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Treatment Options in Patients with Plantar Fasciitis
Am Fam Physician. 2005 Jan 15;71(2):372-374.
Plantar fasciitis is estimated to account for more than 10 percent of adult patients who present with foot problems. It commonly affects runners and other athletes and occurs frequently in persons older than 40 years. Buchbinder reviewed the diagnosis and treatment of this common musculoskeletal condition.
Patients with plantar fasciitis have chronic inflammatory changes at the site of origin of the plantar fascia on the medial tuberosity of the calcaneus. Repetitive microtrauma to the fascia may result from several conditions that are associated with plantar fasciitis, including obesity, high-mileage running, excessive pronation (pes planus), and reduced ankle dorsiflexion. Plantar fasciitis tends to be self-limited, and studies have shown that symptoms resolve in most patients within one year. The author notes that even surgical case series, which represent highly select patients, report surgical intervention rates of only about 5 percent.
The diagnosis of plantar fasciitis is usually straightforward. Patients typically note the gradual onset of inferior heel pain, which often is worse with the first steps of the morning and increases toward the end of the day after prolonged weight-bearing activities.
Imaging is not commonly necessary for diagnosis, but ultrasonography and magnetic resonance imaging have been used to demonstrate increased plantar fascia thickness in affected patients. Plain radiography and bone scans may be used to detect calcaneal stress fracture. The presence of calcaneal bone spurs on plain radiographs has no value in making or excluding the diagnosis of plantar fasciitis.
Although a variety of treatment modalities for this condition exists, many of them lack a firm evidence basis for efficacy. The self-limited nature of plantar fasciitis portends a good prognosis, regardless of treatment. Calf muscle stretching, plantar fascia stretching, and foot taping are widely used but do not have firm data to support their effectiveness. Magnetic insoles have no demonstrated benefit, nor does therapeutic ultrasonography, laser therapy, iontophoresis, or electron-generating devices. Heel cups, pads, and orthotics often are used in the treatment of plantar fasciitis, but evidence from controlled studies about their relative efficacy is limited and sometimes conflicting. The use of night splints to hold the heel in a neutral position or some dorsiflexion also has conflicting evidence support.
Injection of corticosteroids near the plantar fascia origin has been used for treatment, although evidence of its benefit appears to be limited to short-term pain relief, and anecdotal concerns have been raised about an increased risk of fascia rupture. The author suggests a limited role for surgery in carefully selected patients with refractory symptoms after six to 12 months of conservative therapy. Endoscopic surgical approaches to fascia release have reported quicker recovery times compared with the usual open procedures, but these approaches may carry an increased risk of nerve injury.
Buchbinder R. Plantar fasciitis. N Engl J Med. May 20, 2004;350:2159–66.
Copyright © 2005 by the American Academy of Family Physicians.
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