The Orthopedic Section of the American Physical Therapy Association revised clinical guidelines for the examination and treatment of plantar fasciitis, or heel pain. There is moderate evidence describing risk factors for development of plantar fasciitis. These risk factors include limitation in ankle motion, high body mass index in non-athletes, running and work-related weight bearing with limited shock absorption.
Diagnosis and classification of plantar fasciitis, according to the International Classification of Diseases and Functioning, includes the following patient presentation:
- Pain at the inside of the heel (medial heel pain).
- Pain increased after inactivity and upon first several steps, as well as after prolonged weight bearing.
- Pain where the plantar fascia connects to the heel.
- Pain with stretching of the plantar fascia.
- Limited ankle motion, particularly with dorsiflexion (bringing your “toes to your nose”).
- Higher than normal body mass index in non-athletes.
- Abnormal foot/ankle positioning (for example: flat foot or high arch).
Your physician or physical therapist must also be aware of and know other potential causes of heel pain that may mimic plantar fasciitis. A few of these issues include arthritis in the low back (spondyloarthritis), shrinkage of the normal fat pad on the foot (fat pad atrophy), presence of a neuroma on the weight bearing side of the foot/heel and inconsistencies with the above seven symptoms/signs.
Your physical therapist should use a functional outcome questionnaire prior to treatment, during treatment and at discharge to measure progress and adapt treatment as necessary.
Current best evidence and research shows the following treatment(s) interventions to be beneficial:
- Manual therapy to mobilize the soft tissues and joint structures that contribute to pain and limited function.
- Plantar-fascia specific and gastrocnemius/soleus (calf) stretching for short-term relief. Possible use of heel pads.
- Anti-pronation taping for up to three weeks. Elastic (kinesio/rock tape) to calf and plantar-fascia short term (one week).
- Prefabricated or custom fitted foot orthotics to support the arch of the foot and cushion the heel (two weeks to a year).
- One- to three-month program of night splinting for those who have pain with the first step getting out of bed in the morning.
There exists conflicting evidence for the use of electrical stimulation for plantar fasciitis and weak evidence for low level laser, phonophoresis and ultrasound. Weak evidence also exists for prescription of footwear rotation and use of rocker bottom shoes.
Expert opinion suggests patients receive counseling and education in weight loss and fitness, as well as referral to appropriate practitioner to address nutrition. There is foundational/theoretical evidence to suggest the use of therapeutic and neuromuscular exercises. Dry needling has not yet been recommended (based upon scientific literature prior to January 2013).
Clinicians should continue to utilize the most up-to-date research and information in their examination and treatment choices. Plantar fasciitis is a condition that may take weeks or months to completely resolve, so patience and compliance with your treatment regime is important for the most effective and efficient outcome. QCBN
By Laura Markey,
PT, DPT, FAAOMPT, OCS
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