Plantar Fasciitis: Guidelines From the American Physical Therapy Association

Plantar fasciitis is responsible for 15% of foot pain and most commonly presents in men and women 40 to 60 years of age. The gradual onset of pain at the plantar fascia origin at the medial calcaneal tubercle is common and often lasts more than 1 year before patients seek treatment. Plantar fasciitis often has inflammatory and degenerative characteristics. The American Physical Therapy Association (APTA) released updated guidelines for the diagnosis and treatment of plantar fasciitis.

Evaluation

Plantar fasciitis classically presents with plantar medial heel pain that worsens with initial steps after a period of inactivity. An increase in weight bearing can also precipitate pain and is more likely to be present in nonathletic individuals with a high body mass index.

Examination findings include pain with palpation of the proximal insertion of the plantar fascia, a positive windlass test, and limitation of dorsiflexion of the talocrural joint.

Imaging

Although imaging is not necessary if the diagnosis of plantar fasciitis is clear, conventional weight-bearing radiography is recommended as the initial imaging study for chronic foot pain. For negative radiographs, diagnostic ultrasonography should be considered to determine if the fascial thickness is greater than 4 mm and appears hypoechoic.

Manual Therapy

Numerous manual therapies have been proposed to treat plantar fasciitis, and several have evidence of improving pain and function. Dry cupping is a process in which heated glass or ceramic cups are placed on the skin; as the cups cool, they create suction that mobilizes tissue, increases blood flow, and promotes tissue relaxation. In combination with conventional stretching, cupping may lead to improvement in mobility and pain for a few days. Myofascial trigger point release involves finding a specific tender knot and applying gentle, firm pressure until the tension releases. This, particularly in conjunction with therapeutic ultrasound and stretching of the gastrocnemius, soleus, and fibularis muscles, improves mobility and pain for up to 2 weeks. Subtalar mobilization reduces pain and disability for up to 3 weeks, whereas soft tissue mobilization using deep massage to the posterior calf and neural mobilization can improve pain and joint mobility for up to 6 weeks. Instrument-assisted soft-tissue mobilization therapy of the calf and plantar fascia using beveled instruments to cause aggressive mobilization of the fascia leads to measurable improvement for up to 90 days. Adding muscle energy techniques to manual therapy improves outcomes.

Stretching

Low- to moderate-quality evidence supports the benefit of stretching the plantar fascia and the gastrocnemius and soleus muscles to improve pain and disability in plantar fasciitis. Limited evidence suggests that plantar fascial stretching is more beneficial. Combined stretching may be more beneficial than heat treatment and nonsteroidal anti-inflammatory drugs.