Case Study of the Week: Plantar Fascitis

I have been gimping around lately- my left foot really hurts!  An avid runner, I am currently suffering from a self-diagnosed case of planter fascitis.  Not fun.  To further explore the causes, symptoms and treatment of this condition I have selected plantar fascitis for this week's case study.

Plantar Fascitis is the number one cause of heel pain resulting on one million visits per year to medical professionals.  Approximately 10 percent of Americans will experience heel pain at some point in their lives.  Plantar fascitis diagnosis and treatment costs the U.S. healthcare system somewhere between $192 and $376 million each year.  GIven the number of people who experience this condition it is important that we as nurse practitioners know how to diagnose and treat this painful condition. 

Case Presentation

A 35 year old woman presents to your clinic with a complaint of right heel pain.  She states that she runs three miles, five days per week but has not sustained any known injury.  Recently, she has added one six mile run each week to her routine.  Her pain is much worse in the morning when she first steps out of bed.  The pain begins to bother her again if she sits to rest during the work day then stands.  She acknowledges that she does not wear very supportive shoes at work.  She states that only her right heel is affected.  She describes the pain as a sharp, stabbing sensation.  She has no prior medical history.  The woman's vital signs are within normal limits. 

On exam, you do not note any swelling or bruising to the woman's foot.  She is moderately tender at the insertion of the plantar fascia, the medial aspect of the foot near the heel.  You watch the woman walk and note she has a slight limp, especially with her first few steps favoring the affected foot.  You order an X-Ray to rule out other causes including stress fracture and bony tumor.  X-Ray results show no abnormal findings.  Based on the woman's history and physical exam, you diagnose her with plantar fascitis. 

Management and Outcome

Treatment of plantar fascitis can be frustrating for patients as the condition is typically slow to resolve.  80 to 90 percent of plantar fascitis cases resolve within 12 months with conservative treatment.  Only 5 percent of cases require invasive surgical treatment. NSAIDs, rest, ice and modification of activities that may be responsible for causing the condition are the primary treatment for plantar fascitis.  Corticosteroids, splints and orthotics may also help relieve the condition.  Freezing ice in a paper cup then rubbing the ice over the affected area of the foot is the most effective method of icing (slowly peel the paper cup away as ice melts).  Patients who do not have symptom relief with NSAIDS, rest, ice, orthotics, activity modification and steroids after 6 weeks should be fitted for a splint to wear at night.  In cases that do not resolve after 12 weeks of conservative therapy, a foot specialist referral should be condisered.  Physical therapy, injections and/ or a walking boot may also be necessary at this time.  

5 to 10 percent of sufferers of plantar fascitis will require surgery.  If a patient has failed 6 to 12 months of therapy, surgery should be considered.  The procedure involves a release of the plantar fascia in an endoscopic procedure.  Surgery has an overall 70 to 90 percent success rate in treating plantar fascitis. 

Plantar fascitis does not result in chronic problems.  Throughout it's duration, however, patients may expereince significant pain and difficulty with daily activities such as walking.  Limping due to the condition may also lead to a change in weight-bearing patterns and therefore pain in other joints such as the knee and hip.

Discussion

Plantar fascitis, inflammation of the insertion of the plantar fascia on the calcaneus, can cause significant pain affecting quality of life.  The usual presentation includes sharp, localized pain at the medial, anterior aspect of the heel.  Plantar fascitis is often associated with heel spurs.  The condition is usualy caused by microtrauma from repetitive stressing of the fascia.  The condition is seen in patients of all ages, most commonly in individuals ages 40 to 60 years old.  Women are affected twice as often as men.  Patients who are overweight, take on a new form of exercise or increase activity level, are on their feet for long hours, wear high heeled shoes or who have flat feet are at increased risk for the condition. 

Plantar fascitis is easy to diagnose based on history and exam alone.  Nurse practitioners must be familiar with the causes of this condition and its treatment.  Nurse practitioners can easily manage this condition as conservative treatment is the mainstay.  WebMD provides great patient information about plantar fascitis including stretching exercises that may help your patients manage their condition. 

References

Young, Craig. Plantar Fascitis. Medscape. http://emedicine.medscape.com/article/86143-overview  Accessed September 23,2012. 

Plantar Fascitis. Mayo Clinic. http://www.mayoclinic.com/health/plantar-fasciitis/DS00508 Accessed September 23, 2012.

Plantar Fascitis. PubMed Health Medical Encyclopedia. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/ March 1, 2012.

Comments

Plantar fascitis is easy to diagnose based on history and exam alone. Nurse practitioners must be familiar with the causes of this condition and its treatment. Nurse practitioners can easily manage this condition as conservative treatment is the mainstay.

Gate Holloman

This was helpful!

T Kru

Thanks for the great tip!

Erin Tolbert

I have found that several times the route cause of plantar fascitis is spasm and inflammation of the hamstring tendon and that aggressive massage of trigger points and stretching of the whole leg works when conventional treatment has failed.

Rebecca