Plantar Fasciitis

 

Am Fam Physician. 2019 Jun 15;99(12):744-750.

  Patient information: See related handout on plantar fasciitis, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Plantar fasciitis is a common problem that one in 10 people will experience in their lifetime. Plantar fasciopathy is an appropriate descriptor because the condition is not inflammatory. Risk factors include limited ankle dorsiflexion, increased body mass index, and standing for prolonged periods of time. Plantar fasciitis is common in runners but can also affect sedentary people. With proper treatment, 80% of patients with plantar fasciitis improve within 12 months. Plantar fasciitis is predominantly a clinical diagnosis. Symptoms are stabbing, nonradiating pain first thing in the morning in the proximal medioplantar surface of the foot; the pain becomes worse at the end of the day. Physical examination findings are often limited to tenderness to palpation of the proximal plantar fascial insertion at the anteromedial calcaneus. Ultrasonography is a reasonable and inexpensive diagnostic tool for patients with pain that persists beyond three months despite treatment. Treatment should start with stretching of the plantar fascia, ice massage, and nonsteroidal anti-inflammatory drugs. Many standard treatments such as night splints and orthoses have not shown benefit over placebo. Recalcitrant plantar fasciitis can be treated with injections, extracorporeal shock wave therapy, or surgical procedures, although evidence is lacking. Endoscopic fasciotomy may be required in patients who continue to have pain that limits activity and function despite exhausting nonoperative treatment options.

Plantar fasciitis (also called plantar fasciopathy, reflecting the absence of inflammation) is a common problem accounting for approximately 1 million patient visits per year, with about 60% of these to primary care physicians.1 It is the most common cause of heel pain in adults, with a lifetime incidence of about 10%2 and an increased incidence in women 40 to 60 years of age.1 Plantar fasciitis is associated with a variety of sports but is mostly reported in recreational and elite runners (incidence of 5% to 10%).3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComment

Ultrasonography and magnetic resonance imaging are diagnostic options in patients with chronic heel pain despite conservative measures.

C

3, 13, 14

Based on systematic reviews of disease-oriented evidence

Plantar fascia stretches are effective for reducing heel pain.

B

17, 18

Based on small, limited-quality randomized controlled trials

Foot orthoses (prefabricated or custom) may reduce heel pain for up to 12 weeks, but the benefit is generally not clinically meaningful in the long term.

B

21

Based on moderate-quality evidence from a systematic review and meta-analysis

The role of night splints in reducing plantar fasciitis pain is inconclusive.

B

25, 26

Based on inconsistent, limited-quality studies

Extracorporeal shock wave therapy may have a role in chronic plantar fasciitis that does not respond to conservative therapies.

B

27, 28

Based on inconsistent evidence and a meta-analysis

Corticosteroid injections may provide, at best, short-term relief for acute and chronic plantar fasciitis.

B

29

Based on a Cochrane review of low-quality studies


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComment

Ultrasonography and magnetic resonance imaging are diagnostic options in patients with chronic heel pain despite conservative measures.

C

3, 13, 14

Based on systematic reviews of disease-oriented evidence

Plantar fascia stretches are effective for reducing heel pain.

B

17, 18

Based on small, limited-quality randomized controlled trials

Foot orthoses (prefabricated or custom) may reduce heel pain for up to 12 weeks, but the benefit is generally not clinically meaningful in the long term.

B

21

Based on moderate-quality evidence from a systematic review and meta-analysis

The role of night splints in reducing plantar fasciitis pain is inconclusive.

B

25, 26

Based on inconsistent, limited-quality studies

Extracorporeal shock wave therapy may have a role in chronic plantar fasciitis that does not respond to conservative therapies.

B

27, 28

Based on inconsistent evidence and a meta-analysis

Corticosteroid injections may provide, at best, short-term relief for acute and chronic plantar fasciitis.

B

29

Based on a Cochrane review of low-quality studies


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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The Authors

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THOMAS TROJIAN, MD, MMB, FACSM, CAQSM, RMSK, is a professor in the Department of Family, Community and Preventive Medicine; director of the sports medicine fellowship; and chief of the Division of Sports Medicine at Drexel University College of Medicine, Philadelphia, Pa. He is also a chief medical officer for Drexel University Athletics....

ALICIA K. TUCKER, MD, is an assistant professor in the Department of Family, Community and Preventive Medicine at Drexel University College of Medicine.

Address correspondence to Thomas Trojian, MD, MMB, 10 Shurs Ln., Ste. 301, Philadelphia, PA 19127 (e-mail: tht34@drexel.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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