An introduction to the diagnosis and evaluation of plantar fasciitis
Many patients first visit the sports podiatrist complaining of pain in their heels, in order to obtain an evaluation of plantar fasciitis. Plantar fasciitis is a very common cause of plantar heel pain. Whilst the diagnosis of plantar fasciitis is generally fairly straightforward, considering alternative diagnoses is important. There are sometimes a number of differential diagnoses that need to be ruled out through the process of collecting a comprehensive history and conducting a thorough physical examination. Ensuring that the patient receives individualized and effective treatment for their condition is based upon modifying and reducing their risk factors and implementing a sound evidence-based treatment approach.
Clinically relevant anatomy in the evaluation of plantar fasciitis
The diagnosis and evaluation of plantar fasciitis firstly requires an awareness of the clinically relevant anatomy. The plantar fascia is a ligament-like structure that is comprised of three bands of thick and dense connective tissue. The bands originate at the medial tubercle of the calcaneus (the end of the heel bone closest to the toes) and they extend to insert at the base of each proximal phalanx (the base of the toes at the ball of the foot). The plantar fascia supports the foot arch during walking.
Important pathophysiology in the evaluation of plantar fasciitis
Understanding the pathophysiology of the condition is important in the evaluation of plantar fasciitis. Plantar fasciitis is primarily an inflammatory condition affecting the plantar fascia ligament. Repetitive strain or overuse of the ligament causes micro-tearing, which induces the body’s repair response. At the cellular level, there is thickening and fibrosis of the plantar fascia. In chronic cases, the condition becomes degenerative, with collagen necrosis evident and sometimes associated calcification, or formation of heel spurs.
Clinical diagnosis and evaluation of plantar fasciitis
Diagnosis of plantar fasciitis is often based around clinical signs and symptoms that the patient describes. The sports podiatrist will conduct a thorough evaluation of plantar fasciitis, to allow any differential diagnoses to be excluded
in order to ensure that the patient receives the most appropriate treatment for their condition.
Sharp or stabbing plantar heel pain that is worse during the first few steps taken in the morning is a hallmark symptom of plantar fasciitis. The pain may subside after a few minutes of walking. Usually the pain is intense again following prolonged standing or sitting.
Risk factors that are considered in the evaluation of plantar fasciitis in patients include:
- Gender: females at greater risk
- Age: risk increases with age
- Bodyweight: overweight or obesity at greater risk
- Occupation: occupations requiring the person to stand for extended periods of time at greater risk
- Physical activity type: runners at increased risk / quick movement sports
In terms of physical signs in the evaluation of plantar fasciitis, pain is usually reproducible by putting pressure on the base of the heel bone, or by asking the patient to flex their ankle and toes/pull backwards. The assessing sports podiatrist will also note whether a planus (flat foot) or cavus (high arch) foot is apparent.
Diagnostic imaging is not generally indicated in the initial stages of evaluation of plantar fasciitis. In some cases, however, if there are other conditions that need to be ruled out, or there has been persistent pain for some months that has been non-responsive to conservative treatment methods, an xray, MRI or ultrasound may be required.
Differential diagnoses in the evaluation of plantar fasciitis
During the diagnostic process and evaluation of plantar fasciitis, there are some alternative conditions, known as differential diagnoses that the sports podiatrist may need to rule out with the aid of diagnostic imaging. These will depend on the signs and symptoms that the patient presents with, and may include:
- Acute calcaneal fracture
- Calcaneal stress fracture
- Acute plantar fascia rupture
- Fat pad atrophy
- Plantar nerve entrapment.
Treatment following the evaluation of plantar fasciitis
Following the initial diagnosis and evaluation of plantar fasciitis, a treatment plan will be implemented by the sports podiatrist. There are a wide variety of treatments that may be used for plantar fasciitis. Treatment is almost always a combination of appropriate methods, based upon patient factors and the severity of the condition. Some common treatment options include:
- Rest, to reduce irritation and inflammation
- The use of custom-made orthotic inserts to control the foot arch and unload the plantar fascia
- Modification of footwear to be more suitable for the patient’s activity type and foot anatomy
- Extracorporeal shockwave therapy, to stimulate healing and tissue regeneration, and provide pain relief
- Stretching the calf muscles to reduce pressure on the plantar fascia.
- Ice packs
Please be informed that the information delivered in the article above regarding the evaluation of plantar fasciitis is for educational purposes only. It is not intended to be taken as general medical advice. If you suspect you may have plantar fasciitis, it is important that you consult with a qualified sports podiatrist to discuss your condition. Appointments with our podiatrists can be made by emailing [email protected] or by calling 02 0293883322.
Karl Lockett– sports podiatrist