treatment of plantar fasciitis - aafp.orghigh arches) are at increased risk for developing plantar...

FEBRUARY 1, 2001 / VOLUME 63, NUMBER 3 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 467

foot arch. The function of the plantarfascia is to provide static support of thelongitudinal arch and dynamic shockabsorption. Individuals with pes planus(low arches or flat feet) or pes cavus(high arches) are at increased risk fordeveloping plantar fasciitis.

Other anatomic risks include over-pronation, discrepancy in leg length,excessive lateral tibial torsion and exces-sive femoral anteversion. Functional riskfactors include tightness and weaknessin the gastrocnemius, soleus, Achillestendon and intrinsic foot muscles. How-ever, overuse rather than anatomy is themost common cause of plantar fasciitisin athletes. A history of an increase inweight-bearing activities is common,especially those involving running,which causes microtrauma to the plan-tar fascia and exceeds the body’s capacityto recover. Plantar fasciitis also occurs inelderly adults. In these patients, theproblem is usually more biomechanical,often related to poor intrinsic musclestrength and poor force attenuation sec-ondary to acquired flat feet and com-pounded by a decrease in the body’shealing capacity.

On examination, the patient usuallyhas a point of maximal tenderness at theanteromedial region of the calcaneus.The patient may also have pain along theproximal plantar fascia. The pain may be

Plantar fasciitis is a commoncause of heel pain in adults.The pain is usually caused bycollagen degeneration (whichis sometimes misnamed

“chronic inflammation”) at the origin ofthe plantar fascia at the medial tubercleof the calcaneus. This degeneration issimilar to the chronic necrosis of ten-donosis, which features loss of collagencontinuity, increases in ground sub-stance (matrix of connective tissue) andvascularity, and the presence of fibro-blasts rather than the inflammatorycells usually seen with the acute inflam-mation of tendonitis.1 The cause of thedegeneration is repetitive microtears ofthe plantar fascia that overcome thebody’s ability to repair itself.

The classic sign of plantar fasciitis isthat the worst pain occurs with the firstfew steps in the morning, but not everypatient will have this symptom. Patientsoften notice pain at the beginning ofactivity that lessens or resolves as theywarm up. The pain may also occur withprolonged standing and is sometimesaccompanied by stiffness. In moresevere cases, the pain will also worsentoward the end of the day.

The plantar fascia is a thickenedfibrous aponeurosis that originates fromthe medial tubercle of the calcaneus andruns forward to form the longitudinal

Plantar fasciitis is a common cause of heel pain in adults. The disorder classically pre-sents with pain that is particularly severe with the first few steps taken in the morn-ing. In general, plantar fasciitis is a self-limited condition. However, symptoms usuallyresolve more quickly when the interval between the onset of symptoms and the onsetof treatment is shorter. Many treatment options exist, including rest, stretching,strengthening, change of shoes, arch supports, orthotics, night splints, anti-inflamma-tory agents and surgery. Usually, plantar fasciitis can be treated successfully by tailor-ing treatment to an individual’s risk factors and preferences. (Am Fam Physician 2001;63:467-74,477-8.)

O A patient informa-tion handout on plan-tar fasciitis, written bythe authors of thisarticle, is provided onpage 477.

Treatment of Plantar FasciitisCRAIG C. YOUNG, M.D., Medical College of Wisconsin, Milwaukee, Wisconsin DARIN S. RUTHERFORD, M.D., Mercy Sports Medicine, Janesville, WisconsinMARK W. NIEDFELDT, M.D., Medical College of Wisconsin, Milwaukee, Wisconsin

COVER ARTICLEPRACTICAL THERAPEUTICS

Members of variousfamily practice depart-ments develop articlesfor “Practical Therapeu-tics.” This article is onein a series coordinatedby the Department ofFamily and CommunityMedicine at the Med-ical College of Wiscon-sin, Milwaukee. Guesteditors of the series areLinda N. Meurer, M.D.,M.P.H., and DouglasBower, M.D.

exacerbated by passive dorsiflexion of the toesor by having the patient stand on the tips ofthe toes.

