Commentary by Cathy Cruise, M.D. Director Department of Veterans Affairs Care Coordinator, Chair Rehabilitation Council
Case: A 25 year old woman with no significant past medical history presents to walk-in clinic complaining of several days of right heel pain. She notes that the pain is quite sharp and worst when walking. It is so severe that she has skipped her morning run for three consecutive days. She has tried taking acetaminophen which has provided minimal symptom relief. Physical exam reveals mild swelling and point tenderness over the right heel. You suspect that she has plantar fasciitis, but are unsure how to proceed.
The differential diagnosis of heel pain includes plantar fasciitis, bone spurs (which often coexist with plantar fasciitis), tendonitis of the posterior tibialis or flexor digitorum longus and bursitis. Heel pain may also be derived from pathologic processes affecting the calcaneus, such as stress fractures, malignancy, reactive arthritis, Paget’s Disease and sarcoidosis. This patient most likely has plantar fasciitis based on her history.
Plantar fasciitis is characterized by moderate to severe heel pain, worse in the morning, or when initiating activity. It is due to repetitive microtrauma to the plantar fascia of the foot, leading to pain and inflammation. It can be diagnosed by history and physical exam.
The treatment of plantar fasciitis is conservative. In order to allow the fascia to heal, patients should decrease the amount of walking, running and jumping that they do. Proper footware is essential and should include well-cushioned soles and possibly a heel pad. Soft medial arch supports may be beneficial to prevent over-pronation. High heels are to be avoided, as they can lead to shortening of the Achilles tendon. Patients with suspected plantar fasciitis may be referred to Podiatry, Rehab or Orthopedics for selection of appropriate heel and arch supports. The Rehab service can also instruct patients on an exercise program aimed at stretching the plantar fascia and Achilles tendon. Icing, ultrasound and deep friction massage are other modalities that are sometimes employed.
In terms of medical therapy, NSAIDs may provide some relief by decreasing inflammation. Most cases of plantar fasciitis will completely resolve within 6-12 weeks. For persistent cases, cortisol injections can be considered. In the rare instances when relief is not obtained by conservative methods, the plantar fascia can be surgically released from the calcaneus.
The efficacy of preventive measures is not known; however patients should be advised to wear shock absorbent shoes, stretch prior to a work out and control their intensity of running.
Image courtesy of Conrad Nutschan, Wikimedia Commons