Plantar fasciitis is a common cause of heel pain in adults. The disorder classically presents with pain that is particularly severe with the first few steps taken in the morning. In general, plantar fasciitis is a self-limited condition. However, symptoms usually resolve more quickly when the interval between the onset of symptoms and the onset of treatment is shorter. Many treatment options exist, including rest, stretching, strengthening, change of shoes, arch supports, orthotics, night splints, anti-inflammatory agents and surgery. Usually, plantar fasciitis can be treated successfully by tailoring treatment to an individual's risk factors and preferences. (Am Fam Physician 2001; 63:467-74,477-8.)
Plantar fasciitis is a common cause of heel pain in adults. The pain is usually caused by collagen degeneration (which is sometimes misnamed "chronic inflammation") at the origin of the plantar fascia at the medial tubercle of the calcaneus. This degeneration is similar to the chronic necrosis of tendonosis, which features loss of collagen continuity, increases in ground substance (matrix of connective tissue) and vascularity, and the presence of fibroblasts rather than the inflammatory cells usually seen with the acute inflammation of tendonitis.1 The cause of the degeneration is repetitive microtears of the plantar fascia that overcome the body's ability to repair itself.
The classic sign of plantar fasciitis is that the worst pain occurs with the first few steps in the morning, but not every patient will have this symptom. Patients often notice pain at the beginning of activity that lessens or resolves as they warm up. The pain may also occur with prolonged standing and is sometimes accompanied by stiffness. In more severe cases, the pain will also worsen toward the end of the day.
The plantar fascia is a thickened fibrous aponeurosis that originates from the medial tubercle of the calcaneus and runs forward to form the longitudinal foot arch. The function of the plantar fascia is to provide static support of the longitudinal arch and dynamic shock absorption. Individuals with pes planus (low arches or flat feet) or pes cavus (high arches) are at increased risk for developing plantar fasciitis.
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Other anatomic risks include overpronation, discrepancy in leg length, excessive lateral tibial torsion and excessive femoral anteversion. Functional risk factors include tightness and weakness in the gastrocnemius, soleus, Achilles tendon and intrinsic foot muscles. However, overuse rather than anatomy is the most common cause of plantar fasciitis in athletes. A history of an increase in weight-bearing activities is common, especially those involving running, which causes microtrauma to the plantar fascia and exceeds the body's capacity to recover. Plantar fasciitis also occurs in elderly adults. In these patients, the problem is usually more biomechanical, often related to poor intrinsic muscle strength and poor force attenuation secondary to acquired flat feet and compounded by a decrease in the body's healing capacity.
On examination, the patient usually has a point of maximal tenderness at the anteromedial region of the calcaneus. The patient may also have pain along the proximal plantar fascia. The pain may be exacerbated by passive dorsiflexion of the toes or by having the patient stand on the tips of the toes.
Diagnostic testing is rarely indicated for the initial evaluation and treatment of plantar fasciitis. Plantar fasciitis is often called "heel spurs," although this terminology is somewhat of a misnomer because 15 to 25 percent of the general population without symptoms have heel spurs and many symptomatic individuals do not.2 Heel spurs are bony osteophytes that can be visualized on the anterior calcaneus on radiography. However, diagnostic testing is indicated in cases of atypical plantar fasciitis, in patients with heel pain that is suspicious for other causes (Table 1) or in patients who are not responding to appropriate treatment.
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