in the clinic plantar fasciitis in theclinic · in the clinic plantar fasciitis ... (flat feet,...

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PlantarFasciitisPrevention page ITC1-2

Diagnosis page ITC1-3

Treatment page ITC1-7

Tool Kit page ITC1-14

Patient Information page ITC1-15

CME Questions page ITC1-16

Physician WriterCraig Young, MD

Section EditorsDeborah Cotton, MD, MPHDarren Taichman, MD, PhDSankey Williams, MD

The content of In the Clinic is drawn from the clinical information and educationresources of the American College of Physicians (ACP), including PIER (Physicians’Information and Education Resource) and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinicfrom these primary sources in collaboration with the ACP’s Medical Education andPublishing divisions and with the assistance of science writers and physician writ-ers. Editorial consultants from PIER and MKSAP provide expert review of the con-tent. Readers who are interested in these primary resources for more detail canconsult http://pier.acponline.org, http://www.acponline.org/products_services/mksap/15/?pr31, and other resources referenced in each issue of In the Clinic.

CME Objective: To review current bone the prevention, diagnosis, and treatmentof plantar fasciitis.

The information contained herein should never be used as a substitute for clinicaljudgment.

© 2012 American College of Physicians

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What are the risk factors forplantar fasciitis?Risk factors for plantar fasciitis canbe intrinsic or extrinsic. Intrinsicfactors are those that are internal tothe body. Extrinsic risk factors arethose that are not related to thebody.

Intrinsic risk factorsIntrinsic risk factors includeanatomical risk factors, functionalrisk factors, and degenerative riskfactors. Anatomical risk factors in-clude pes planus (flat feet, fallenarches), overpronation (excessiveinward roll of the foot after land-ing on a firm surface), pes cavus(high arches), leg-length discrep-ancy, excessive lateral tibial torsion(twisting of the shinbone), and ex-cessive femoral anteversion (inward

twisting of the femur) (13–16).Leg-length discrepancy, excessivelateral tibial torsion, and excessivefemoral anteversion can lead to analteration of running biomechan-ics, which may increase stress onthe plantar fascia. Pronation is anormal motion during walking andrunning, providing foot-to-surfaceaccommodation and impact ab-sorption by allowing the foot tounlock and become a flexible struc-ture. Overpronation, on the otherhand, can lead to increased tensionon the plantar fascia. Individualswho are overweight are at in-creased risk because the increasedbody weight increases the forcesplaced across the plantar fascia.Foot strike of low-arched or high-arched feet places increases stress

© 2012 American College of Physicians ITC1-2 In the Clinic Annals of Internal Medicine 3 January 2012

1. Rompe JD, Furia J.Weil L. Maffulli N.Shock wave therapyfor chronic plantarfasciopathy. Br MedBull. 2007; 81-82:183-208. [PMID: 17456546]

2. Knobloch K, Yoon U.Vogt PM. Acute andoveruse injuries cor-related to hours oftraining in masterrunning athletes.Foot Ankle Int. 2008;29:671-6. [PMID: 18785416]

3. Tenforde AS. SayresLC. McCurdy ML. Col-lado H. Sainani KL.Fredericson M. Over-use injuries in highschool runners: life-time prevalence andprevention strategies.PM & R. 2011; 3:125-31. [PMID: 21333951]

4. Moseley JB Jr, Chi-menti BT. Foot andankle injuries in theprofessional athlete.In: The Foot and An-kle in Sport. St. Louis:Mosby; 1995:321-328.

5. Riddle DL, SchappertSM. Volume of ambu-latory care visits andpatterns of care forpatients diagnosedwith plantar fasciitis:a national study ofmedical doctors. FootAnkle Int. 2004;25:303-10. [PMID: 15134610]

6. Tong KB. Furia J. Eco-nomic burden ofplantar fasciitis treat-ment in the UnitedStates. Am J Orthop.2010; 39:227-31.[PMID: 20567740]

7. Kogler GF, Solomoni-dis SE, Paul JP. In vitromethod for quantify-ing the effectivenessof the longitudinalarch support mecha-nism of a foot ortho-sis. Clin Biomech(Bristol, Avon). 1995;10:245-252. [PMID: 11415561]

8. Kogler GF, Solomoni-dis SE, Paul JP. Biomechanics of longitudinal archsupport mechanismsin foot orthoses andtheir effect on plantaraponeurosis strain.Clin Biomech. 1996;11:243-252. [PMID: 11415628]

9. Kogler GF, Veer FB,Solomonidis SE, PaulJP. The influence ofmedial and lateralplacement of orthotic wedges onloading of the plantaraponeurosis. J BoneJoint Surg Am. 1999;81:1403-13. [PMID: 10535590]

In the United States, up to 10% of adults will have heel pain in their life-time (1) and plantar fasciitis is one of the more common causes of heelpain in adults. It is among the top 5 diagnoses of foot and ankle pain in

runners (2, 3) as well as in professional football, baseball, and basketball play-ers (4). Per year, plantar fasciitis affects 2 million people in the United Statesand results in approximately 1 000 000 visits to physicians, 62% of which areto primary care physicians (5). The annual cost of treatments for this disor-der is between $192 and $376 million (6).

The plantar fascia is a sheet of dense, fibrous, collagenous connective tissue(aponeurosis) that originates from the medial tubercle of the calcaneus, runsforward to insert into the deep short transverse ligaments of the metatarsalheads, and continues forward to form the fibrous flexor sheathes on theplantar aspect of the toes. The portion of plantar fascia near the origin is thethickest and strongest section and also is the segment most likely to beinvolved with plantar fasciitis. Studies on cadavers have supported the bio-mechanical theory that the function of the plantar fascia is to provide staticsupport for the longitudinal arch of the foot and to assist with dynamicshock absorption during foot strike (7–9), which is important because duringrunning, foot-strike forces may reach 2–3 times body weight (10).

Historically, plantar fasciitis was believed to be a chronic inflammatory con-dition. However, recent histopathologic studies of tissue from people withplantar fasciitis show that it is more similar to tendinopathy and to chronicproblems at the sites where tendons or ligaments insert into the bone (enthe-ses). These conditions involve collagen degeneration, fiber disorientation, increased ground substance, and an absence of inflammatory cells (11, 12).Thus, it seems that the underlying pathology is more degenerative than in-flammatory. This finding has led some observers to advocate that we replacethe term “plantar fasciitis” with “plantar fasciosis” to better reflect the degen-erative nature of the condition. This change in understanding of the underly-ing pathology has also led to new treatment options and approaches.

Prevention


© 2012 American College of PhysiciansITC1-3In the ClinicAnnals of Internal Medicine3 January 2012

on the plantar fascia (17). Func-tional risk factors include tightnessin the gastrocnemius and soleusmuscles and the Achilles tendon(18). Weakness of the gastrocne-mius, soleus, and intrinsic footmuscles is also a risk factor. De-generative risk factors include ag-ing and atrophy of the heel fat pad.

Extrinsic risk factorsExtrinsic risk factors include exces-sive use, training error, and improp-er footwear.

