Plantar Fasciitis and Bone Spurs
Julie Adkins and Jill C. Cash
Definition
A.Plantar fasciitis is an inflammatory condition in the plantar fascia (foot) that causes pain in the arch of the foot and radiates to the heel. The plantar fascia is a long, thin ligament lying directly beneath the skin on the bottom of the foot. It connects the heel to the front of the foot and supports the arch. Even though many people with plantar fasciitis have heel spurs, the spurs are not the cause of plantar fasciitis pain.
Incidence
A.Plantar fasciitis is the most common cause of heel pain in the United States. Plantar fasciitis is seen in both men and women and most often affects active men ages 40 to 70 (U.S. National Library of Medicine, 2013). Approximately two million patients are treated for this condition every year. One out of ten people have heel spurs, but only one out of twenty people with heel spurs has foot pain.
Pathogenesis
A.Repetitive small tears in the plantar fascia causing collagen breakdown at the medial tubercle of the calcaneus.
Predisposing Factors
A.Athletes: Overuse injury from running.
B.Tight or weak muscles/tendons (Achilles tendon, heel cord, gastrocnemius, soleus muscle).
C.Poor arch support/improper footwear (poor support in shoes).
D.Anatomic abnormalities (low arch support, flat foot, high arch, tibial torsion, overpronated foot, leg-length discrepancy, forefoot varus, thinning of fat pad).
E.Obesity.
Common Complaints
A.Severe foot pain in the bottom of the foot, especially first thing in the morning.
B.Burning pain when walking.
C.Stiffness in foot/heel.
D.May be worse in the morning, improve during day, and then get painful at the end of day.
Other Signs and Symptoms
A.Both heels may be affected.
B.Pain is located in the medial tubercle of the calcaneus, medial of the longitudinal arch.
C.Heel spurs may or may not be present.
D.Pain worsens with standing for long periods of time.
Subjective Data
A.Ask the patient when pain began and how long it lasts.
B.Does pain occur with walking, running, and standing?
C.Does pain begin on the first few steps after getting out of bed or after long periods of sitting or resting? Pain may subside after a few minutes of walking.
D.Is pain constant, stabbing pain? Rate pain on scale of 0 to 10.
E.Locate pain site; does pain radiate into toes or leg?
Physical Examination
A.Check pulse and blood pressure.
B.Inspect:
1.Examine feet bilaterally. Assess for high arch.
2.Note swelling, discoloration, or rash.
C.Palpate:
1.Palpate both feet, noting tenderness at point tenderness. Point tenderness will be noted over insertion on medial heel (calcaneus medial tubercle).
2.Perform passive dorsiflexion of toes and ankle. Have the patient stand on tips of toes to see if this elicits pain.
D.Auscultate the heart and lungs.
Diagnostic Tests
A.X-ray may be performed but is often normal and not needed. Perform if tumor, spur, or fracture is suspected.
B.MRI may be ordered if thickening of proximal plantar fascia is noted or rupture of proximal fascia is suspected.
Differential Diagnoses
A.Plantar fasciitis.
B.Heel pain.
C.Heel spur.
D.Fracture.
Plan
A.General interventions:
1.Conservative treatment includes no long periods of standing for the next 6 to 8 weeks.
B.Patient education:
1.Arch support: Encourage the patient to get a pair of shoes with good arch supports. New shoes with supportive arches or adding arch supports into the shoes is suggested.
2.Shoe inserts are suggested. Suggest getting proper shoe fitting for running if the patient is an athlete.
3.The patient should avoid walking on hard surfaces and never go barefoot. The patient should also avoid wearing sandals and flip-flops.
4.Ice therapy may help with pain control and swelling.
5.Exercises:
a.Roll foot arch with a tennis ball for 20 to 30 minutes each evening to help stretch plantar fascia.
b.Perform calf stretches against a wall, leaning forward against the wall, extending one leg behind you, one leg in front of you, stretch the leg, and reverse.
C.Pharmaceutical therapy:
1.Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin) 800 mg three times daily or naproxen (Naprosyn) 500 mg by mouth twice a day for comfort.
2.Cortisone injections may be attempted for severe cases. A corticosteroid lidocaine 1 to 1.5 mL injected directly into the most tender area on the sole of the foot may be helpful.
Follow-Up
A.Recommend follow-up in 4 weeks following treatment. Pain should slowly improve with aggressive treatment management. The patient must be compliant with instructions given for improvement. May take 6 to 12 months for complete resolution.
B.If pain worsens, consider diagnostic workup (x-ray or MRI).
C.Use caution with steroid injections. Multiple injections can cause the plantar fascia to rupture, resulting in flat foot and chronic pain.
Consultation/Referral
A.Refer to a podiatrist if conservative treatment therapy fails after 6 weeks.
B.Recommend physical therapy to stretch calf muscles and plantar fascia, using specialized ice treatments and/or massage.
C.Surgical treatment: Only after 12 months of aggressive nonsurgical treatments. Possible surgery may be recommended to lengthen the calf muscle (gastrocnemius) or to have a plantar fascia release procedure whereby the ligament is partially cut to relieve tension in the tissue. Large bone spurs may be surgically removed with open incision if indicated.
Individual Considerations
A.Geriatrics:
1.Caution when using NSAIDs in the geriatric population due to gastrointestinal or kidney disorders.
2.Fall precautions should be discussed when having severe pain and difficulty walking.
3.Evaluate support systems for transportation to physical therapy if patient is unable to drive.
4.In the geriatric population, the ability to retain ambulation is directly related to foot health, and plantar fasciitis is one of the most common orthopedic complaints. Eighty percent of plantar fasciitis pain and inflammation in older adults will spontaneously resolve within one year.
5.Common causes for plantar fasciitis in elderly patients include flat feet, overuse of weight-bearing on toes/balls of feet, rheumatic disease, sedentary lifestyle, obesity, and bone spurs on toes/feet.
6.Exercises to alleviate fasciitis pain: Calf-plantar stretch, foot–ankle circles, and toe curls.
7.Suggest proper wearing arch support, such as wearing new shoes with arch support or inserting silicone heel inserts into the shoe.
8.Encourage preventive measures of avoiding walking barefoot or wearing house shoes/slippers (slip-on or clog type).
9.Lidocaine patches or short-term steroids/NSAIDs may be effective to control plantar fasciitis and bone spur pain. Surgery is not recommended until a minimum of nonoperative measures have been implemented for 6 months and outcomes were unsuccessful.
10.Aim for interventions to support the older adult’s mobility function that maximize independence and quality of life.