NSAIDs should be avoided during pregnancy.
• Pediatric population - Obtain informed consent from the parent or legal guardian before proceeding with examination or any injection.
• Geriatric patients - Use NSAIDs with caution in elderly patients, monitoring for the most common adverse effects and for any drug interactions.
• Diabetes - Some patients with diabetes may experience a transient elevation in blood glucose levels after corticosteroid injection.

ACKNOWLEDGMENTS

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Debra Ibrahim, 4th year medical student, New York College of Osteopathic Medicine, Class of 2008, assisted with the 2007 revision of this manuscript.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

1. Brinker MR, Miller MD. Common adult conditions of the foot. In: Fundamentals of Orthopaedics. Philadelphia, Pa: WB Saunders; 1999:349-58.
2. McGee DJ. Lower leg, ankle and foot. In: Orthopedic Physical Assessment. 2^nd ed. Philadelphia, Pa: WB Saunders; 1992:448-513.
3. Snider RK. Plantar fasciitis. In: Snider RK, ed. Essentials of Musculoskeletal Care. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997:464-9.
4. Tarquinio TA. Foot. In: Steinberg GG, Akins CM, Baran DT, eds. Orthopaedics in Primary Care. 3^rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999:268-96.
5. Young JL, Olsen NK, Press JM. Musculoskeletal disorders of the lower limbs. In: Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders; 1996:783-812.
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7. Cole C, Seto C, Gazewood J. Plantar fasciitis: evidence-based review of diagnosis and therapy. Am Fam Physician. Dec 1 2005;72(11):2237-42. [Medline]. [Full Text].
8. Hsu CC, Tsai WC, Chen CP, et al. Ultrasonographic examination of the normal and injured posterior cruciate ligament. J Clin Ultrasound. Jul-Aug 2005;33(6):277-82. [Medline].
9. Radford JA, Landorf KB, Buchbinder R, et al. Effectiveness of calf muscle stretching for the short-term treatment of plantar heel pain: a randomised trial. BMC Musculoskelet Disord. Apr 19 2007;8:36. [Medline]. [Full Text].
10. Flanigan RM, Nawoczenski DA, Chen L, et al. The influence of foot position on stretching of the plantar fascia. Foot Ankle Int. Jul 2007;28(7):815-22. [Medline].
11. Bazaz R, Ferkel RD. Results of endoscopic plantar fascia release. Foot Ankle Int. May 2007;28(5):549-56. [Medline].
12. Geiringer SR. Tendon sheath and insertion injections. In: Lennard TA, ed. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:44-8.
13. Lee TG, Ahmad TS. Intralesional autologous blood injection compared to corticosteroid injection for treatment of chronic plantar fasciitis. A prospective, randomized, controlled trial. Foot Ankle Int. Sep 2007;28(9):984-90. [Medline].
14. Porter MD, Shadbolt B. Intralesional corticosteroid injection versus extracorporeal shock wave therapy for plantar fasciopathy. Clin J Sport Med. May 2005;15(3):119-24. [Medline].
15. Govindarajan R, Bakalova T, Doss NW, et al. Posterior tibial nerve block in the therapeutic management of painful calcaneal spur (plantar fasciitis): a preliminary experience. Can J Anaesth. Oct 2003;50(8):862-3. [Medline]. [Full Text].
16. Kane D, Greaney T, Bresnihan B, et al. Ultrasound guided injection of recalcitrant plantar fasciitis. Ann Rheum Dis. Jun 1998;57(6):383-4. [Medline]. [Full Text].
17. Tsai WC, Wang CL, Tang FT, et al. Treatment of proximal plantar fasciitis with ultrasound-guided steroid injection. Arch Phys Med Rehabil. Oct 2000;81(10):1416-21. [Medline].
18. Ogden JA, Alvarez RG, Marlow M. Shockwave therapy for chronic proximal plantar fasciitis: a meta-analysis. Foot Ankle Int. Apr 2002;23(4):301-8. [Medline].
19. Babcock MS, Foster L, Pasquina P, et al. Treatment of pain attributed to plantar fasciitis with botulinum toxin A: a short-term, randomized, placebo-controlled, double-blind study. Am J Phys Med Rehabil. Sep 2005;84(9):649-54. [Medline].
20. Allen BH, Fallat LM, Schwartz SM. Cryosurgery: an innovative technique for the treatment of plantar fasciitis. J Foot Ankle Surg. Mar-Apr 2007;46(2):75-9. [Medline].

Article Last Updated: Mar 31, 2008