Training errors are among the moreimportant causes of plantar fasciitisin athletes. Common training er-rors involve a too-rapid increase inthe distance, intensity, duration, orfrequency of activities that involverepetitive impact loading of thefeet—for example, walking, run-ning, and jumping. Particularlyhigh-risk behaviors are speed work-outs, hill workouts, and plyomet-rics, which stretch (“load”) musclebefore it is contracted—for exam-ple, by crouching down to stretch

muscles and then contracting thosemuscles to jump. Running indoorson a poorly cushioned surface is arisk factor. Problems with footwearcan also be a risk factor becauseathletic shoes rapidly lose cushion-ing properties (17); some athletesdo not change shoes often enough,especially if they repair shoe soles;and some athletes train in light-weight and minimally cushionedshoes.

Although there have been few studies re-garding extrinsic risk factors, in a cross-sec-tional observational study of 407 full-timeemployees who had been working at least6 months in an automobile engine assem-bly plant, researchers found that rotatingbetween at least 2 different pairs of shoesduring the work week was associated with a 72% decrease in the risk for plantarfasciitis—a statistically significant differ-ence. However, the study did not examinewhether the individuals who rotated shoeswere supervisors, held other types of posi-tions, or had other confounding factorsthat may have accounted for the de-creased frequency of plantar fasciitis (19).

10. Cavanagh PR, Lafor-tune MA: Ground reaction forces indistance running. J Biomech 1980; 13:397-406. [PMID: 7400169}

11. Maffulli N, Wong J,Almekinders LC.Types and epidemi-ology of tendinopa-thy. Clin Sports Med.2003; 22:675-92.[PMID: 14560540]

12. Yuan J, Wang MX,Murrell GA. Celldeath andtendinopathy. ClinSports Med. 2003;22:693-701. [PMID: 14560541]

13. Wearing SC,Smeathers JE, UrrySR, Hennig EM, HillsAP. The pathome-chanics of plantarfasciitis. Sports Med.2006; 36:585-611.[PMID: 16796396]

14. Aldridge T. Diagnos-ing heel pain inadults. Am FamPhysician. 2004;70:332-8. [PMID: 15291091]

15. Krivickas LS.Anatomical factorsassociated withoveruse sports in-juries. Sports Med.1997; 24:132-46.[PMID: 9291553]

16. Pohl MB. Hamill J.Davis IS. Biomechan-ical and anatomicfactors associatedwith a history ofplantar fasciitis in fe-male runners. Clin JSport Med. 2009;19:372-6. [PMID: 19741308]

17. Reid DC: Running:injury patterns andprevention. In:Sports Injury Assess-ment and Rehabilita-tion. NY: ChurchillLivingstone; 1992:1131-1158

18. Riddle DL, Pulisic M,Pidcoe, P Pidcoe, PPidcoe P: Risk factorsfor plantar fasciitis: amatched case-control study. J BoneJoint Surg Am 2003;85A: 872-877.

19. Werner RA. Gell N.Hartigan A. Wigger-man N. KeyserlingWM. Risk factors forplantar fasciitisamong assemblyplant workers. PM&R.2010; 2:110-6.[PMID: 20193937]

extensive walking or standing. Inmore mild cases, athletes may notethat the classic type of morningpain occurs only after periods ofmore vigorous exercise. In moder-ate cases, the pattern is similar tothat of classic overuse injuries,which decrease as the athletewarms up and return after activitystops. The pain of plantar fasciitistends to be especially aggravatedby sprinting and jumping. In addi-tion to pain, patients may havestiffness in the foot and localizedswelling in the heel. The pain may

What symptoms suggest plantarfasciitis?The essential symptom of “classic”plantar fasciitis is intense, sharpheel pain with the first couple ofsteps in the morning. Pain is pri-marily at the origin of the plantarfascia where it attaches to the an-terior calcaneus, but it may radiateproximally in more severe cases.Also, in more severe cases patientsmay have pain when standing upafter prolonged sitting, or theymay have a dull ache in the heel atthe end of the day, especially after

Prevention... Clinicians should advise patients participating in sports to use propertraining and conditioning techniques. Clinicians should encourage all patients toexercise to maintain calf strength and flexibility, to wear appropriate shoes, andto rotate shoes on a regular basis.

CLINICAL BOTTOM LINE

Diagnosis


20. De Garceau D, DeanD, Requejo SM, Thor-darson DB. The asso-ciation between diagnosis of plantarfasciitis and Windlasstest results. Foot Ankle Int. 2003;24:251-5. [PMID: 12793489]

21. Kinoshita M, OkudaR, Morikawa J, Jo-toku T, Abe M. Thedorsiflexion-eversiontest for diagnosis oftarsal tunnel syn-drome. J Bone JointSurg Am. 2001;83:1835-9. [PMID: 11741063]

22. Levy JC, Mizel MS,Clifford PD, TempleHT. Value of radi-ographs in the initialevaluation of non-traumatic adult heelpain. Foot Ankle Int.2006; 27:427-30.[PMID: 16764799]

23. Osborne HR, Brei-dahl WH, Allison GT.Critical differences inlateral X-rays withand without a diag-nosis of plantar fasci-itis. J Sci Med Sport.2006; 9:231-7.[PMID: 16697701]

24. Sabir N, Demirlenk S,Yagci B, Karabulut N,Cubukcu S. Clinicalutility of sonographyin diagnosing plan-tar fasciitis. J Ultra-sound Med. 2005;24:1041-8. [PMID: 16040817]


be exacerbated by walking barefootor by walking in shoes that haveminimal arch support. Neurologicsymptoms suggest an alternativediagnosis (Box: Common Symp-toms of Plantar Fasciitis, andTable 1)

What physical examinationfindings should clinicians look forto diagnose plantar fasciitis?Palpation over the medial tubercleof the calcaneus usually reproducesthe pain of plantar fasciitis (Fig-ure 1). In more severe cases, painmay also be reproduced by palpa-tion over the proximal portion ofthe plantar fascia. Specific maneu-vers that may reproduce the pain of plantar fasciitis include passivedorsiflexion of the toes, which issometimes called a “windlass test.”A positive windalss test is reliablefor diagnosing plantar fasciitis, but

the test can be negative when plan-tar fasiitis is present (i.e., low sensi-tivity). Having the patient standwhile the windlass test is per-formed increases the sensitivity ofthe test from 13.5% to 31.8% (20).Examine the foot for variations infoot shape, such as pes planus andpes cavus. Observe the patient’sgait and stance, looking for over-pronation and varus heel alignment. In general, pain in the posteriorheel or over the anterior or mid-longitudinal arch or over the poste-rior tibial tendon sheath suggestsan alternative diagnosis. Examinethe thickness of the heel fat pad—atrophy suggests the heel fat pad syndrome. If abnormal neu-rologic findings are noted, considerdoing a Tinel test of the tarsal tun-nel region, which would suggestnerve entrapment if positive (21).