Diagnostic testing is rarely indicated for theinitial evaluation and treatment of plantarfasciitis. Plantar fasciitis is often called “heelspurs,” although this terminology is some-what of a misnomer because 15 to 25 percentof the general population without symptomshave heel spurs and many symptomatic indi-viduals do not.2 Heel spurs are bony osteo-phytes that can be visualized on the anteriorcalcaneus on radiography. However, diagnos-tic testing is indicated in cases of atypicalplantar fasciitis, in patients with heel painthat is suspicious for other causes (Table 1) or

in patients who are not responding to appro-priate treatment.

TreatmentIn general, plantar fasciitis is a self-limiting

condition. Unfortunately, the time until reso-lution is often six to 18 months, which canlead to frustration for patients and physi-cians. Rest was cited by 25 percent of patientswith plantar fasciitis in one study as the treat-ment that worked best.3 Athletes, active adultsand persons whose occupations require lotsof walking may not be compliant if instructedto stop all activity. Many sports medicinephysicians have found that outlining a plan of“relative rest” that substitutes alternativeforms of activity for activities that aggravatethe symptoms will increase the chance ofcompliance with the treatment plan.4

It is equally important to correct the prob-lems that place individuals at risk for plantarfasciitis, such as increased amount of weight-

468 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 63, NUMBER 3 / FEBRUARY 1, 2001

TABLE 1

Differential Diagnosis of Heel Pain

Disease or injury Differentiating clinical features

Neurologic causes (entrapment syndromes) Radiating burning pain, numbness and tingling, especially at night

Tarsal tunnel syndrome Diffuse symptoms over plantar surfaceMedial calcaneal branch of the Medial and plantar heel symptoms

posterior tibial nerve entrapmentAbductor digiti quinti nerve entrapment Burning pain in heel pad area

Skeletal causes Bony point tendernessCalcaneal stress fracture activity Pain with weight-bearing; worsens with prolonged

weight-bearing Paget’s disease Bowed tibias, kyphosis, headachesTumor Deep bone pain; constitutional symptoms late in the courseCalcaneal apophysitis (Sever’s disease) Posterior heel pain in adolescents

Soft tissue causesFat pad syndrome Atrophy of heel padHeel bruise History of acute impact injuryBursitis Usually retrocalcaneal; swelling and erythema of posterior heelPlantar fascia rupture Sudden acute, knife-like pain, ecchymosisTendonitis Pain with resisted motionsPlantar fasciitis See text.

The pain of plantar fasciitis is caused by collagen degenera-tion associated with repetitive microtears of the plantar fascia.

bearing activity, increased intensity of activ-ity, hard walking/running surfaces and wornshoes. Early recognition and treatment usu-ally lead to a shorter course of treatment aswell as increased probability of success withconservative treatment measures.3,5,6

STRETCHING AND STRENGTHENING

Stretching and strengthening programs playan important role in the treatment of plantarfasciitis and can correct functional risk factors

such as tightness of the gastrocsoleus complexand weakness of the intrinsic foot muscles.Increasing flexibility of the calf muscles is par-ticularly important. Frequently used stretchingtechniques include wall stretches (Figure 1)and curb or stair stretches (Figure 2).

Other effective techniques include use of aslant board (Figure 3) or placing a two-inch 3four-inch piece of wood (Figure 4) in areaswhere the patient stands for a prolonged time(e.g., workplaces, kitchen or stoves) to use in

Plantar Fasciitis


FIGURE 1. Wall exercises for calf stretching. (Left) Gastrocnemius stretch. (Right) Soleus stretch.

FIGURE 2. Stair stretch. FIGURE 3. Slant board.

stretching the calf. Dynamic stretches such asrolling the foot arch over a 15-oz size can or atennis ball are also useful (Figure 5). Cross-friction massage above the plantar fascia (Fig-ure 6) and towel stretching (Figure 7) may bedone before getting out of bed and serve tostretch the plantar fascia.

