Authors

  1. Cichminski, Lucille MSN

Article Content

Plantar fasciitis (PF)-one of the most common causes of heel pain-affects about 2 million people in the US alone and accounts for up to 600,000 outpatient visits per year. Patients affected by this condition seek relief from their symptoms by visiting primary care physicians, foot specialists, and physical therapists. About 10% of PF cases occur among runners; however, it's also a common condition among military personnel. More than 80% of patients who experience PF see symptom improvement within 12 months; only 5% will require surgery.

  
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This article discusses the pathophysiology, causes, risk factors, signs and symptoms, and diagnosis of PF; treatment options for patients diagnosed with PF; and priority nursing assessment and patient education points.

 

Pathophysiology

The plantar fascia is a thick band of tissue that extends across the bottom of the foot and connects the heel bone to the toes. The plantar fascia originates in the medial tubercle of the calcaneus, runs the length of the foot spanning the arch, and terminates into the transverse ligaments of the metatarsal heads. Its basic action is to act as a cantilever for the arch of the foot. The simple act of walking puts pressure down on the arch, which in turn stretches the ligament. When we release the pressure on the arch with retraction, the plantar fascia snaps back to keep the arch from collapsing.

 

PF is the loss of healthy connective tissue and the development of scar tissue. When the plantar fascia gets inflamed or develops tears in the tissue, it results in pain (see A closer look at PF). The fibrous bands of tissue are like a rubber band, stretching and contracting with every step and absorbing a large amount of weight and pressure. That's why the pain from PF is usually worse with the first few steps in the morning and patients won't experience pain during exercise but after they've completed exercise.

 

Causes

PF is an injury caused by overuse, similar to carpel tunnel syndrome or tennis elbow. A major cause of PF is an overload of physical activity and exercise. Wearing shoes that don't fit correctly or don't provide adequate support or cushioning also contributes to PF. Walking in the "wrong" shoes can cause weight distribution to be impaired, leading to stress on the plantar fascia. Another common cause is arthritis, which can lead to tendon inflammation. In addition, as we get older, our tissue also gets older and tends to become weaker and more susceptible to damage.

 

Risk factors

To remember common risk factors for PF, think BEWARE FOOT:

 

* Being pregnant, which leads to increased weight and hormonal changes, can contribute to PF.

 

* Excess body weight results in extra stress on the plantar fascia.

 

* Walking in incorrect shoes, high heel shoes, or barefoot on hard surfaces can cause PF.

 

* Age between 40 and 60 is the most common demographic for PF.

 

* Runners are at increased risk for PF.

 

* Excessive standing due to occupations that require long periods of standing on hard surfaces can cause PF.

 

* Foot mechanics, such as high arches or flat feet, contribute to PF.

 

* Onset of PF is more common in postmenopausal women.

 

* Other diseases such as diabetes and arthritis can contribute to PF.

 

* Types of exercise that place enormous pressure on the heel, such as long-distance running and gymnastics, aerobics, and tennis on concrete surfaces, can cause PF.

 

 

Signs and symptoms

Patients may experience:

 

* foot discomfort

 

* sharp heel pain upon waking up in the morning

 

* unilateral foot pain

 

* severe foot pain after exercise (not during)

 

* tight Achilles tendon

 

* tight calf muscles

 

* improper gait

 

* heel swelling.

 

 

Diagnosis

Diagnosing PF is based on the patient's medical history and a physical exam. During the exam, findings may include tenderness when palpating the medial calcaneal tubercle and discomfort with passive dorsiflexion of the first toe. Also assess for the presence of limited ankle dorsiflexion range of motion. In nonathletic patients, a measurement of body mass index may be done. Imaging tests may be ordered to rule out other causes of the pain, such as a fractured bone, heel spur, lumbar spine disorder, neuropathy, Achilles tendonitis, heel contusion, plantar fascia rupture, posterior tibial tendonitis, and retrocalcaneal bursitis.