When should clinicians orderimaging or other diagnosticstudies in patients with suspectedplantar fasciitis?A heel spur is found often inasymptomatic individuals (15%–25% of the general population), andmany patients with plantar fasciitishave no heel spur (22, 23). A heelspur does increase the probability ofplantar fasciitis (sensitivity 85.2%;specificity 77.2%; likelihood ratiopositive 3.74) but its presence orabsence should not change the clin-ical diagnosis (23). Also, changes inthe consistency and thickness of theplantar fascia have been noted onboth ultrasonography and magneticresonance imaging (MRI) in pa-tients with plantar fasciitis (24–27).

Experienced clinicians, however,usually diagnose plantar fasciitis after a history and physical examination

Common Symptoms of PlantarFasciitis

• Pain typically occurs with first stepsin the morning.

• Pain should be located at the plantar fascia origin; pain at otherlocations suggests an alternative diagnosis.

• There should be no neurologicsymptoms.

Figure 1. Palpation of the medial tubercle of thecalcaneus. The borders of the plantar fascia are drawnon the bottom of the foot.

Physical Findings Suggestive ofPlantar Fasciitis

• Pain at the origin of or in the proxi-mal plantar fascia

• Pes cavus foot type• Positive “windlass test”• Absence of neurologic findings


25. Kane D, Greaney T,Shanahan M, Duffy G, Bresnihan B,Gibney R, et al. Therole of ultrasonogra-phy in the diagnosisand management of idiopathic plantarfasciitis. Rheumatol-ogy (Oxford). 2001;40:1002-8. [PMID: 11561110]26. Wear-ing SC, SmeathersJE, Sullivan PM, Yates B, Urry SR,Dubois P. Plantarfasciitis: are pain andfascial thickness as-sociated with archshape and loading?Phys Ther. 2007;87:1002-8. [PMID: 17553919]

27. Mahowald S, LeggeBS, Grady JF. Thecorrelation betweenplantar fascia thick-ness and symptomsof plantar fasciitis. JAm Podiatr Med As-soc. 2011;101:385-9.[PMID: 21957269]

28. Frater C, Vu D, Vander Wall H, Perera C,Halasz P, Emmett L,Fogelman I. Bonescintigraphy predictsoutcome of steroidinjection for plantarfasciitis. J Nucl Med.2006; 47:1577-80.[PMID: 17015890]


pool images responded to the injection(28).

What is the differential diagnosisof plantar fasciitis?The vast majority of people withplantar fasciitis will present with aclassic history of heel pain that isworse with the first couple of stepsin the morning and a physical ex-amination that reveals pain near theorigin of the plantar fascia. Individ-uals who spend a significantamount of time standing, walking,or running may have pain eitherduring or after these activities.Consider other diagnoses when theevaluation is not compatible withplantar fasciitis. The most commonalternative diagnoses include cal-caneal stress fracture, the heel fatpad syndrome, longitudinal archstrain, and the nerve entrapmentsyndrome (Table 2). A history ofacute trauma, neurologic changes,female athlete triad (menstrual ab-normalities, eating disorder, anddecreased bone mineral density),and constitutional symptoms (suchas fever, weight loss, or nightsweats) should prompt considera-tion of alternative diagnoses.

and usually do not order diagnosticstudies. Tests should be obtainedonly if the diagnosis is uncertain orthe patient is not responding toappropriate treatment. Consider aplain radiograph to rule out a bone tumor or fracture before aninvasive intervention, such as aninjection. MRI or diagnostic ultra-sonography should be reserved forthe rare cases when there is a needto confirm plantar fasciitis or toevaluate the patient for plantar fascia rupture. Nerve conductionstudies may help rule out nerve entrapment syndromes. Bone scansare useful when the clinician sus-pects stress fracture, tumor, or in-fection. A bone scan with localizeduptake on the blood pool increasesthe likelihood of the presence of aninflammatory process and has beenshown to predict increased chancesfor a positive response to cortico-steroid injections.

In 1 study of 32 cases of plantar fasciitisthat were injected with corticosteroids, 14 of the 20 feet that responded to the injection had focal hyperemia on theblood pool images, whereas none of the feet with diffuse uptake on the blood

Table 1. History and Physical Examination Elements for Plantar FasciitisCategory Element Notes

History Location of pain Pain at a location other than the plantar fascia origin suggests an alternative diagnosis Traumatic injury Suggests alternative diagnosis Connective tissue disease Suggests alternative diagnosis Exacerbating factors Ask about pain with first step in the morning, worsening pain with weight-bearing activities, pain after prolonged sitting, pain that is worse when barefoot or when wearing shoes with minimal arch supportPhysical Foot examination for Look for pain at plantar fascia origin; note

examination location of pain that pain in the posterior heel or anterior or mid-longitudinal arch or over the posterior tibial tendon sheath suggests alternative diagnosis Foot examination for Pes planus and other variations in foot type anatomical abnormalities and alignment may contribute to plantar fasciitis; loss of heel fat pad suggests the heel fat pad syndrome Windlass test Pain is produced by passive dorsiflexion of the toes Neurologic examination for May suggest nerve entrapment motor or sensory abnormalities



consultation when heel pain ispresent and the diagnosis is un-clear and when the patient doesnot respond to the usual plantarfasciitis treatments. Also, considerconsulting a neurologist or physia-trist if a nerve entrapment syn-drome is suspected.

Under what circumstances shouldclinicians consider consultationwith an orthopedic surgeon,sports medicine specialist, orother specialist for diagnosis?In general, referral to a specialist is not needed. However, cliniciansshould consider referral for a

Table 2. Differential Diagnosis of Plantar FasciitisDisease Characteristics Notes

Plantar fascia Sudden acute, knife-like pain at the plantar Plantar fasciitis is not usually associated with rupture fascia origin followed by ecchymosis acute onset of pain or ecchymosis

Calcaneal fracture Point tender over a single site on the body The pain of plantar fasciitis is usually directly of the calcaneus over the plantar fascia origin; calcaneal fracture can occur anywhere on the calcaneus and may have pain with simultaneous compression of the medial and lateral calcaneal surfaces; calcaneal fracture is usually caused by acute injury but plantar fasciitis is notCalcaneal stress Point tender over a single site on the body of The pain of plantar fasciitis is usually directly

fracture the calcaneus over the plantar fascia origin; a calcaneal stress fracture can occur anywhere on the calcaneus and may have pain with simultaneous compression of the medial and lateral calcaneal surfaces; calcaneal stress fracture is less likely unless the patient is involved in running or other repetitive impact-loading activity of the heelCalcaneal apophysitis Posterior heel pain in adolescents The pain of plantar fasciitis is usually directly

(Sever disease) over the plantar fascia originBursitis Usually retrocalcaneal in location with The pain of plantar fasciitis is usually directly accompanying swelling and erythema over the plantar fascia originTendinitis Pain with resisted motions The pain of plantar fasciitis is usually not aggravated by resisted motionsThe heel fat Diffusely tender over the entire body of the The pain of plantar fasciitis is usually directly

pad syndrome calcaneus; atrophy of the fat pad is often over the plantar fascia origin, which is anterior present to the fat padLongitudinal arch Tenderness over the longitudinal arch, often Plantar fasciitis has posterior (if any) arch pain;

strain mid or anterior longitudinal arch strain may have an associated component of plantar fasciitisNerve entrapment Neurologic changes, particularly numbness Plantar fasciitis has no associated neurologic and tingling with a Tinel test changesHeel contusion History of trauma Plantar fasciitis is not usually associated with traumaPaget disease Can occur in the bones of the foot, usually in None of these elements are typically found in

of bone the calcaneus; look for a history of headaches plantar fasciitis; look for elevated in serum and hearing loss and bowed tibias and alkaline phosphatase levels kyphosis on physical examinationTumor Constant, deep bone pain; late—constitutional Plantar fasciitis pain typically waxes and wanes symptoms with activities

Diagnosis... Plantar fasciitis can usually be diagnosed on the basis of history,which should reveal pain at the origin of the plantar fascia in the morning, andthe physical examination, which should find palpable pain at the origin of theplantar fascia and a positive windlass test. Symptoms or signs of neurologic problems suggest alternative diagnoses. Reserve radiography and other diagnostictesting for patients with atypical presentations.