In one study,3 83 percent of patientsinvolved in stretching programs were success-fully treated, and 29 percent of patients in thestudy cited stretching as the treatment thathad helped the most compared with use oforthotics, nonsteroidal anti-inflammatory


FIGURE 5. Dynamic stretching with a 15-ozcan.

FIGURE 6. Cross-friction massage above theplantar fascia.

FIGURE 7. Towel stretching.

FIGURE 4. Use of two-inch 3 four-inch piece ofwood for stretching.

The Authors

CRAIG C. YOUNG, M.D., is an associate professor of orthopedic surgery and commu-nity and family medicine and the medical director of sports medicine for the MedicalCollege of Wisconsin, Milwaukee. He received his medical degree from the Universityof California, San Diego, School of Medicine and completed a family medicine resi-dency at the University of California, Los Angeles, UCLA School of Medicine and a pri-mary care sports medicine fellowship at the Cleveland Clinic Hospital, Cleveland, Ohio.

DARIN S. RUTHERFORD, M.D., is in private practice at Mercy Sports Medicine inJanesville, Wis. He received his medical degree from the University of Iowa College ofMedicine, Iowa City, and completed his family medicine residency at the Medical Col-lege of Wisconsin St. Mary’s program and a primary care sports medicine fellowship atthe Medical College of Wisconsin.

MARK W. NIEDFELDT, M.D., is an assistant professor of community and family medi-cine and orthopedic surgery for the Medical College of Wisconsin. He received hismedical degree from the Medical College of Wisconsin and completed his family med-icine residency at the Medical College of Wisconsin St. Mary’s program and a primarycare sports medicine fellowship at the Medical College of Wisconsin.

Address correspondence to Craig C. Young, M.D., 9200 W. Wisconsin Ave., Milwau-kee, WI 53226. Reprints are not available from the authors.

drugs (NSAIDs), ice, steroid injection, heat,heel cups, night splints, walking, plantar strap-ping and shoe changes.3

Strengthening programs should focus onintrinsic muscles of the foot. Exercises usedinclude towel curls and toe taps. Exercisessuch as picking up marbles and coins with thetoes are also useful. To do a towel curl, thepatient sits with the foot flat on the end of atowel placed on a smooth surface. Keepingthe heel on the floor, the towel is pulledtoward the body by curling the towel with thetoes. To do toe taps, all the toes are lifted offthe floor and, keeping the heel on the floorand the outside four toes in the air, the big toeis tapped to the floor repetitively. Next, theprocess is reversed, and the outside four toesare repetitively tapped to the floor while keep-ing the big toe in the air.

In another study,6 strengthening programswere cited as the most helpful treatment by34.9 percent of the subjects, compared withexercise, night splints, orthotics, heel cups,NSAIDs, steroid injection or surgery.

SHOES

A change to properly fitting, appropriateshoes may be useful in some patients. Someindividuals wear shoes that are too small,which can exacerbate many types of footpain.7 Patients often find that wearing shoeswith thicker, well-cushioned midsoles, usuallymade of a material like high-density ethylenevinyl acetate (such as is found in many run-ning shoes), decreases the pain associated withlong periods of walking or standing. Studies5

have shown that with age, running shoes losea significant portion of their shock absorp-tion. Thus, simply getting a new pair of shoesmay be helpful in decreasing pain.

For individuals with flat feet, motion controlshoes or shoes with better longitudinal archsupport may decrease the pain associated withlong periods of walking or standing.5 Motioncontrol shoes usually have the following char-acteristics: a straight last, board or combina-tion lasted construction, an external heel

counter, a wider flare and extra medial sup-port.5 A change in shoes was cited by 14 per-cent of patients with plantar fasciitis as thetreatment that worked best for them.3

ARCH SUPPORTS AND ORTHOTICS

Patients with low arches theoretically have adecreased ability to absorb the forces gener-ated by the impact of foot strike.5 The threemost commonly used mechanical correctionsare arch taping, over-the-counter arch sup-ports and custom orthotics. Arch taping andorthotics were found to be significantly betterthan use of NSAIDs, cortisone injection orheel cups in one randomized treatmentstudy.8 Arch taping was cited by 2 percent ofpatients as the treatment that worked best forplantar fasciitis in another study.3 A single tap-ing treatment is much less expensive than anover-the-counter arch support or an orthotic.