 

Treatment

Conservative treatments for PF include resting; exercises to stretch and strengthen the plantar fascia, Achilles tendon, and lower leg muscles; icing the heel; and nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce plantar fascia inflammation. If pain isn't relieved by NSAIDs, steroid injection into the painful area of the plantar fascia is an option to reduce inflammation and ease pain for about 1 month.

 

Other therapies may include:

 

* foot massage

 

* contrast bath therapy

 

* percutaneous ultrasonic fasciotomy

 

* night splints to stretch the calf and arch of the foot while sleeping

 

* custom-fitted orthotics to more evenly distribute pressure on the feet.

 

 

If there's no progress after several months, more aggressive treatment may be recommended, including:

 

* platelet-rich plasma injection-a relatively new procedure that's guided ultrasonically

 

* extracorporeal shockwave therapy-this procedure uses soundwaves to stimulate blood flow in the foot, which, in turn, helps the tissue heal; mostly used for patients experiencing chronic PF that hasn't responded to conservative treatments

 

* Tenex procedure-this minimally invasive procedure involves removal of plantar facia scar tissue

 

* surgery-this is rare and involves detaching the plantar fascia from the heel bone; patients who opt for surgery are generally experiencing severe pain.

 

 

Nurse's corner: Assess and educate

Nurses play an important role in treating patients with PF, including priority assessment and patient education. Begin your assessment by asking the patient these questions:

 

* Have you ever experienced heel (foot) pain before?

 

* Do you have any changes in your life, such as wearing new shoes, participating in new hobbies/activities, or a new job?

 

* What are your exercise habits like?

 

* Where's the pain located and what type of pain is it?

 

* What's your level of pain on a scale of 0 to 10?

 

* When do you experience the most pain?

 

* Does the pain ease when you point your toes downward? (If pain grows fainter, it's most likely PF.)

 

 

Continue your assessment by observing the patient's gait (patients tend to bear weight on their unaffected foot), looking for impairment of body function and type of footwear. Next, perform range of motion of the foot joints, paying special attention to the ankle joint. Palpate the foot to detect tenderness at the medial calcaneal tubercle. Observe the foot for edema, ecchymosis, and skin changes.

 

Patient teaching is an essential component of PF treatment. Patients must understand foot anatomy, risk factors for PF, and treatment options. To remember patient teaching points, think EDUCATE:

 

* Educate yourself using reliable internet sources, such as the National Library of Medicine (https://medlineplus.gov/ency/article/007021.htm), American Academy of Orthopaedic Surgeons (https://orthoinfo.aaos.org/en/diseases-conditions/heel-pain), and American Podiatric Medical Association (http://www.apma.org/Patients/FootHealth.cfm?ItemNumber=985).

 

* Don't delay treatment. Symptoms will only worsen. The key is early intervention.

 

* Understand the risk factors: long periods of standing, excessive pronation of the foot, reduced ankle dorsiflexion, and inferior calcaneal exostosis.

 

* Control diet, activity, and choice of footwear. Remember that your foot absorbs three times your body weight, which increases to seven times when running.

 

* Arch of the foot (high arch) or shortened Achilles tendon can contribute to PF.

 

* Triggers-identify them. Recognize what causes your symptoms and correct it.

 

* Extended recovery time is to be expected. Patience is the key.

 

 

For prevention of PF recurrence, teach your patients to follow these measures to get RELIEF:

 

* Replace worn-out or old shoes.

 

* Eliminate causes by changing to a low-impact sport such as swimming or bicycling.

 

* Lose weight if you're overweight or obese to minimize stress on your plantar fascia.

 

* Ice the area of pain four to five times a day for 15 to 20 minutes or after activity.

 

* Eliminate bad choices from your diet.

 

* Forget high heels; choose instead to wear shoes with a low-to-moderate heel, good arch support, and shock absorbency.

 

 

Happy feet, happy life

PF can be a painful, debilitating, and chronic condition for our patients. However, if initiated early, treatment for PF can be simple, inexpensive, and highly successful. PF can lead to serious injury if left untreated, resulting in worsening pain and requiring more aggressive forms of treatment. With your help, patients can have happy feet for a happy life.