29. Stanley KL, WeaverJE. Pharmacologicmanagement ofpain and inflamma-tion in athletes. ClinSports Med. 1998;17:375-92. [PMID: 9580848]

30. Donley BG, Moore T,Sferra J, Gozdano-vic J, Smith R. The efficacy of oral nonsteroidal anti-inflammatory med-ication (NSAID) inthe treatment ofplantar fasciitis: arandomized,prospective, place-bo-controlled study.Foot Ankle Int. 2007;28:20-3. [PMID: 17257533]


than inflammatory (11, 12), use ofanti-inflammatory drugs is primari-ly for controlling pain (29) and notfor treating the underlying patholo-gy. Use of an antiinflammatorydrug may speed symptom resolu-tion by allowing greater participa-tion in the rehabilitation program.However, they probably have mini-mal effect on the ultimate outcome(30). If all other options fail, con-sider surgical release.

The pain of plantar fasciitis is usually slow to resolve, but in most cases it eventually disappearscompletely.

What should clinicians tell theirpatients about plantar fasciitis?Education should be an integralpart of treatment because it can affect disease outcome and the patient’s choice of treatment. Rela-tive rest and correcting training errors are critical to the treatmentof those who are physically active. Patients—especially those who areathletes participating in runningactivities—must modify activitiesthat aggravate the condition. The

How should clinicians manageplantar fasciitis?Management of plantar fasciitisshould be individualized to ad-dress specific findings on the history and clinical examination,including heel pain, activity pat-terns, obesity, malalignment, flexibility, and muscle weakness.Comprehensive management in-cludes a combination of treat-ment options that are directedtoward the common goals of alle-viating pain and increasing toler-ance for activity. The treatmentplan should be flexible andreevaluated at regular intervals so it can be altered according to functional and symptomaticresponses.

Initial treatment of plantar fasciitisusually consists of a variety of non-invasive, nondrug treatment options(Table 3 and Box: Treatment Ad-vice for Patients). Historically,plantar fasciitis was treated usingnonsteroidal anti-inflammatorydrugs (NSAIDs). However, sincethe underlying pathology is nowbelieved to be a degenerative rather

Treatment

Table 3. Treatment Options for Plantar FasciitisTreatment Option Notes

Weight loss For overweight patientsStretching Primary focus: plantar fascia; secondary focus: calfStrengthening Primary focus: calf; secondary focus: intrinsic foot musclesActivity modification Especially for athletesAppropriate foot wear Replace worn shoes and match shoes to foot typeHeel cups Not recommendedArch support Try over-the-counter first, especially if arch is neutralNight splints Especially for patients with first step in morning pain and tightness in calf and Achilles tendonPhysical therapy For patients who need assistance in learning and/or complying with stretching and strengthening programModalities For patients who do not respond to first-line treatments or for

(e.g., ultrasonography, professional athletesiontophoresis, extracorporeal shock wave therapy)

Medication Secondary treatment—used as adjunct to allow better compliance with exercise program or for pain controlInjection For patients who do not respond to first-line treatmentsSurgery For patients who do not respond to second-line treatment


31. Quillen WS, MageeDJ, Zachazewski JE:The process of ath-letic injury and reha-bilitation. In: AthleticInjuries and Rehabili-tation. Philadelphia:WB Saunders Co;1996: 3-8.

32. Cole C, Seto C, Gaze-wood J. Plantar fasci-itis: evidence-basedreview of diagnosisand therapy. AmFam Physician. 2005;72:2237-42. [PMID: 16342847]

33. Crawford F, Thom-son C. Interventionsfor treating plantarheel pain. CochraneDatabase Syst Rev.2003;CD000416.[PMID: 12917892]

34. Wolgin M, Cook C,Graham C, MauldinD. Conservativetreatment of plantarheel pain: long-termfollow-up. Foot Ankle Int. 1994;15:97-102. [PMID: 7951946]

35. Goff JD, Crawford R.Diagnosis and treat-ment of plantarfasciitis. Am FamPhysician. 2011;84:676-82. [PMID: 21916393]

36. DiGiovanni BF, Nawoczenski DA,Lintal ME, Moore EA,Murray JC, WildingGE, et al. Tissue-specific plantar fascia-stretching ex-ercise enhances out-comes in patientswith chronic heelpain. A prospective,randomized study. J Bone Joint SurgAm. 2003; 85-A:1270-7. [PMID: 12851352]

37. Young CC, Ruther-ford DS, NiedfeldtMW. Treatment ofplantar fasciitis. AmFam Physician. 2001;63:467-74, 477-8.[PMID: 11272297]


adjunct to treatment in overweightpatients. Patience is important because most cases of plantar fasci-itis eventually resolve completely(32–35). In general, patients aremore likely to comply with treat-ment if they understand the underlying cause of their pain,have good instructions for theirstretching and strengthening program, and understand those instructions. It is important to setand maintain realistic goals and expectations.

modification may be as simple asdecreasing the amount, frequency,or intensity of the activity. Athletesare more compliant with a de-creased level of activity if they are allowed to increase othernonaggravating activities (31). Replacing worn-out shoes and selecting appropriate shoes are also important (19). Runners should replace shoes every 250–500 miles(400–800 km) to maintain optimum shoe cushioning (17).Weight loss can be useful as an

Treatment Advice for PatientsStretching, strengthening, weight loss, appropriate exercise patterns, and wearing

appropriate footwear are more important than medications.Stretching in the morning before getting out of bed and throughout the day when

possible are helpful.• Consider keeping a towel by the bed to allow for calf and arch stretches before

doing any weight-bearing (Figure 2).

• Do cross-friction massage by rubbing the foot’s arch perpendicular to the toe–heelaxis before doing any weight bearing (Figure 3).

Figure 2. Calf and arch stretch using a towel.

Figure 3. Cross-friction massage.



Stretching the calf and foot are especially important. Include wall stretches with the kneeboth in the extended and flexed positions.• To perform a wall stretch, stand about 3 feet from a wall with your hands on the

wall. While keeping your toes pointed straight and the heel on the ground, you shouldlean your hips toward the wall and hold this position for 30–40 seconds (Figure 4).