Taping provides only transient support,with studies9,10 showing that as little as 24minutes of activity can decrease the effective-ness of taping significantly. Arch taping can beused as definitive treatment or as a trial todetermine if the expense of arch supports ororthotics is worth the benefit. Taping may bemore cost effective for acute onset of plantarfasciitis, and over-the-counter arch supportsand orthotics may be more cost-effective forchronic or recurrent cases of plantar fasciitisand for prevention of injuries. In athletes,arches must be retaped at least for every newgame or practice session, whereas an over-the-counter arch support usually lasts a full sportsseason and a custom orthotic usually lasts formany seasons.

Over-the-counter arch supports may beuseful in patients with acute plantar fasciitisand mild pes planus. The support provided

Plantar Fasciitis


Early recognition and treatment of plantar fasciitis usuallylead to a shorter course of the problem and increased suc-cess of conservative measures.

by over-the-counter arch supports is highlyvariable and depends on the material used tomake the support. In general, patients shouldtry to find the most dense material that is softenough to be comfortable to walk on. Over-the-counter arch supports are especially use-ful in the treatment of adolescents whoserapid foot growth may require a new pair ofarch supports once or more per season.

Custom orthotics are usually made by tak-ing a plaster cast or an impression of the indi-vidual’s foot and then constructing an insertspecifically designed to control biomechanicalrisk factors such as pes planus, valgus heelalignment and discrepancies in leg length. Forpatients with plantar fasciitis, the most com-mon prescription is for semi-rigid, three-quar-ters to full-length orthotics with longitudinalarch support. Two important characteristicsfor successful treatment of plantar fasciitiswith orthotics are the need to control over-pronation and metatarsal head motion, espe-cially of the first metatarsal head.11 In onestudy,3 orthotics were cited by 27 percent ofpatients as the best treatment. The main disad-vantage of orthotics is the cost, which mayrange from $75 to $300 or more and which isfrequently not covered by health insurance.

Heel cups are used to decrease the impacton the calcaneus and to theoretically de-crease the tension on the plantar fascia byelevating the heel on a soft cushion. Al-though heel cups have been found to be use-ful by some physicians and patients,6 in ourexperience they are more useful in treatingpatients with fat pad syndrome and heelbruises than patients with plantar fasciitis. Ina survey of 411 patients with plantar fasci-itis,12 heel cups were ranked as the least effec-tive of 11 different treatments.

NIGHT SPLINTS

Night splints usually are designed to keep aperson’s ankle in a neutral position overnight.Most individuals naturally sleep with the feetplantar-flexed, a position that causes the plan-tar fascia to be in a foreshortened position. A

night dorsiflexion splint allows passivestretching of the calf and the plantar fasciaduring sleep. Theoretically, it also allows anyhealing to take place while the plantar fascia isin an elongated position, thus creating lesstension with the first step in the morning. Anight splint can be molded from plaster orfiberglass casting material or may be a prefab-ricated, commercially produced plastic brace(Figure 8).

Several studies13,14 have shown that use ofnight splints has resulted in improvement inapproximately 80 percent of patients usingnight splints. Other studies15,16 found thatnight splints were especially useful in individ-uals who had symptoms of plantar fasciitisthat had been present for more than 12months. Night splints were cited as the besttreatment by approximately one third of thepatients with plantar fasciitis who triedthem.3,6 Disadvantages of night splints includemild discomfort, which may interfere with thepatient’s or a bed partner’s ability to sleep.

