A 65-year-old tennis player comes to the office due to worsening right heel pain for the past 4 weeks. In the last week, she had to end several practices early because the pain had become increasingly unbearable toward the end of the day. The patient has had no acute trauma to the foot. She has a history of osteopenia for which she takes calcium and vitamin D. On examination, there is significant tenderness over the medioplantar region of the right heel, worsened by passive dorsiflexion of the big toe. The ankle has full range of active motion without pain. Sensation of the foot is intact. Foot x-ray reveals a decrease in bone density and a calcaneal bone spur but no fracture. Which of the following is the best initial treatment of the patient's condition?
Plantar fasciitis | |
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This patient most likely has plantar fasciitis, a degenerative condition of the plantar aponeurosis at its insertion at the calcaneus caused by overuse. The plantar aponeurosis is a thick, fibrous band that extends from the calcaneus to the metatarsal heads and supports the arch of the foot. High-impact activities (eg, running), prolonged standing on hard surfaces, and conditions that place excessive stress on the arch (eg, obesity, flat feet) increase the risk of plantar fasciitis.
The pain is often worse when first standing from rest and after long periods of standing or walking. Examination shows tenderness at the insertion of the plantar fascia at the calcaneus (ie, anteromedial heel), especially with the toes passively dorsiflexed.
The diagnosis is based on clinical findings; no imaging is necessary unless a secondary pathology (eg, calcaneal stress fracture due to osteopenia) is suspected, as in this patient. Initial management includes activity modification (eg, avoiding walking barefoot, reducing high-impact exercise), physical therapy (eg, fascial stretching, muscle strengthening exercises), and padded heel inserts, which reduce strain on the fascia. About 80% of patients recover within 1 year.
(Choice A) Although plantar fasciitis is a degenerative rather than an inflammatory condition, a corticosteroid injection at the calcaneal insertion of the plantar aponeurosis can be attempted if initial measures fail. Injections provide short-term pain relief but carry the risks of fascial rupture and fat pad atrophy of the heel.
(Choice B) Fasciotomy is considered for patients who do not improve with less aggressive measures but is rarely needed.
(Choice D) A short leg cast (ie, below the knee to the base of toes) is used to immobilize metatarsal and distal tibia and fibula fractures. Immobilization is not recommended for plantar fasciitis due to the risk of muscle atrophy.
(Choice E) Plantar calcaneal spurs (ie, calcification of the proximal plantar aponeurosis) are a common incidental finding on x-ray; in one study, over 50% of normal individuals (controls) and 80% patients with plantar fasciitis had calcaneal spur. By itself, a heel spur does not cause pain, and surgical removal is not indicated.
Educational objective:
Plantar fasciitis is a degenerative condition of the plantar aponeurosis at its insertion at the calcaneus caused by overuse. Pain is typically worsened by prolonged standing and is located at the anteromedial heel. First-line treatments include activity modification, physical therapy (stretching), and padded heel inserts. Calcaneal spurs are incidental and do not require treatment.