Limiting impact loading gives the injured structures a better chance of healing.• Use ice as an anti-inflammatory to limit any new inflammation that was acutely

caused by recent activity.Applying ice for 20 minutes after repetitive impact-loading activities and at the end of the

day is helpful.Ice baths should be taken with the toes out of the water or with toe caps.

Figure 4a. Wall stretches. With the knee in extension.

Figure 4b. With the knee in slight flexion.


38. Flanigan RM, Nawoczenski DA,Chen L, Wu H, DiGio-vanni BF. The influ-ence of foot positionon stretching of theplantar fascia. FootAnkle Int. 2007;28:815-22. [PMID: 17666175]

39. Chia KK. Suresh S.Kuah A. Ong JL.Phua JM. Seah AL.Comparative trial ofthe foot pressurepatterns betweencorrective orthotics,formthotics, bonespur pads and flatinsoles in patientswith chronic plantarfasciitis. Ann AcadMed, Singapore.2009; 38:869-75,[PMID: 19890578]

40. Seligman DA, Daw-son DR. Customizedheel pads and softorthotics to treatheel pain and plan-tar fasciitis. ArchPhys Med Rehabil.2003; 84:1564-7.[PMID: 14586928]

41. Roos E, Engstrom M,Soderberg B. Footorthoses for thetreatment of plantarfasciitis. Foot AnkleInt. 2006; 27:606-11.[PMID: 16919213]

42. Lee SY, McKeon P,Hertel J. Does theuse of orthoses im-prove self-reportedpain and functionmeasures in patientswith plantar fasciitis?A meta-analysis.Phys Ther Sport.2009; 10:12-8.[PMID: 19218074]

43. Landorf KB, KeenanAM, Herbert RD. Ef-fectiveness of footorthoses to treatplantar fasciitis: arandomized trial.Arch Intern Med.2006; 166: 1305-10.[PMID: 16801514]

44. Baldassin V, GomesCR, Beraldo PS. Effec-tiveness of prefabri-cated and cus-tomized footorthoses made fromlow-cost foam fornoncomplicatedplantar fasciitis: arandomized con-trolled trial. ArchPhys Med Rehabil.2009;90:701-6.[PMID: 19345789]

45. Powell M, Post WR,Keener J, Wearden S.Effective treatment ofchronic plantar fasci-itis with dorsiflexionnight splints: a cross-over prospective ran-domized outcomestudy. Foot Ankle Int.1998;19: 10-8.[PMID: 9462907]


A prospective study of 100 patients withchronic plantar fasciitis who were treatedwith a variety of nonsurgical treatments,including stretching, taping, ice, and cush-ioned inserts, found that after an averagefollow-up time of 47 months (range, 24–132 mo), 97 had returned to full activities,although 15 continued to have some heelpain. Only 3 still had limitations in activity(34).

What kind of exercise should clinicians recommend for patients with plantar fasciitis?The initial home exercise program for plantar fasciitis shouldemphasize stretching of the calf and foot. Strengtheningand stretching should also focuson gastrocnemius, soleus, and

intrinsic foot muscles. Stretchestargeted at the plantar fascia areparticularly important (18, 36, 37).Stretching with the ankle andmetatarsal–phalangeal joint inmaximal dorsiflexion results in themost stress in the plantar fascia(38).

When should clinicians prescribearch supports, orthotics, heel cups,or night splints?Supporting the arch takes pressure off the plantar fascia during weight-bearing activity.Heel cups do not unload the plan-tar fascia and have generally notbeen found to be effective (39).Foot orthoses, commonly calledorthotics, have been shown to be

Using ice bags with a towel wrapped around the bag should be considered.• Stretch the healing tissue to decrease the stiffness and potential for reinjury when

stressed (Figure 5).

Repetitive impact-loading activities, such as running, should be limited to every other day;rest or cross-training can be considered for nonrunning days.

Figure 5b. Manually stretching the plantar fascia.

Figure 5a. Stretching healing tissue. Using a canfor a dynamic rolling stretch of the arch.


46. Berlet GC, AndersonRB, Davis H, KiebzakGM. A prospectivetrial of night splint-ing in the treatmentof recalcitrant plan-tar fasciitis: the AnkleDorsiflexion Dynas-plint. Orthopedics.2002; 25:1273-5.[PMID: 12452346]

47. Barry LD, Barry AN,Chen Y. A retrospec-tive study of standinggastrocnemius-soleus stretchingversus night splint-ing in the treatmentof plantar fasciitis. J Foot Ankle Surg.2002;41: 221-7.[PMID: 12194511]

48. Landorf KB, RadfordJA, Keenan AM, Red-mond AC. Effective-ness of low-Dye tap-ing for the short-termmanagement ofplantar fasciitis. J AmPodiatr Med Assoc.2005; 95:525-30.[PMID: 16291843]

49. Young, C. PlantarFasciitis. Accessed athttp://pier.acpon-line.org/physicians/diseases/d065/d065.html on Octo-ber 4, 2011.

50. Gudeman SD, EiseleSA, Heidt RS Jr,Colosimo AJ, StroupeAL. Treatment ofplantar fasciitis byiontophoresis of0.4% dexametha-sone. A randomized,double-blind, place-bo-controlled study.Am J Sports Med.1997; 25:312-6.[PMID: 9167809]

51. Gerdesmeyer L, FreyC, Vester J, Maier M,Weil L Jr, Weil L Sr, etal. Radial extracorpo-real shock wave ther-apy is safe and effec-tive in the treatmentof chronic recalci-trant plantar fasciitis:results of a confirma-tory randomizedplacebo-controlledmulticenter study.Am J Sports Med.2008;36:2100-9.[PMID: 18832341]

52. Speed CA, NicholsD, Wies J,Humphreys H,Richards C, Burnet S,et al. Extracorporealshock wave therapyfor plantar fasciitis. Adouble blind ran-domised controlledtrial. J Orthop Res.2003;21:937-40.[PMID: 12919884]

53. Wang CJ, Wang FS,Yang KD, Weng LH,Ko JY. Long-term re-sults of extracorpo-real shockwavetreatment for plantarfasciitis. Am J SportsMed. 2006;34:592-6.[PMID: 16556754]


effective for relieving the paincaused by plantar fasciitis (40–42).Patients with neutral arches are often effectively treated with over-the-counter orthotics, whichare significantly less expensivethan custom orthotics (43, 44).Tension splints allow for moderatestretching of the plantar fascia andthe calf through the night (45–47).

When should clinicians prescribephysical and occupationaltherapy?Refer patients with plantar fasciitis to a physical therapist forinstruction in stretching andstrengthening and arch taping(48). Consider ultrasonography,iontophoresis, laser, or extracorpo-real shock wave therapy when pa-tients are not obtaining enoughbenefit from their own exerciseprogram. In theory, these modali-ties improve blood flow to the affected area or use other physical processes to stimulatehealing. However, cliniciansshould recognize that evidence of the effectiveness of thesemodalities is limited. Cliniciansshould not prescribe them routinely but reserve them for cases of plantar fasciitis that are resistant to other treatments(33, 49)

A randomized, double-blind, placebo-con-trolled trial in 36 patients evaluated the effectiveness of dexamethasone iontopho-resis 6 times over 2 weeks. Participantswere assessed by using the Maryland Foot Score. By week 1, the treated groupshowed significantly better improvementthan the control group, but the differencebecame insignificant at 1-month follow-up, at which time both groups had im-provement (50).

