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Plantar Fasciitis - P2.1

Definition of condition:  Plantar fasciitis is an inflammation of the plantar fascia and the perifascial structures.

Issue statement: Plantar fasciitis is a common cause of heel pain in athletes as well as in persons not involved in sports.  A clear relationship with work activities has not be established.

WCB-Alberta position

Work relationship criteria

Plantar fasciitis is usually gradual in onset with few cases attributable to a specific inciting event.

A plantar fascial injury can however occur with direct trauma or forceful stretching of the plantar fascia in a specific incident.

Plantar fasciitis has not been shown to be caused by standing or walking (the vast majority of the literature reviewed is silent on the issue of whether or not standing or walking can cause or aggravate plantar fasciitis).  However, it has been directly related to activities that require frequent, forceful, repetitive push-off motions such as those seen in running, tennis, basketball, soccer and gymnastics.  The force required to cause plantar fasciitis has been described in the running gait - each foot strike is two to four times that of body weight and occurs 800 to 2,000 time per mile run.

Because of the condition, pain may occur when standing and walking in both occupational and non-occupational settings.

Non-work related factors include:

Overuse resulting from: Athletic training error Increased volume of training Increased intensity of training Hill running	Degenerative change Heel fat pad flattening Aging	Systemic disorders Seronegative spondylarthritis - Reiter's syndrome - ankylosing spondylitis Rheumatoid arthritis Gout Nutritional osteomalacia
Adverse biomechanics Hyperpronation Talipes cavus Pes planus Externally rotated lower limb Leg length discrepancy	Poor equipment e.g. Footwear	Poor strength and/or flexibility Tight and/or weak triceps surae Tight Achilles tendon

Clinical criteria

Plantar fasciitis is characterized by the following signs and symptoms:

Acute plantar fasciitis

• pain is usually worse in the morning but may improve when activity continues; if the plantar fasciitis is severe, activity will exacerbate the pain, pain will worsen during the day and may radiate to calf or forefoot
• pain may be described anywhere from "minor pulling" sensation, to "burning", or to "knife-like"
• the plantar fascia may be taut or thickened
• passive stretching of the plantar fascia or the patient standing on their toes may exacerbate symptoms
• acute tenderness deep in the heel-pad along the insertion of the plantar aponeurosis at the medial calcaneal tuberosity and along the length of the plantar fascia
• may have localized swelling

Chronic plantar fasciitis 

• plantar fasciitis is classified as "chronic" if it has not resolved after six months
• pain occurs more distally along the aponeurosis and spreads into the Achilles tendon

Diagnostic criteria

Plantar fasciitis is a clinical diagnosis and there are no specific tests from which to make the diagnosis. 

X-ray (plain films), bone scan, MRI or lab tests may be used for difficult diagnostic problems to establish the diagnosis with certainty (both feet).

Recommended management

85% to 95% of patients with plantar fasciitis are significantly improved by a well-directed, non-operative treatment regimen.

The following algorithm illustrates the recommended stepwise approach to the management of plantar fasciitis.

Conservative Treatment

Short-term management

Short term management should focus on reducing fascial inflammation, encouraging patient participation in a rehabilitation program, and countering any predisposing factors.

Methods:

• a trial of NSAIDs for 2 weeks in conjunction with a physical program.  If beneficial, NSAIDs may be repeated for another 2 weeks.
• ice packs or ice massage, 5 - 10 minutes, 4 to 6 times a day.  Ice packs may relieve discomfort both prior to specific stretches and after activity.  Heat may be applied for 10 minutes to warm up the muscles prior to stretching.
• Modified activity: 
  i)establish an accurate pre-injury activity history
  ii)institute modified activity (reduced intensity/duration, increased rest periods) to decrease plantar fascia tension, stress and impact (cycling, water-running)
• Home exercise program: to begin as soon as possible after injury (once pain begins to subside - few days to 1 - 2 weeks):
  Progressive program:
  i)gentle static stretches of the Achilles tendon and triceps surae muscle with the foot supported to minimize plantar fascia stress, initiate 60 second stretches twice daily, progressing as tolerated to 180 seconds, to maximize collagen stretch
  ii)plantar fascia stretches to establish full range of motion at the MTP joint
  iii)isometric contractions of medial longitudinal arch in standing
  iv)aggressive strengthening of short and long toe flexors (towel-gripping)
  v)strengthening exercises for the triceps surae and dorsiflexors, including eccentric loading heel raises
  vi)balance and proprioception
• heel pads cut from felt insoles to reduce strain on the plantar fascia and increase shock absorption (used bilaterally)

Optional:

• ultrasound, deep frictions
• night splinting - posterior slab with foot maintained in maximal dorsiflexion, applied to maintain the length of the plantar fascia overnight (decreasing stiffness and contractions).  Continue with usual rehab program.
• Steroid injections in cases of non-traumatic injury.  Medial approach.  If single injection not effective for 2 months (or greater) do not repeat.

Recommended against:

• casting

Long-term management & care for chronic Plantar Fasciitis

Long-term management should focus on reducing plantar fascial strain.

• taping the arch of the foot may support the plantar fascia (low dye strapping)
• orthoses or footwear adaptations may be appropriate to control pre-existing adverse biomechanics
• long term use of heel cups may be appropriate in cases of heel fat pad destruction
• strengthening exercises and stretching of the plantar fascia, Achilles tendon and triceps surae should continue at home

Surgical treatment

In rare situations of recalcitrant plantar fasciitis, plantar fascial release may be indicated if conservative treatment fails after a 12 month trial.

Fitness to work criteria

• modified employment may be required until pain and inflammation subsides (usually 2 to 3 weeks)
• if plantar fasciotomy has been performed, may need accommodation or modified duties while non-weight bearing (for approximately 2 to 3 weeks); Follow up with surgeon in 2 to 3 weeks.  May require between 8 to 16 weeks of modified duties.

Permanent clinical impairment criteria

No permanent clinical impairment expected.

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