What is plantar fasciitis, its common demographics, symptoms, and treatment options?

Plantar Fasciitis Overview

Plantar fasciitis is a degenerative condition (not primarily inflammatory) of the plantar fascia causing characteristic heel pain, most commonly affecting middle-aged adults, obese individuals, runners, and those with prolonged standing occupations. 1, 2

Definition and Pathophysiology

Plantar fasciitis represents inflammation or degeneration of the fascial lining on the plantar aspect of the foot and is the leading cause of heel pain in adults, affecting more than 1 million persons per year. 1, 3 The term "plantar fasciopathy" is actually more accurate than "fasciitis" because the condition involves degenerative changes rather than acute inflammation. 2

The pathophysiology involves either:

• Inflammatory mechanisms with vasodilation and immune system activation 1
• Non-inflammatory fibroblastic hypertrophy 1

Demographics and Risk Factors

Common populations affected include:

• Middle-aged and elderly individuals 2, 4
• Athletes, particularly runners (accounts for 10% of running injuries) 4
• Sedentary populations 3
• One in 10 people will experience this condition in their lifetime 2

Key risk factors include:

• Obesity and increased body mass index 3, 2
• Limited ankle dorsiflexion 2
• Excessive foot pronation 3
• Prolonged standing 3, 2
• Anatomical deformities such as pes planus (flat foot) 1
• Chronic diseases including diabetes mellitus 1

Clinical Presentation

Characteristic symptoms include:

• Stabbing, nonradiating pain in the proximal medioplantar surface of the foot, worst with first steps in the morning or after prolonged sitting 3, 2
• Pain worsens at the end of the day after hours of weight-bearing activities 1
• Sharp pain with palpation of the medial plantar calcaneal region 3

Physical examination findings:

• Tenderness to palpation of the proximal plantar fascial insertion at the anteromedial calcaneus 2
• Discomfort elicited by passive ankle/first toe dorsiflexion (windlass test) 3, 5
• Heel squeeze test 5

Diagnosis

Plantar fasciitis is predominantly a clinical diagnosis based on characteristic history and physical examination, with imaging reserved for cases persisting beyond 3 months or when diagnosis is uncertain. 6, 3

Imaging recommendations when needed:

• Weightbearing radiographs are the initial imaging study if diagnosis is unclear or symptoms persist beyond 3 months (85% sensitivity, 95% specificity) 6
• Ultrasound shows good diagnostic accuracy (80% sensitivity, 88% specificity), with key findings including plantar fascia thickness >4mm, abnormal focal echogenicity, and perifascial edema 7, 6
• MRI is the most sensitive imaging study for definitive diagnosis when uncertainty remains, allowing accurate characterization of the plantar fascia and detection of complete or partial tears 7, 6
• US elastography demonstrates even higher accuracy (95% sensitivity, 100% specificity) 6

Important differential diagnoses to exclude:

• Calcaneal stress fracture 6
• Tarsal tunnel syndrome (may require electromyography or nerve conduction studies) 6, 5
• Plantar fascia rupture 6
• Calcaneal apophysitis in adolescents 6

Treatment Approach

With proper treatment, 80% of patients improve within 12 months, and 90% respond to conservative measures. 3, 2

Initial Conservative Therapies

First-line treatments to implement for several weeks:

• Rest and activity modification 3, 5
• Ice massage 3, 2
• Oral analgesics (NSAIDs) 3, 2
• Plantar fascia stretching exercises (primary intervention) 3, 2
• Proper footwear with adequate support 7

Intermediate Therapies (if pain persists)

Physician-prescribed interventions:

• Physical therapy modalities 3
• Foot orthotics (especially if foot deformities present) 7, 3
• Night splinting 3
• Corticosteroid injections 3
• Photobiomodulation therapy (PBMT) 5
• Extracorporeal shock wave therapy (ESWT) 5, 2

Important caveat: Many standard treatments like night splints and orthoses have not shown benefit over placebo in some studies, though they remain commonly prescribed. 2

Specialized Therapies (for recalcitrant cases)

For chronic plantar fasciitis lasting 6 months or longer:

• Platelet-rich plasma (PRP) injections 5
• Dry needling 5
• Extracorporeal shock wave therapy 3, 2

Surgical Options (last resort)

Reserved for patients with pain limiting activity despite exhausting nonoperative options:

• Endoscopic plantar fasciotomy 5, 2
• Plantar fascia release 3

Prevention Strategies

For bilateral or contralateral involvement:

• Ensure proper weight distribution when walking with assistive devices 7
• Use shoe lift on contralateral limb when using offloading devices 7
• Maintain proper footwear and orthotic support 7
• Address modifiable risk factors (weight reduction, activity modification) 1

Critical consideration: MRI findings must be correlated with clinical symptoms to avoid overcalling plantar fasciitis, as imaging abnormalities can be present in asymptomatic patients. 6