In 1 randomized, placebo-controlled trialof extracorporeal shock wave therapy in245 patients with chronic plantar fasciitis,treatment proved significantly superior toplacebo, with a reduction in the visualanalogue scale composite score of 72.1%compared with 44.7% and an overall suc-cess rate of 61.0% compared with 42.2%at 12 weeks. Superiority was even more

pronounced at 12 months, and all sec-ondary outcome measures in treated pa-tients were significantly superior to place-bo (51).

In a second randomized, controlled trial of extracorporeal shock wave therapy in 88 patients with plantar fasciitis, a positiveresponse (50% improvement from baselinein pain at 3 months) occurred in 37% oftreated patients and in 24% of patients inthe sham group. Also, night pain improvedin 41% of treated patients and in 31% ofpatients in the sham group. However, nostatistically significant outcome differ-ences were found between the groups at 6 months (52).

In a third randomized, controlled trial ofextracorporeal shock wave therapy in patients with chronic plantar fasciitis, 149 treated patients were compared with70 control patients. Treated patients werereevaluated 60 to 72 months later. Con-trol patients received typical nonsurgicaltreatments and were reevaluated 34 to 64 months later. Treated patients ratedtheir responses significantly better thancontrol patients: excellent, 69.1% vs. 0%;good, 13.6% vs. 55%; fair, 6.2% vs. 36%;and poor, 11.1% vs. 9%. Also, the recur-rence rate was significantly lower for thetreated group than the control group,11% vs. 55% (53).

In a fourth randomized, controlled trial of extracorporeal shock wave therapy in272 patients with chronic plantar fasciitis,12 weeks after intervention there was nosignificant difference in the success rate(34% in the treated group vs. 30% in theplacebo group). Also, at 1 year there wasno difference in pain ratings or walkingability (54).

Which analgesic should cliniciansprescribe first?Since plantar fasciitis seems prima-rily to be a chronic degenerativecondition, the main purpose ofNSAIDs is to control pain. Sinceall NSAIDs are associated with significant potential toxicity (29), acetaminophen in doses up to 4 g/day is the oral analgesicof choice for mild to moderate pain in plantar fasciitis (Table 4). Other NSAIDs may be added or substituted in patients who do not respond adequately to


54. Haake M, Buch M,Schoellner C, Goebel F, Vogel M,Mueller I, et al. Extra-corporeal shockwave therapy forplantar fasciitis: ran-domised controlledmulticentre trial.BMJ. 2003;327:75.[PMID: 12855524]

55. Acevedo JI, BeskinJL. Complications ofplantar fascia rup-ture associated withcorticosteroid injec-tion. Foot Ankle Int.1998; 19:91-7.[PMID: 9498581

56. Sellman JR. Plantarfascia rupture associ-ated with corticos-teroid injection. FootAnkle Int. 1994;15:376-81. [PMID: 7951973]

57. Fadale PD, WigginsME. CorticosteroidInjections: Their Useand Abuse. J AmAcad Orthop Surg.1994; 2:133-140.[PMID: 10709001]

58. Yucel I, Yazici B, De-girmenci E, Erdog-mus B, Dogan S.Comparison of ultra-sound-, palpation-,and scintigraphy-guided steroid injec-tions in the treat-ment of plantarfasciitis. Arch OrthopTrauma Surg. 2009;129:695-701.[PMID: 18839190]

59. Tsai WC, Hsu CC,Chen CP, Chen MJ,Yu TY, Chen YJ. Plan-tar fasciitis treatedwith local steroid in-jection: comparisonbetween sonograph-ic and palpationguidance. J Clin Ul-trasound. 2006;34:12-6. [PMID: 16353228]

60. Martin RP. Autolo-gous Blood Injectionfor Plantar Fasciitis: ARetrospective Study[abstract]. ClinicalJournal of Sport Med-icine. 2005; 15:387-8.

61. Kiter E, Celikbas E,Akkaya S, DemirkanF, Kiliç BA. Compari-son of injectionmodalities in thetreatment of plantarheel pain: a random-ized controlled trial. JAm Podiatr Med As-soc. 2006; 96:293-6.[PMID: 16868321


acetaminophen. The use of medica-tion for adjunctive pain controlseems to help speed healing inplantar fasciitis because it may al-low patients to exercise more bycontrolling pain (30).

When should clinicians considerinjection?When plantar fasciitis fails to respond to first-line treatments,consideration may be given to injection. Traditionally, cortico-steroids have been injected. How-ever, because of the degenerativenature of plantar fasciitis, corti-costeroids may have only limitedeffectiveness, and they have manypotential side effects, includinginfection, tendon rupture, fat pad atrophy, and skin atrophy(Table 4) (55–57). Crawford and

Thompson concluded in theirmeta-analysis of 5 studiesthatalthough cortisone injectionmay have some benefits, they wereshort-term in nature and thatthere was no difference in long-term outcome. (33).

A randomized, controlled trial compared25 patients receiving either ultrasound-guided betamethasone injections or palpation-guided injections. There weresignificant improvements in visual ana-logue pain scores and decreases in plantar fascia thickness and hypoe-chogenicity in both groups. The numberof patients with plantar fascia pain de-creased after steroid injection in bothgroups, but the recurrence rate of plantarfasciitis was significantly higher in thepalpation-guided group (46%) than inthe sonographically guided group (8%)(58). However, another randomized,

Table 4. Drug Treatment for Plantar FasciitisAgent/Action Typical Adult Dosage Benefits Side Effects

Acetaminophen/Inhibits synthesis of 325–650 mg q 4–6 h Pain control Liver toxicity with prostaglandins in CNS acute overdose and

nephrotixicity with chronic overdoseIbuprofen/Inhibits prostaglandin synthesis 400–800 mg tid–qid Pain control, Epigastric pain

in inflammatory cascade through anti-inflammatory (3%–9%), dizziness inhibition of cyclooxygenase (3%–9%); rarer, acute

renal failure, ulcersNaproxen/Inhibits prostaglandin synthesis 250–500 mg bid Pain control, Edema, dizziness,

in inflammatory cascade through anti-inflammatory headache, abdominal inhibition of cyclooxygenase pain, nausea, tinnitus

(all 3%–9%); rarer: acute renal failure, ulcersTriamcinolone/Suppression of migration of 10–20 mg injected Pain control, Fat pad atrophy,

polymorphonuclear leukocytes and anti-inflammatory plantar fascia rupture, reversal of increased capillary permeability soft tissue and skin

atrophyDexamethasone/Suppression of neutrophil 1–3 mg injected Pain control, Fat pad atrophy,

migration, decreased production of anti-inflammatory plantar fascia rupture, inflammatory mediators and reversal soft tissue and skin of increased capillary permeability atrophy

Erythrocyte injection 2 mL Stimulation of an Pain at injection site, acute inflammatory infection reaction that leads to reinitiation of the healing processBotulinum toxin type A/Neurotoxin 70–200 IU Pain control Headache, stiffness,

produced by Clostridium botulinum numbness, weakness, prevents calcium-dependent release of anxiety; not approved acetylcholine at the presynaptic by the FDA for this membrane of the neuromuscular junction useto produce a state of denervation and muscle inactivation

bid = twice daily; CNS = central nervous system; FDA = Food and Drug Administration; IU = international units.


