Correctiezolen.nlPRACTICAL MANAGEMENT Plantar Fasciitis David D. Dyck, Jr., DO,* and Lori A. Boyajian-O'Neill, DO, FAOASM*† dial tubercle of the calcaneus. The plantar fascia extends from (Clin J Sport Med 2004;14:305–309) this tubercle to the metatarsal heads, forming the longitudinalarch that provides support for the foot. Excessive load or ten-sion on this aponeurosis can lead to the condition commonly present annually for medical treatment.1 Runners comprise been considered an inflammatory process. However, in recal- over 76% of athletes with this condition.2,3 Men and women citrant cases, it appears that a degenerative process affecting appear to be equally affected.4 Plantar fasciitis classically collagen5 or degenerative fasciosis10 occurs without evidence presents as medial heel pain that is sharp and most severe with of inflammation. Lemont et al10 performed histologic exami- the first step out of bed in the morning or after prolonged rest.
nation of surgical biopsies, revealing increased fibroblasts, This condition is generally self-limiting, but complete resolu- ground substance, and vascularity, not the expected inflamma- tion may take 6 to 18 months or longer.5 Aggressive manage- tory mediators.5,10 This improved understanding may impact ment using combination therapies is most efficacious and af- the use of anti-inflammatory therapies for chronic plantar fords athletes the best opportunity to recover quickly and fully.
An understanding of risk factors and pathophysiology willhelp in identifying athletes predisposed to developing plantar fasciitis, as well as in formulating the most effective preven- Treatment should be aggressive, should be initiated as tive and therapeutic treatment plan.
early as possible, and should include a multifaceted approachthat addresses underlying anatomic and biomechanic condi- RISK FACTORS
tions, training errors, and risk factors. Assessment of underly- Plantar fasciitis can occur acutely, as with trauma, but ing risk factors is the foundation for successful treatment and more often presents as chronic plantar foot pain of insidious prevention. Treatment options discussed are summarized in onset associated with chronic overload. In approximately 85% of patients, the etiology is undetermined.6,7 Risk factors for developing plantar fasciitis can be divided into anatomic, bio- Relative rest must be a part of the treatment plan, allow- mechanical, and environmental and are presented in Table 1.
ing athletes to continue to train in some capacity without ex- Limited ankle dorsiflexion (ⱕ10°) has been reported as the acerbating symptoms. Relative rest relieves microtrauma most important independent risk factor.8 This limitation may caused by repetitive overload. Wolgin et al11 reported 25% of cause compensatory excessive pronation of the subtalar joint, patients citing rest as the treatment that best relieved pain.
which increases the tensile load to the plantar aponeurosis.9 Cross-training should be considered to maintain aerobic fit-ness levels. Relieving the overuse component through rest is critical to the prevention of further injury.
Plantar fasciitis has been referred to as heel pain syn- drome and heel spur syndrome, because the pain is usually localized to the insertion of the plantar aponeurosis at the me- Stretching is the single most effective method of treat- ment. Of the 83% of patients who improved with stretching,29% indicated that stretching was most effective in relieving Received for publication February 2004; accepted May 2004.
pain as compared with other modalities.11 Stretching should From the *Department of Family Medicine, Kansas City University of Medi- cine and Biosciences, Kansas City, MO; and †Primary Care Sports Medi- include techniques targeted at the entire lower extremity, es- cine, Kansas City University of Medicine and Biosciences, Kansas pecially the plantar fascia and gastrocsoleus-Achilles com- Reprints: David D. Dyck, Jr., DO, Kansas City University of Medicine and The athlete can target the plantar fascia at home using a Biosciences, 1750 Independence Avenue, Kansas City, MO 64106-1453 tennis ball, golf ball, or 15-oz can rolled under the arch to pro- Copyright 2004 by Lippincott Williams & Wilkins vide an adequate stretch. To accentuate further the stretch on Clin J Sport Med • Volume 14, Number 5, September 2004
Dyck and Boyajian-O'Neill Clin J Sport Med • Volume 14, Number 5, September 2004 TABLE 1. Classification of Risk Factors for Plantar Fasciitis
Anatomical Risk Factors
Biomechanical Risk Factors
Environmental Risk Factors
• Weak plantar flexor muscles • Deconditioning • Weak intrinsic muscles of the foot • Hard surfaces • Tarsal coalition • Excessive subtalar joint pronation • Walking barefoot • Leg length discrepancy • Poor footwear • Prolonged weight-bearing • Fat pad atrophy • Limited ankle dorsiflexion • Inadequate stretching • Shortened Achilles tendon the fascia, the athlete can rest the affected foot on the contra- use may decrease duration of symptoms, and they can be pur- lateral or unaffected thigh, applying firm dorsiflexion of the chased without a prescription. Powell et al13 reported that 88% great toe, thus increasing the stretch of the plantar fascia (Fig.
