Updated: 12/28/2021

Plantar Fasciitis

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  • Snapshot
    • A 45-year-old woman presents to the physician’s office for foot pain. She reports that this pain has been going on for 6 months now. The pain is worse in the morning or after a nap and improves with walking. As a marathon runner, she is worried that her daily running has caused this condition. She is counseled and reassured that no surgery is needed.
  • Introduction
    • Clinical definition
      • degenerative condition of the plantar fascia that causes sharp pain on the bottom of the foot pain
  • Epidemiology
    • Demographics
      • female > male
      • 40-60 years of age
      • older and obese patients
    • Location
      • plantar fascia originates at the calcaneal tubercle
    • Risk factors
      • obesity
      • flat feet (pes planus)
      • overpronation of the foot
      • prolonged walking or running
  • Etiology
    • May be due to bony spur but often the etiology is unknown
    • Pathogenesis
      • repetitive microtrauma from prolonged use of foot causes tensile overload and damage to the plantar fascia
    • Associated conditions
      • Achilles tendinopathy
  • Presentation
    • Symptoms
      • sharp heel pain, like a tack in the foot
        • pain is worse with first step in the morning or after a period of rest, then improves with walking
        • may be worse again at the end of the day with prolonged weight-bearing
        • may also improve with stretching, massage, and rest
    • Physical exam
      • tenderness to palpation at the underside of the heel, at the insertion of the plantar fascia
      • positive windlass test
        • pain elicited when the clinician dorsiflexes the hallux and stretches the plantar fascia
  • Imaging
    • Radiography
      • indication
        • typically not indicated unless the diagnosis is unclear
      • findings
        • may have a bony spur at the location of the pain
  • Differential
    • Tarsal tunnel syndrome
      • distinguishing factors
        • presents with pain or numbness along the plantar surface of the foot that is worsened by tapping the tarsal tunnel
        • in comparison with plantar fasciitis, pain does not get better with rest and rather may be the worst at night
  • DIAGNOSIS
    • Making the diagnosis
      • most cases are clinically diagnosed
  • Treatment
    • Conservative
      • stretching of the foot and calf
        • indication
          • for all patients
      • orthotics or night splinting
        • indication
          • for all patients
    • Medical
      • nonsteroidal anti-inflammatory drugs (NSAIDs)
        • indication
          • pain management
      • steroid injection
        • indication
          • pain management refractory to NSAIDs
  • Complications
    • None
  • Prognosis
    • Typically resolves spontaneously in 1-2 years
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Questions (2)

(M2.OR.17.4754) A 24-year-old woman presents to her primary care physician’s office complaining of right foot pain for the last week. She first noticed this pain when she awoke from bed one morning and describes it as deep at the bottom of her heel. The pain improved as she walked around her apartment but worsened as she attended ballet practice. The patient is a professional ballerina and frequently rehearses for up to 10 hours a day, and she is worried that this heel pain will prevent her from appearing in a new ballet next week. She has no past medical history and has a family history of sarcoidosis in her mother and type II diabetes in her father. She drinks two glasses of wine a week and smokes several cigarettes a day but denies illicit drug use. At this visit, the patient’s temperature is 98.6°F (37.0°C), blood pressure is 117/68 mmHg, pulse is 80/min, and respirations are 13/min. Examination of the right foot shows no overlying skin changes or swelling, but when the foot is dorsiflexed, there is marked tenderness to palpation of the bottom of the heel. The remainder of her exam is unremarkable. Which of the following is the best next step in management?

QID: 108969

Orthotic shoe inserts

12%

(21/170)

Glucocorticoid injection

8%

(13/170)

Plain radiograph of the foot

41%

(69/170)

Resting of the foot

35%

(60/170)

Ultrasound of the foot

3%

(5/170)

M 7 E

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