ANTI-INFLAMMATORY AGENTS

Anti-inflammatory agents used in the treat-ment of plantar fasciitis include ice, NSAIDs,iontophoresis and cortisone injections. Ice isapplied in the treatment of plantar fasciitis byice massage, ice bath or in an ice pack. For icemassage, the patient freezes water in a smallpaper or foam cup, then rubs the ice over the


FIGURE 8. An example of a commercially pro-duced night splint.

painful heel using a circular motion and mod-erate pressure for five to 10 minutes. To use anice bath, a shallow pan is filled with water andice, and the heel is allowed to soak for 10 to 15minutes. Patients should use neoprene toecovers or keep the toes out of the ice water toprevent injuries associated with exposure tothe cold. Crushed ice in a plastic bag wrappedin a towel makes the best ice pack, because itcan be molded to the foot and increase thecontact area. A good alternative is the use of abag of prepackaged frozen corn wrapped in atowel. Ice packs are usually used for 15 to 20minutes. Icing is usually done after complet-ing exercise, stretching, strengthening andafter a day’s work.

The use of anti-inflammatory drugs inchronic inflammatory diseases is somewhatcontroversial.1,17 Eleven percent of the patientsin one study3 cited NSAIDs as the treatmentthat worked best for them, and 79 percent ofthe patients using NSAIDs were in the success-fully treated group.3 Advantages of NSAIDs arethe acceptability of the use of an oral medica-tion as a treatment modality by many patients,the convenience and ease of administration,and the acceptance by medical insurance. Dis-advantages of NSAIDs are many, including therisk of gastrointestinal bleeding, gastric painand renal damage.18

IONTOPHORESIS

Iontophoresis is the use of electric impulsesfrom a low-voltage galvanic current stimula-tion unit to drive topical corticosteroids intosoft tissue structures. One study19 found thatthe use of iontophoresis resulted in significantimprovement after two weeks but no long-term differences at six weeks. The major dis-advantages of iontophoresis are cost and timebecause, to be effective, it must be adminis-tered by an athletic trainer or physical thera-pist at least two to three times per week. Thus,iontophoresis use is probably best reserved forthe treatment of elite athletes and of laborerswith acute plantar fasciitis whose symptomsare preventing them from working.

CORTICOSTEROID INJECTIONS

Corticosteroid injections, like iontophoresis,have the greatest benefit if administered earlyin the course of the disease but, because of theassociated risks, they are usually reserved forrecalcitrant cases. A plain radiograph of thefoot or calcaneus should always be obtainedbefore injecting steroids to ensure that thecause of pain is not a tumor. Steroids can beinjected via plantar or medial approaches withor without ultrasound guidance. Studies20,21

have found steroid treatments to have a successrate of 70 percent or better.

Potential risks include rupture of the plantarfascia and fat pad atrophy.22,23 Rupture of theplantar fascia was found in almost 10 percentof patients after plantar fascia injection in oneseries.22 Long-term sequelae of plantar fasciarupture were found in approximately one halfof the patients with plantar fascia rupture, withlongitudinal arch strain accounting for morethan one half of the chronic complications.22,23

On the other hand, one author24 found thatmost individuals with rupture of the plantarfascia had resolution of symptoms with restand rehabilitation.

SURGERY

In cases that do not respond to any conser-vative treatment, surgical release of the plantarfascia may be considered. Plantar fasciotomymay be performed using open, endoscopic orradiofrequency lesioning techniques. Overall,the success rate of surgical release is 70 to 90percent in patients with plantar fasciitis.24-27

Potential risk factors include flattening of thelongitudinal arch and heel hypoesthesia aswell as the potential complications associatedwith rupture of the plantar fascia and compli-cations related to anesthesia.

Plantar Fasciitis


The time until resolution of plantar fasciitis is often six to 18 months, which can lead to frustration for patients and physi-cians.

Plantar Fasciitis

TYPICAL TREATMENT PLAN

In general, we start by correcting trainingerrors. This usually requires relative rest, theuse of ice after activities, and an evaluation ofthe patient’s shoes and activities. Next, we trycorrection of biomechanical factors with astretching and strengthening program. If thepatient still has no improvement, we considernight splints and orthotics. Finally, all othertreatment options are considered. Non-steroidal anti-inflammatory medications areconsidered throughout the treatment course,although we explain to the patient that thismedicine is being used primarily for pain con-trol and not to treat the underlying problem.