of patients using night splints for 1 month experienced im- 1).12 Manual stretching techniques such as myofascial release provement in their symptoms. They can be bulky and uncom- and deep tissue massage can be used to stretch the fascia.
fortable but may return the athlete to peak performance more Stretching the gastrocsoleus-Achilles complex is quickly. Frequently, night splints are reserved for recalcitrant achieved using wall stretches with a straight knee to isolate the plantar fasciitis; we propose that they be considered at the on- gastrocnemius muscle and with a bent knee to target the soleus set of symptoms in athletes.
muscle. These stretches can also be performed using a curb orstair. Stretching techniques focusing on the plantar fascia has been shown to accelerate recovery time and is more effective Plantar flexor muscle strength deficits were cited by than those directed exclusively at the gastrocsoleus-Achilles Kibler et al14 as contributing to plantar fasciitis. Martin et al15 complex.12 Early prescriptions should be given for a home reported that strengthening exercises provide the greatest de- stretching program and possibly for physical therapy referral.
crease in pain in 34.9% of patients with plantar fasciitis.
Specific stretching techniques appear in Table 2.
Strengthening exercises for the intrinsic muscles of the foot aredesigned to improve longitudinal arch support and decrease stress on the plantar fascia.
Dorsiflexion night splints (90°) relieve pain by provid- Athletes can perform strengthening exercises every hour ing continuous passive stretching during rest and sleep. Their throughout the day by simple tapping of the toes with the footplanted. The desired technique is to raise the toes and pressthem each individually to the floor. Additionally, with a towelplaced on the floor, the athlete is instructed to keep the heelplanted and gather the towel by curling the toes. As strengthimproves, weight can be added to the towel to increase resis-tance.
Strengthening of the gastrocsoleus-Achilles complex is accomplished using heel raises. The athlete begins with bothlegs at once and progresses to single leg repetitions. Asstrength improves, resistance can be increased using dumb-bells or free weights. We recommend that athletes performstrengthening exercises 3 times per day with 12 to 15 repeti-tions per set. Pain should be monitored with modifications infrequency and intensity to avoid exacerbation or return ofsymptoms.
Recent histologic evidence identifying collagen degra- FIGURE 1. Effective stretching of the plantar fascia accom-
dation, as opposed to inflammatory markers in surgical biopsy plished by applying firm dorsiflexion of the great toe. Leftindex finger points at the medial aspect of the stretched fascia.