62. Lee TG, Ahmad TS.Intralesional autolo-gous blood injectioncompared to corti-costeroid injectionfor treatment ofchronic plantar fasci-itis. A prospective,randomized, con-trolled trial. Foot An-kle Int. 2007; 28:984-90. [PMID: 17880872]

63. Placzek R, Deuret-zbacher G, Buttgere-it F, Meiss AL. Treat-ment of chronicplantar fasciitis withbotulinum toxin A:an open case serieswith a 1 year followup [Letter]. AnnRheum Dis. 2005;64:1659-61. [PMID: 16227422]

64. Babcock MS, Foster L,Pasquina P, Jabbari B.Treatment of pain attributed to plantarfasciitis with botu-linum toxin a: a short-term, randomized,placebo-controlled,double-blind study.Am J Phys Med Reha-bil. 2005;84:649-54.[PMID: 16141740]

65. Saxena A. Uniportalendoscopic plantarfasciotomy: aprospective studyon athletic patients.Foot Ankle Int. 2004;25:882-9. [PMID: 15680101]

66. Hogan KA, Webb D,Shereff M. Endo-scopic plantar fasciarelease. Foot AnkleInt. 2004; 25:875-81.[PMID: 15680100]

67. Bazaz R, Ferkel RD.Results of endo-scopic plantar fasciarelease. Foot AnkleInt. 2007; 28:549-56.[PMID: 17559761]

68. Graves RH 3rd, LevinDR, Giacopelli J,White PR, Russell RD.Fluoroscopy-assistedplantar fasciotomyand calcaneal exos-tectomy: a retro-spective study andcomparison of surgi-cal techniques. J Foot Ankle Surg.1994; 33:475-81.[PMID: 7849673]

69. Tomczak RL, Haver-stock BD. A retro-spective comparisonof endoscopic plan-tar fasciotomy toopen plantar fas-ciotomy with heelspur resection forchronic plantar fasci-itis/heel spur syn-drome. J Foot AnkleSurg. 1995;34:305-11.[PMID: 7550197]


controlled trial in 35 heels found no difference in effectiveness between ultrasound-guided and palpation-guided cortisone injections at follow-up approxi-mately 2 years later (59).

More recently, some clinicianshave begun injecting autologousblood or platelet-rich plasma using the theory that these substances stimulate an acute inflammatory reaction that leadsto reinitiation of the healingprocess. Evidence on the effective-ness of this practice is limited (60–62).

In a case series of 16 patients with plantarfasciitis who were injected with autolo-gous blood, the average pain severityscale decreased from 7.1 to 2.8. The average Nirschl activity staging scale decreased from 6.2 to 2.9. Ten of the 16 patients were able to resume strenuousactivity, and of these 7 had no pain. Threepatients reported no response to blood in-jection (60).

In a randomized, controlled trial of 44 patients who were injected with either autologous blood or methylprednisoloneacetate, both groups had similar decreasesin visual analogue pain scores at 6-monthfollow-up (61).

In a randomized, controlled trial of 61patients who were injected with eitherautologous blood or corticosteroid,blinded observers found decreased painin both groups at 6 weeks and 6 months,with more rapid pain decreases in pa-tients who had corticosteroid injections(62).

Even more recently, a few cliniciansare injecting botulinum toxin in recalcitrant cases of plantar fasciitis,but this remains an experimentalprocedure.

In a case series of 9 patients with chronicplantar fasciitis who were injected with asingle dose of botulinum toxin A, signifi-cant reductions in pain were noted at 2 weeks and continued at 1-year follow-up(63).

A randomized, double-blind, placebo-controlled study of 27 patients with plan-tar fasciitis compared a single dose ofbotulinum toxin A with saline injectedinto the heel and arch. There was signifi-cant improvement in the botulinum toxinpatients vs. the saline patients for multi-ple pain scales at 3 weeks and 8 weeks(64).

When should clinicians consider referring for surgicalrelease?Consider referring patients for asurgical plantar fascia release whenthe pain of plantar fasciitis is unre-lenting and conservative treatmentis ineffective. Remind the patientthat most cases of plantar fasciitisresolve spontaneously, usuallywithin 2 years, irrespective of in-terventions. Discuss the risks ofsurgery, which include loss of footarch, infection, scarring, nervedamage, and chronic pain. Selec-tion of an appropriate patient for surgical intervention usually re-sults in a good treatment response(65–69).

Treatment... Comprehensive management includes a combination of treatmentoptions that are directed toward alleviating pain and increasing tolerance for ac-tivities. The treatment plan should be flexible and reevaluated at regular intervals,so that it can be altered according to functional and symptomatic responses.First-line treatment for plantar fasciitis should emphasize nonpharmacologictreatments, including weight loss, stretching, strengthening, and arch support.Pain should be controlled with NSAIDs, if necessary, to facilitate other first-linetreatments. Ultrasonography, laser, extracorporeal shock wave therapy, and injec-tions can be used for patients who do not respond to initial therapies. Surgeryshould be reserved for patients with intractable symptoms that do not respond toother measures.



Inthe

C linicTool Kit

In the Clinic

Plantar Fasciitis

PIER Modulehttp://pier.acponline.org/physicians/diseases/d065/d065.htmlPIER module on plantar fasciitis

from the American College ofPhysicians (ACP). PIER modulesprovide evidence-based, updatedinformation on current diagnosis and treatment in an electronicformat designed for rapid access at the point of care.

Patient Informationhttp://pier.acponline.org/physicians/diseases/d065/d065-pi.htmlPatient Information material that

appears on the following page forduplication and distribution topatients.

www.nlm.nih.gov/medlineplus/ency/article/007021.htm (English)www.nlm.nih.gov/medlineplus/spanish/ency/article/007021.htm (Spanish)Information on plantar fasciitis from

the National Institutes of Health’sMedlinePLUS, in English andSpanish.

http://familydoctor.org/online/famdocen/home/healthy/physical/injuries/140.html(English)http://familydoctor.org/online/famdoces/home/healthy/physical/injuries/140.html(Spanish)Answers to common questions

about plantar fasciitis from theAmerican Academy of FamilyPhysicians.

www3.aaos.org/product/productpage.cfm?code=03105Patient brochure on plantar fasciitis,

from the American Academy ofOrthopaedic Surgeons.

Clinical Guidelineswww.jospt.org/members/getfile.asp?id=4158Clinical practice guideline on

heel pain: plantar fasciitis, from the Orthopaedic Section of the American Physical Therapy Association, published in 2008.

