Plantar fasciitis is one of the most common disorders encountered in health care practices, particularly practices that deal with conditions of the ankle and foot. Unfortunately, despite being routinely encountered, plantar fasciitis is not routinely resolved. The disorder presents several challenges, remains symptomatic for extended periods and frequently recurs.
Signs and Symptoms
Plantar fasciitis can occur suddenly or over a period of time. In instances of sudden onset, the mechanism of injury typically involves sudden and forceful dorsiflexion of the foot combined with extension of the toes. In instances of gradual onset, injury is often the result of repetitive stresses, poor foot postures, faulty footwear and/or body weight.
The general signs and symptoms of plantar fasciitis include pain along the bottom of the foot. The pain can worsen with walking barefoot, walking on the toes or climbing stairs. Tightness of the Achilles tendons is common.
Patients often experience an increase in the severity of their pain when they stand or walk after periods of rest. This is especially true when taking the first steps of the morning.
Evaluation Tips
Evaluation of patients with suspected plantar fasciitis includes the following:
Inspection: Observe gait for signs of excessive pronation. The toeing-off phase of gait may be painful, resulting in the patient walking on the heel. Observe the feet for forefoot valgus, pes planus or pes cavus. The patient's body habitus also should be noted.
Palpation: Assess subtalar mobility and Achilles tension / flexibility.
Range of motion: Observe and test ankle range of motion, active and passive.
Manual muscle testing: Test ankle, foot and toe strength, especially the flexor digitorum brevis.
Special tests: The navicular drop test is important in assessing pronation.
Helbing's and too-many-toes signs are also helpful in evaluating pronation, as is the Fick angle.
Neurological: Tinel's sign should be performed to rule out tarsal tunnel syndrome.
Imaging: Plain film may only serve to identify the presence of heel spurring. Plantar fasciitis and heel spurring often occur together. However, only 50 percent of patients with plantar fasciitis have accompanying heel spurs. Heel spurs occur in approximately 20 percent of patients without plantar fasciitis. The absence of heel spurs in some plantar fasciitis cases is reasonable considering plantar fasciitis can onset suddenly, as described above. Soft-tissue changes, inflammation or thickening of the fascia may be detectable with the use of MRI.
Employing the examination tips recommended above will help diagnose plantar fasciitis and will also differentiate the condition from other conditions. Problems related specifically to heel spurs, tarsal tunnel syndrome, calcaneal stress fractures and gout are examples of conditions that must be ruled out to arrive at an accurate diagnosis.
Medical vs. Chiropractic Treatment
Seventy to 80 percent of plantar fasciitis cases improve over a 12-month period with or without treatment. If treatment is sought in the medical field, care is usually conservative. Care consists of anti-inflammatory and pain medications, use of orthotics / heel cups, improvements in footwear, stretching the Achilles tendons and corticosteroid injections.
It should be noted that corticosteroid injections are avoided initially due to their association with rupture of the plantar fascia. They are usually employed when other methods of care are failing. Surgery would be the only option beyond this point in medicine.
Chiropractic care of plantar fasciitis is also conservative. Adjusting the ankle and foot, pulsed ultrasound underwater, low-Dye taping, improvements in footwear, myofascial release techniques and stretching the Achilles tendons are common methods of care.
The largest contrasts in medical vs. chiropractic care are ankle and foot adjustments and lower risk factors for chiropractic treatments.
When low-Dye taping is used, if results are seen within two weeks, it is a solid indicator for long-term orthotic use.
Other Considerations
A final area of concern for the patient with plantar fasciitis is activity levels. You may need to alter a patient's activities temporarily to decrease stress during healing. Alterations for patients are typically made on an individual basis. However, one consideration related to activity levels should be universal: All alterations must be applied as equally as possible to occupational, recreational and household activities. Altering only one or two of the three can be ineffective.
While there is improvement in plantar fasciitis with time, 12 months is a long period of time to wait for relief. Fault on the side of providing appropriate care.
Resources
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