eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions

Plantar Fasciitis

Author: Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service, University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Coauthor(s): Todd P Stitik, MD, Professor, Department of Physical Medicine and Rehabilitation, Acting Director of Sports Medicine, UMDNJ-New Jersey School of Medicine; Lead Physician, Practice Medical Director of University Hospital PM & R Clinic
Contributor Information and Disclosures

Updated: Mar 31, 2008

Introduction

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

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.

More on Plantar Fasciitis

Overview: Plantar Fasciitis
Differential Diagnoses & Workup: Plantar Fasciitis
Treatment & Medication: Plantar Fasciitis
Follow-up: Plantar Fasciitis
References
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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. 2nd 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. 3rd 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.

  6. Lennard TA. Fundamentals of procedural care. In: Lennard TA, ed. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:1-13.

  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].

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Further Reading

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Keywords

heel pain syndrome, plantar heel pain, proximal plantar fasciitis, subcalcaneal pain, orthotic arch support, shoe insert, heel pad, fat pad, heel spur, exostosis

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Contributor Information and Disclosures

Author

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service, University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

Coauthor(s)

Todd P Stitik, MD, Professor, Department of Physical Medicine and Rehabilitation, Acting Director of Sports Medicine, UMDNJ-New Jersey School of Medicine; Lead Physician, Practice Medical Director of University Hospital PM & R Clinic
Todd P Stitik, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, Phi Beta Kappa, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Medical Editor

Everett C Hills, MD, MS, Medical Director, Penn State Hershey Rehabilitation Hospital, Assistant Professor of Orthopaedics and Rehabilitation, Assistant Professor of Neurology, Penn State Milton S. Hershey Medical Center and Penn State University College of Medicine
Everett C Hills, MD, MS is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Physical Medicine and Rehabilitation, American College of Physician Executives, American Congress of Rehabilitation Medicine, American Medical Association, American Society of Neurorehabilitation, Association of Academic Physiatrists, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Michael T Andary, MD, MS, Residency Program Director, Professor, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine
Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

 
 
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