Quality of Care Guidelineswww.ncbi.nlm.nih.gov/pubmed/12917892Cochrane review of interventions for

treating plantar heel pain, publishedin 2003.

Diagnostic Tests and Criteriahttp://pier.acponline.org/physicians/diseases/d065/tables/d065-tlab.htmlTable listing imaging studies for

planar fasciitis.

3 January 2012Annals of Internal MedicineIn the ClinicITC1-14© 2012 American College of Physicians


In the ClinicAnnals of Internal Medicine

Pati

ent

Info

rmat

ion

THINGS YOU SHOULDKNOW ABOUT PLANTARFASCIITIS

What is plantar fasciitis?• The plantar fascia is a band of tissue similar to a

ligament that runs under the heel to the toes andsupports the arch.

• Plantar fasciitis occurs when degenerative abnor-malities develop in the plantar fascia.

• Plantar fasciitis is the most common cause of heelpain.

What factors increase risk?• Being over 40 years of age.

• Being overweight or obese.

• Being on your feet for extended periods.

• Increase in intensity, duration or frequency ofimpact loading physical activities, particularlyrunning.

• Wearing shoes with poor cushioning or no archsupport.

What are the common symptoms?• Symptoms are worse in the morning and lessen with

moderate foot activity.

• Limping or other signs of foot discomfort whenwalking.

How is it diagnosed?• Your doctor will ask about the nature of your heel

pain and about your general health and physicalactivity.

• Your doctor will also examine your foot, checking fortenderness and pain.

How is it treated?• Avoid walking barefoot.

• Wear shoes with good arch support and cushionedheels, such as athletic shoes.

• Massage and stretch the fascia in the morning, suchas by rolling the foot over a can.

• Use ice after exercise and over-the-counter painrelievers.

• Orthotic devices are sometimes useful.

• An injection may be useful, but there are risks ofadverse effects.

• Plantar fasciitis usually improves within a year or 2.

For More Informationwww.nlm.nih.gov/medlineplus/heelinjuriesanddisorders.htmlOverview on heel injuries and disorders from the National

Institutes of Health’s MedlinePLUS.

http://orthoinfo.aaos.org/topic.cfm?topic=A00149&return_link=0Information on plantar fasciitis from the American Academy of

Orthopaedic Surgeons.

http://orthoinfo.aaos.org/topic.cfm?topic=A00172&return_link=0Information on orthotic devices for various foot conditions from

the American Academy of Orthopaedic Surgeons.


CME Questions

3 January 2012Annals of Internal MedicineIn the ClinicITC1-16© 2012 American College of Physicians

Questions are largely from the ACP’s Medical Knowledge Self-Assessment Program (MKSAP, accessed at http://www.acponline.org/products_services/mksap/15/?pr31). Go to www.annals.org/intheclinic/

to complete the quiz and earn up to 1.5 CME credits, or to purchase the complete MKSAP program.

1. A 37-year-old woman is evaluated for a 6-week history of graduallyprogressive, aching right heel pain. The pain is worse in the morning,especially when she first steps out ofbed. She has no numbness or tinglingin her feet. She is overweight andbegan jogging several months ago tolose weight. She was carefully fittedfor comfortable running shoes beforeshe began running. Her only medicalproblem is hypothyroidism, for whichshe takes thyroxine.

On physical examination, she has nobony abnormalities, swelling, or skinchanges over the feet and ankles. Thereis tenderness on palpation only over themedial aspect of the right calcaneus;dorsiflexion of the toes increases heelpain. Ankle range of motion is intact; shehas no pain with inversion or eversionand dorsiflexion of the foot. She also has no discomfort with reflex hammertapping over the medial aspect of theheel just below and behind the medialmalleolus or with compression of thecalcaneus.

Which of the following is the most likelydiagnosis in this patient?

A. Achilles tendonitisB. Calcaneal stress fractureC. Plantar fasciitisD. Tarsal tunnel syndrome

2. A 52-year-old woman is evaluated for a2-year history of burning feet. Symptomsare constant and are worse at night. Thepatient is overweight and has a history ofhypertension treated with lisinopril. Thereis no known family history of peripheralneuropathy.

On physical examination, the patient isafebrile; blood pressure is 134/88 mmHg, pulse rate is 66/min, respiration rateis 12/min, and BMI is 28. Neurologic

examination shows diminished pinprickand temperature sensation on the dorsaland plantar surfaces of both feet. Cranialnerve examination and testing of manualmuscle strength, deep tendon reflexes,proprioception, and coordination revealno abnormalities.

Laboratory studies show a fasting plasmaglucose level of 102 mg/dL (5.7 mmol/L).Results of a complete blood count,vitamin B

12measurement, and serum

protein electrophoresis are all normal.

Electromyographic testing shows a mildreduction in the sensory nerve actionpotential in the legs, compatible withmild peripheral neuropathy. MRI of thelumbar spine is normal.

Which of the following is the mostappropriate next diagnostic test?

A. Cerebrospinal fluid examinationB. Genetic testing for Charcot-Marie-

Tooth diseaseC. Glucose tolerance testD. Skin biopsyE. Bilateral foot x-rays for bone spurs

3. A 45-year-old woman is evaluated for a2-month history of right heel pain. Shehas been trying to lose weight andbegan walking, but the pain has limitedher ability to continue. The pain isworse in the morning—particularly thefirst steps in the morning or afterresting. She has had decreased painwhen taking NSAIDs, but overall, thecondition is worsening. Her onlymedication is ibuprofen.

On physical examination, there istenderness along the anterior edge of theright calcaneus. Pressing into the sole atthe level of the heel elicits pain. Whenthe ankle is maximally dorsiflexed, andthe toes are then dorsiflexed by theexaminer, the pain is reproduced.

Which of the following is the mostappropriate next step in this patient’smanagement?

A. Corticosteroid injectionB. Heel magnet insertsC. MRID. Plain film radiographyE. Plantar fascial stretching exercises

4. A 21-year-old woman is evaluated for an8-week history of gradually progressiveaching right heel pain. The pain istypically is felt at night shortly afterstarting her daily run and becomesprogressively worse throughout the run.She has no numbness or tingling in herfeet. She is an experienced runner andtraining for a half-marathon. She buysnew running shoes every 6 months. Heronly medical problem is a history ofirregular menstrual periods.

On physical examination, she appears tohave an athletic build, but does not seemunderweight. She has no boneabnormalities, swelling, or skin changes overthe feet and ankles. There is tenderness topalpation only over the center of the rightcalcaneus; dorsiflexion of the toes does noteffect the heel pain. Ankle range of motionis intact; she has no pain with inversion oreversion and dorsiflexion of the foot. Shealso has no discomfort with reflex hammertapping over the medial aspect of the heeljust below and behind the medial malleolus.She has no pain with walking. She notessome pain with compression of thecalcaneus and when the bottom of her footis thumped.

Which of the following areas is mostimportant and needs to be explored inmore detail in this patient?

A. Dietary historyB. Family history of cancerC. Obstetric historyD. Occupational history


in the clinic plantar fasciitis in theclinic · in the clinic plantar fasciitis ... (flat feet,...

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