 

memory jogger

For common PF risk factors, remember BEWARE FOOT.

  
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Being pregnant

 

Excess body weight

 

Walking in incorrect shoes, high heel shoes, or barefoot on hard surfaces

 

Age between 40 and 60

 

Runners

 

Excessive standing

 

Foot mechanics, such as high arches or flat feet

 

Onset in postmenopausal women

 

Other diseases, such as diabetes and arthritis

 

Types of exercise

 

consider this

Joann, a 55-year-old married mother of four teenage children, is an avid marathon runner who runs at least 3 to 5 miles per day and even longer on weekends. As a second hobby, Joann likes to play outdoor tennis on public park courts at least once a week. She's always conscious of wearing padded athletic socks and quality, supportive sneakers for all her sports activities.

  
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Joann woke up one morning and, without warning, experienced a sharp stabbing pain in her heel when she attempted to walk to the bathroom. She was in so much pain that she scheduled a visit with her primary care physician and canceled her tennis match for that evening. Joann initially thought she had developed a heel spur and was surprised when she was diagnosed with PF, a condition with which she was unfamiliar.

 

Upon learning of her diagnosis, Joann researched her condition using reliable internet sources, forums for people with PF, and the pamphlets she received from her physician. Her treatment included physical therapy three to four times a week and home remedies, including wearing supportive shoes; icing her heel after exercise for 15 to 20 minutes; rolling her foot over a tennis ball for 5 to 7 minutes, three to five times a day; stretching her foot periodically during the day; taking NSAIDs; and resting her foot for long periods during the day to promote blood flow.

 

Because it took 5 months for her symptoms to resolve, Joann took preventive measures to avoid developing PF again. She changed her sports regimen, reducing high-impact sports and adding low-impact activities to her exercise routine. Instead of running every day, Joann decreased her jogging to one to two times a week for only 1 to 2 miles at a time. She joined a gym and added swimming to her regimen. On other days, Joann goes bike riding and even bought herself a kayak, which she uses on the weekends. Tennis is still included in her weekend activities, but she now only plays doubles (not singles) on clay courts, which are softer on the knees and feet. Joann also avoids wearing high heels, replacing them with flat shoes. She's keeping her sports footwear up-to-date and has discarded her worn-out sneakers.

 

memory jogger

When teaching your patients preventive measures, remember RELIEF.

  
Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Replace worn-out or old shoes.

 

Eliminate causes by changing to a low-impact sport.

 

Lose weight if you're overweight or obese to minimize stress on your plantar fascia.

 

Ice the area of pain four to five times a day for 15 to 20 minutes or after activity.

 

Eliminate bad choices from your diet.

 

Forget high heels; wear shoes with a low-to-moderate heel, good arch support, and shock absorbency.

 

REFERENCES

 

Buchbinder R. Clinical practice. Plantar fasciitis. N Engl J Med. 2004;350(21):2159-2166.

 

Cole C, Seto C, Gazewood J. Plantar fasciitis: evidence-based review of diagnosis and therapy. Am Fam Physician. 2005;72(11):2237-2242.

 

Ingraham P, McGee L. Save yourself from plantar fasciitis! PainScience.com. 2019. http://www.painscience.com/tutorials/plantar-fasciitis.php.

 

Johnson RE, Haas K, Lindow K, Shields R. Plantar fasciitis: what is the diagnosis and treatment. Orthop Nurs. 2014;33(4):198-204.

 

Martin RL, Davenport TE, Reischl SF, et al Heel pain-plantar fasciitis: revision 2014. J Orthop Sports Phys Ther. 2014;44(11):A1-A33.

 

Mayo Clinic. Plantar fasciitis. 2018. http://www.mayoclinic.org/diseases-conditions/plantar-fasciitis/symptoms-causes/ clinic.

 

Roberts A. Plantar fasciitis and foot pain in nursing. Ausmed. http://www.ausmed.com/cpd/articles/plantar-fasciitis.

 

Schwartz EN, Su J. Plantar fasciitis: a concise review. Perm J. 2014;18(1):e105-e107.