The authors thank Chris McLauglin for her help inediting the manuscript and Nic Kellner, M.S., A.T.,C.,Janel Novack, A.T.,C., and Sharon Busey, M.D., fortheir help with the photography.

REFERENCES

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8. Lynch DM, Goforth WP, Martin JE, Odom RD,Preece CK, Kotter MW. Conservative treatment ofplantar fasciitis. A prospective study. J Am PodiatrMed Assoc 1998;88:375-80.

9. Lohrer H, Alt W, Gollhofer A. Neuromuscular prop-erties and functional aspects of taped ankles. Am JSports Med 1999;27:69-75.

10. Manfroy PP, Ashton-Miller JA, Wojtys EM. Theeffect of exercise, prewrap, and athletic tape on

the maximal active and passive ankle resistance ofankle inversion. Am J Sports Med 1997;25:156-63.

11. Kwong PK, Kay D, Voner RT, White MW. Plantarfasciitis. Mechanics and pathomechanics of treat-ment. Clin Sports Med 1988;7:119-26.

12. Gill LH, Kiebzak GM. Outcome of nonsurgicaltreatment for plantar fasciitis. Foot Ankle Int1996;17:527-32 [Published erratum appears inFoot Ankle Int 1996;17:722].

13. Powell M, Post WR, Keener J, Wearden S. Effectivetreatment of chronic plantar fasciitis with dorsiflex-ion night splints: a crossover prospective random-ized outcome study. Foot Ankle Int 1998;19:10-8.

14. Mizel MS, Marymont JV, Trepman E. Treatment ofplantar fasciitis with a night splint and shoe modi-fication consisting of a steel shank and anteriorrocker bottom. Foot Ankle Int 1996;17:732-5.

15. Batt ME, Tanji JL, Skattum N. Plantar fasciitis: aprospective randomized clinical trail of the tensionnight splint. Clin J Sports Med 1996;6:158-62.

16. Wapner KL, Sharkey PF. The use of night splints fortreatment of recalcitrant plantar fasciitis. FootAnkle 1991;12:135-7.

17. Stanley KL, Weaver JE. Pharmacologic manage-ment of pain and inflammation in athletes. ClinSports Med 1998;17:375-92.

18. McCarthy D. Nonsteroidal anti-inflammatory drug-related gastrointestinal toxicity: definitions and epi-demiology. Am J Med 1998;105:3S-9S.

19. Gudeman SD, Eisele SA, Heidt RS, Colosimo AJ,Stroupe AL. Treatment of plantar fasciitis by ion-tophoresis of 0.4% dexamethasone. A random-ized, double-blind, placebo-controlled study. Am JSports Med 1997;25:312-6.

20. Kane D, Greaney T, Bresnihan B, Gibney R, FitzGer-ald O. Ultrasound guided injection of recalcitrantplantar fasciitis. Ann Rheum Dis 1998;57:383-4.

21. Furey JG. Plantar fasciitis. The painful heel syn-drome. J Bone Joint Surg 1975;57:672-3.

22. Acevedo JI, Beskin JL. Complications of plantar fas-cia rupture associated with corticosteroid injection.Foot Ankle Int 1998;19:91-7.

23. Sellman JR. Plantar fascia rupture associated withcorticosteroid injection. Foot Ankle Int 1994;15:376-81.

24. Leach RE, Seavey MS, Salter DK. Results of surgeryin athletes with plantar fasciitis. Foot Ankle1986;7:156-61.

25. Daly PJ, Kitaoka HB, Chao YS. Plantar fasciotomyfor intractable plantar fasciitis: clinical results andbiomechanical evaluation. Foot Ankle 1992;13:188-95.

26. Benton-Weil W, Borrelli AH, Weil LS, Weil LS. Per-cutaneous plantar fasciotomy: a minimally invasiveprocedure for recalcitrant plantar fasciitis. J FootAnkle Surg 1998;37:269-72.

27. Sollitto RJ, Plotkin EL, Klein PG, Mullin P. Early clin-ical results of the use of radiofrequency lesioning inthe treatment of plantar fasciitis. J Foot Ankle Surg1997;36:215-9,256.


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