specimens, raises questions about the utility of anti- 2004 Lippincott Williams & Wilkins Clin J Sport Med • Volume 14, Number 5, September 2004 Plantar Fasciitis TABLE 2. Treatment Options for Plantar Fasciitis
Decrease pain, slow degenerative process Cross-training to maintain fitness Increase mobility of plantar fascia Plantar fascia: 15-oz can rolled under arch, cross-friction Decrease tension of gastrocsoleus-Achilles complex massage, great toe extension, towel stretch Gastrocsoleus: slant board, wall stretch, curb or stair stretch Night splints (90°) Prolonged passive stretch Commercially available, compliance difficult Improve structural integrity of longitudinal arch Improve plantar flexor strength Toe tapsHeel raises Anti-inflammatory agents Short courseRisk of GI problems Local pain control 15 minutes 2–3 times day Decrease inflammation, local pain control Time-consuming, reserve for elite athletes or laborers Decrease inflammation, local pain control Use in later stages, risk of plantar fascia rupture, atrophy Stabilize midfoot structures Inexpensive, trial modality OTC arch supports Stabilize midfoot structures Mild pes planusAdolescents experiencing rapid growthSymptoms less than 8 weeks Customs orthotics Stabilize midfoot structures Ideal for anatomical problems Correct anatomical problems Correct anatomical and biomechanical factors Change shoes every 300–500 milesCheck for correctable problems Induce inflammatory response High-energy: single treatment, local anesthesia needed Low-energy: multiple treatment sessions, no anesthesianeeded, standardization still needed Failed conservative therapy at least 6 months, often much inflammatory therapy such as NSAIDs for chronic plantar plantar fasciitis. Studies have shown a 70% success rate using fasciitis.5,10 While NSAIDs are effective in some patients and steroid injections when applied early in the disease process.7,18 were reported in 1 study to be the most effective treatment by Injections can be performed using a plantar or medial approach 11% of subjects,11 the use of NSAIDs should be limited to a with or without ultrasound guidance. Complications include brief duration. Specifically, this may be 1 to 2 weeks at a time rupture of the plantar fascia and fat pad atrophy. Although rup- during the most acute flare-ups.
ture of the plantar fascia is uncommon, injection of corticoste- Ice applied to the attachment of the aponeurosis follow- roids has been suggested as a contributing factor.3,19,20 Most ing activity can decrease pain and inflammation. At home, the patients had resolution of symptoms associated with rupture athlete can use ice massage to stretch the fascia. Iontophoresis within 6 to 8 weeks.3,21 Still, the use of corticosteroid injec- can be used to deliver corticosteroid such as dexamethasone to tions in plantar fasciitis remains controversial.
the deep plantar aponeurosis. Gudeman et al reported improve-ment after 2 weeks but no long-term difference at 6 weeks.16,17 Difficulties with this treatment are the time requirement and The longitudinal arch is designed to distribute forces expense, as optimal therapy requires administration 2 to 3 generated at heel strike. Anatomic, biomechanical, and envi- times per week by a qualified professional. Recommendations ronmental factors causing abnormal distribution of these are to reserve iontophoresis for elite athletes and laborers pre- forces can result in plantar fasciitis. Arch supports, through vented from working due to symptoms.16 taping or orthoses, can alter the transmission of forces and de- Corticosteroid injections are controversial and are not a crease stress. As a simple noninvasive treatment, they can be first-line therapy due to the associated risks and possible com- considered a first-line treatment of plantar fasciitis in combi- plications. They should be reserved for recalcitrant cases of nation with a stretching program.
2004 Lippincott Williams & Wilkins Dyck and Boyajian-O'Neill Clin J Sport Med • Volume 14, Number 5, September 2004 Arch taping is also a simple, cost-effective treatment of A review of current literature suggests that moderate- plantar fasciitis. In patients with pes planus or pes cavus, a energy ESWT given over several sessions is an ineffective single arch taping treatment is less expensive than over-the- treatment.4,29,30 However, using single high-energy treatment, counter (OTC) arch supports. It is also useful as a treatment Alvarez31 reported that at 12 months, 20 of 20 patients met trial. If arch taping relieves pain, then advancing to an OTC or criteria for success, and 65% were pain-free at 24 months. This custom-made orthotic should be considered.
brings up the main point of controversy surrounding this treat- Patients with mild pes planus may benefit from OTC ment: whether single high-energy treatments will ultimately arch supports.22 They are useful for pediatric athletes who ex- prove effective when repeated moderate-energy doses have perience rapid foot growth, making custom orthotics cost- not. The US FDA granted approval of electrohydraulic devices prohibitive. OTC arch supports coupled with a formal stretch- for single high-energy use in chronic proximal plantar fasci- ing program offer greater benefit than custom-made orthotics itis.32 However, more research is needed to support the use of for the initial treatment of plantar fasciitis of duration less than single high-energy ESWT in this condition. When considered, ESWT use should be limited to patients who have had pain for In patients with plantar fasciitis of duration greater than at least 6 months and have not satisfactorily responded to con- 8 weeks, the use of custom orthotics may be efficacious.23 In a servative management strategies including stretching, pilot study of 15 patients with a mean age of 44 years and strengthening, orthoses, and corticosteroid injections.
