Plantar fasciitis (PF) stands as a prevalent overuse injury, frequently encountered in primary care settings. This condition arises from repeated stress on the plantar fascia at its attachment to the heel bone. Representing a significant portion of running-related injuries (8–10%) and the majority of heel pain cases (80%), plantar fasciitis is a common musculoskeletal issue managed by primary care physicians. Individuals with foot arch abnormalities like flat feet (pes planus) or high arches (pes cavus) are more susceptible to developing PF. Other contributing factors include wearing inadequate footwear and engaging in excessive walking or weight-bearing activities, often seen in professions requiring prolonged standing or walking. A history of heel pain and elevated body mass index also increase the risk of plantar fasciitis. This condition commonly affects middle-aged individuals, with equal occurrence in both men and women, and has a lifetime prevalence estimated at 10%.
CLINICAL DIAGNOSIS OF PLANTAR FASCIITIS
Diagnosis of plantar fasciitis is typically achieved through clinical evaluation. Patients often describe a gradual onset of heel pain, typically localized to the inner aspect of the heel and extending into the arch of the foot. A hallmark symptom is pain that is most intense in the morning, particularly with the first few steps after waking up. This morning pain often lessens with movement as the fascia warms up; however, as plantar fasciitis progresses, pain may recur and intensify during physical activity. While imaging is not routinely needed for diagnosis, ultrasound may reveal thickening and swelling of the plantar fascia if there is diagnostic uncertainty. Although calcaneal spurs might be visible on X-rays, they are not considered a direct cause of plantar fasciitis pain, and radiography is generally not recommended in the standard management of this condition. It’s important to consider other conditions in the differential diagnosis, such as fat pad contusion of the heel, calcaneal stress fractures, retrocalcaneal bursitis, and nerve entrapment syndromes. Fat pad contusion shares similar initial management strategies with plantar fasciitis, often involving heel cushions and activity modification. Calcaneal fractures, especially stress fractures, should be suspected in cases of localized tenderness following trauma or repetitive high-impact activity and are best evaluated with plain X-rays. Retrocalcaneal bursitis, in contrast, presents with pain at the back of the heel, near the Achilles tendon insertion, which is a more posterior location than typical plantar fasciitis pain.
Alt text: Pain distribution in plantar fasciitis, highlighting the medial heel and arch radiating pain, relevant for primary care diagnosis.
A careful history is crucial in diagnosing plantar fasciitis. Clinicians should inquire about recent changes in footwear or increases in physical activity, both recreational and occupational, which could trigger the condition. It is also pertinent to ask about a past history of other enthesopathies, such as Achilles tendinosis or lateral epicondylopathy (tennis elbow), as their presence might suggest underlying systemic conditions like ankylosing spondylitis. In cases where symptoms are bilateral or accompanied by systemic symptoms, consider broader differential diagnoses such as Reiter’s syndrome or rheumatoid arthritis.
Physical examination typically reveals tenderness upon palpation of the anteromedial aspect of the plantar calcaneus, with pain radiating along the plantar fascia into the arch. This tenderness is often exacerbated by stretching the plantar fascia by dorsiflexing the big toe. Tight calf muscles are recognized as a contributing factor in the development of plantar fasciitis. Calf tightness can be assessed clinically using tests like the ‘lunge test’ or ‘knee to wall’ test, which are valuable in primary care assessments.
MANAGEMENT STRATEGIES FOR PLANTAR FASCIITIS IN PRIMARY CARE
The management of plantar fasciitis in primary care begins with conservative measures. Acute or ‘reactive’ plantar fasciitis may resolve with rest and conservative treatments. However, chronic plantar fasciitis often requires a more structured and intensive rehabilitation approach. The core of management involves stretching and strengthening the plantar fascia and addressing contributing factors, such as high-impact activities and inappropriate footwear.
Conservative Management
Conservative treatment forms the cornerstone of plantar fasciitis management in primary care. Plantar fascia stretching is performed by placing the toes against a wall while keeping the heel grounded, then leaning forward to lengthen the arch of the foot. Calf stretches, targeting both the soleus (knee slightly bent) and gastrocnemius (knee fully extended) muscles, are also beneficial to address calf tightness. Night splints or Strasbourg socks can provide relief by maintaining the foot in dorsiflexion during sleep, thus passively stretching the plantar fascia overnight.
Alt text: Plantar fascia stretch exercise technique for plantar fasciitis management, useful for primary care patient education.
Strengthening exercises for the intrinsic foot muscles can be achieved by using the toes to pull a towel towards the heel. Self-massage techniques, such as rolling a golf ball or a frozen water bottle under the arch, can help alleviate pain symptoms. Gel heel inserts can reduce heel impact during weight-bearing activities, while orthotics and footwear with good arch support can correct biomechanical imbalances. For overweight or obese individuals, weight loss is an important recommendation to decrease heel strike forces and improve symptoms. Runners should be advised to reduce their training load by incorporating cross-training activities like swimming or cycling to replace some running volume.
Interventional Treatments
When conservative measures are insufficient, interventional treatments may be considered for plantar fasciitis management in primary care, although some may require specialist referral. Corticosteroid injections into the proximal plantar fascia can provide short-term pain relief, but they carry risks, including plantar fascia rupture and heel fat pad atrophy, which can lead to prolonged pain. Local injections of autologous blood or platelet-rich plasma (PRP) are emerging treatments favored by musculoskeletal specialists for plantar fasciitis, showing early promise, but long-term evidence is still needed, and these are not currently standard in primary care. Extracorporeal Shockwave Therapy (ESWT) has been approved by NICE for treating persistent plantar fasciitis and has shown encouraging results in some cases.
Surgical Options and Referral
Surgical intervention is rarely necessary and is reserved for intractable plantar fasciitis cases where conservative treatments have failed after 6–12 months. Surgery can provide good functional outcomes in most selected cases. Referral to a sport and exercise medicine physician is appropriate for patients with intractable plantar fasciitis, allowing for further evaluation and consideration of specialist treatments.
PATIENT EDUCATION AND RESOURCES
Patient education is a critical component of plantar fasciitis management in primary care. Providing patients with resources and information empowers them to actively participate in their care and improve outcomes. A useful resource for patient information is available at http://www.patient.co.uk/health/Plantar-Fasciitis.htm. Educating patients about the importance of adherence to conservative treatments, including stretching exercises, appropriate footwear, and activity modification, is essential for successful management. Patients should also understand the expected recovery timeline and the importance of consistent self-care strategies.
REFERENCES
[1] Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical care. Foot Ankle Int. 2004;25(5):303-12.
[2] Trojian T, Tucker AK. Plantar fasciitis. Am Fam Physician. 2019;99(10):656-62.
[3] Crawford F, Thomson CE. Evidence-based treatment for plantar fasciitis. J Am Podiatr Med Assoc. 2003;93(3):234-40.
[4] Cole C, सेटo J, Karatekin C, et al. Plantar fasciitis: evidence-based review of diagnosis and therapy. Am Fam Physician. 2005;72(11):2237-42.
[5] Young CC. Diagnosis and treatment of plantar fasciitis. J Am Acad Orthop Surg. 2012;20(1):40-8.
[6] Dragoo JL, Warkentine FH,队伍n CJ. Platelet-rich plasma for treatment of plantar fasciitis: a prospective randomized controlled trial. Am J Sports Med. 2014;42(3):484-91.
[7] Saxena A, Ramdath D. Platelet-rich plasma injection for chronic plantar fasciitis: a prospective randomized controlled trial. J Foot Ankle Surg. 2011;50(6):727-32.
