Plantarfascitis

Diagnosis/Definition

Inflammation of the thick fibrous band of tissue that courses through the arch of the foot and inserts into the inferior aspect of the heel. It is the most common cause of arch and heel pain and is commonly associated with a heel spur.

Initial Diagnosis and Management

• History: Patient complains of either a diffuse area of pain in the arch area which increases with any type of prolonged activity (generalized type) or pain in the heel when rising out of bed which slowly improves after several minutes of walking (localized type). The localized type of fasciitis is commonly associated with a heel spur and is more common in middle aged people. Patients should be questioned about the following factors, all of which can cause/exacerbate plantar fasciitis: barefoot walking, wearing sandals, loafers, moccasins, deck shoes, badly worn shoes, shoes with no arch support or shoes with a flexible shank (the shank is the middle part of the sole, immediately in front of the heel- it should be rigid/stiff), excessive running or running on unstable surfaces (e.g. sand), or recent weight gain.

• Exam: Tenderness along the fascia as it courses through the arch (generalized type) or point tender at the plantar/medial plantar area of the heel (localized type). Check ankle joint ROM. Less than 10 degrees of dorsiflexion with the knee extended will aggravate fasciitis. Check posture of foot with patient standing. Plantar fasciitis can be seen in any foot type but is more prevalent in the overpronated (flat) foot.

• Radiograph Evaluation: Lateral and AP weight bearing views of the foot. (The presence of an infra-calcaneal heel spur does not change the management of plantar fasciitis; symptoms are identical whether or not a spur is present.)

• Initial Treatment: Treatment is the same for the generalized type (arch pain) and the localized type (heel pain). Limit activity for 30 days. No barefoot walking. Lace-up rigid shanked shoes only (e.g. moderate to high quality running shoe, walking shoe or cross-trainer). No wearing of sandals, loafers, badly worn shoes, slippers or flexible shanked shoes. Add OTC arch support (e.g. “ Polysorb” insoles) to shoes, NSAIDs, and calf stretches.

Ongoing Management and Objectives

Major objective is to prevent excessive stretch of the plantar fascia by wearing an appropriate shoe with an arch support in it whenever the patient is standing, walking or running, including off-duty for military patients. If symptoms persist beyond 30 days continue initial treatment and have the patient use an NSAID different from the one given originally. The patient should be instructed in manually stretching the plantar foot before arising from bed or after periods of prolonged non-weight bearing by bringing the great toe upward into dorsiflexion and holding for 15 seconds.

Indications for Specialty Care Referral

If symptoms have not improved after one month the patient should be sent to physical therapy for evaluation and fitting for a plantar fasciitis orthosis or other interventions as indicated.

The above treatments should be utilized for at least six months before a referral to podiatry is considered. The patient needs to be informed of the recalcitrant nature of this condition and the importance of wearing an appropriate shoe with an arch support, every day, whenever weight bearing, in order for the condition to resolve. Patients can expect possible injection treatment in the Podiatry clinic.

Information on the evaluation and treatment of plantar fasciitis is available in the Podiatry Clinic.

Criteria for Return to Primary Care

Patient will be returned to primary care provider for chronic management following resolution of acute condition along with recommendations for long term treatment.

Patients requiring surgery will be followed in the podiatry clinic until the peri-operative period is complete