plantar fasciitis with a duration of 21 months, semirigid cus-tom orthotics significantly improved pain and functional dis-ability scores by 66% and 75%, respectively.24 Custom or- thotic devices for plantar fasciitis are commonly semirigid, Surgical intervention has been the last resort for the 5% covering 3/4 to the entire foot.24,25 They have been extremely of all patients with plantar fasciitis who have failed all other effective in controlling overpronation, first metatarsal head options.33 In general, the success rate for surgical intervention motion, pes planus, valgus heel alignment, and leg length dis- is quite high. In some studies, over 90% achieved a satisfactory crepancies, all of which may be risk factors for this condition.
functional outcome.34 Generally, the surgical approach, openor endoscopic, involves transection of the plantar aponeurosis.
Complications of surgical procedures include flattening of the Shoes that are properly fitted with well-supported arches longitudinal arch and heel hypoesthesia.
and midsoles can absorb forces transmitted through the footduring walking and prolonged standing. Athletes should be en- couraged to limit time spent walking barefoot or in sandals.
Athletes should be educated about the symptoms of Some popular recommendations for footwear include using plantar fasciitis and advised to seek medical attention early so shoes with a minimal 1⬙ heel height and a stable midfoot shank, that aggressive mechanical management may be implemented as recent shoe design changes utilizing a 2-piece outsole may and the duration of condition shortened.
contribute to developing plantar fasciitis.26 These design Athletes are highly motivated to return to competition, changes result in weaker midsoles that increase stress on the and those with plantar fasciitis will benefit most from a multi- plantar fascia and thus should be avoided.
faceted approach to treatment, including a good home exercise A simple change in shoes is reported to improve symp- program. Management should be directed toward treating un- toms in 14% of patients with plantar fasciitis.15 Runners derlying causes (e.g., pes planus) and implementing an aggres- should replace their shoes every 300 to 500 miles because of an sive plan of relative rest, stretching, and strengthening. Physi- older shoe's tendency to provide inadequate support.
cal therapy should include manual techniques directed specifi-cally to the plantar fascia and consideration of modalities such Extracorporeal Shock Wave Therapy
as iontophoresis. Nonsteroidal anti-inflammatory therapies Extracorporeal shock wave therapy (ESWT) is delivered can be beneficial in acute plantar fasciitis, but corticosteroid as acoustic waves that propagate rapidly in 3-dimensional injections should be used with caution due to the increased risk space and cause a sudden rise in pressure at the wave front (i.e., of rupture of the fascia. There is burgeoning evidence to sup- medial tubercle of the calcaneus).27,28 The intent is to elicit an port collagen degeneration and not inflammation as the pri- inflammatory response that promotes neovascularization and mary pathology of recalcitrant plantar fasciitis. ESWT pro- healing. In most studies using ESWT, success is defined as vides a nonsurgical option for athletes with plantar fasciitis of 50% reduction in pain. It is customarily given as either 3 mod- duration at least 6 months resistant to aggressive home and erate-energy treatments given over a 3-week period requiring physical therapy. Plantar fasciotomy and other operative pro- no anesthesia or as a single high-energy treatment requiring cedures should be reserved for athletes who have failed all other therapies.
2004 Lippincott Williams & Wilkins Clin J Sport Med • Volume 14, Number 5, September 2004 Plantar Fasciitis by iontophoresis of 0.4% dexamethasone: a randomized, double-blind,placebo-controlled study. Am J Sports Med. 1997;25:312–316.
The authors thank Lenora M. Adams, BA, MSIV, for her 17. deleted in proof assistance in preparation of the manuscript.
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