Checked: 24-10-2014 by
vicky.ryan Next Review: 21-10-2016
Plantar fasciitis - management NS MOM
diagnosis and management of plantar fasciitis in primary and secondary care in adults
considerations of alternative causes of plantar heel pain in adults
detailed management of alternative causes of plantar heel pain
Out of scope:
achilles tendon rupture
other foot/ankle injuries
plantar fasciitis refers to persistent pain associated with chronic degenerative and reparative processes affecting the origin of the plantar fascia and surrounding peri-fascial surfaces :
this causes pain which often radiates from the central part of the heel pad or from the plantar fascia insertion at the medial tubercle of the calcaneum 
the pain may radiate along the plantar fascia into the medial longitudinal arch of the foot 
plantar fasciitis is the most common cause of plantar heel pain 
plantar fasciitis is one of the most common causes of foot pain in adults  
plantar fasciitis accounts for about 80% of cases of heel pain, with a lifetime prevalence of around 10% 
it is most common in people of age 40–60 years 
primarily affects people from middle age to later life 
in athletes, plantar fasciitis is the most common cause of heel pain :
it is attributed to mechanical stresses, probably due to repetitive trauma 
it accounts for a quarter of all foot injuries related to running 
it affects both athletic and sedentary people, and does not seem to be influenced by gender 
it may co-exist with heel spurs 
Aetiology and risk factors:
the aetiology is uncertain 
possible risk factors include:
reduced ankle dorsiflexion motion 
reduced range of motion in the ankle and first metatarsophalangeal joint 
reduced knee extension [7,8]
occupations requiring prolonged standing 
excessive jumping (although more likely to cause heel bruise syndrome, another common cause of heel pain)
flat feet (pes planus) 
the prognosis for plantar fasciitis is good 
most people with plantar fasciitis will make a complete recovery within 1 year 
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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties
This care map has been drafted using the Map of Medicine editorial methodology (URL) and represents best clinical practice according to the highest quality evidence available, including the following guidelines:
 PRODIGY. Plantar fasciitis. Version 1.0. Newcastle upon Tyne: PRODIGY; 2009.
 Thomas JL, Christensen JC, Kravitz SR et al. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg 2010; 49: S1-19.
 McPoil TG, Martin RL, Cornwall MW et al. Heel pain--plantar fasciitis: clinical practice guidelines linked to the international classification of function, disability, and health from the orthopaedic section of the American Physical Therapy Association. J Orthop Sports Phys Ther 2008; 38: A1-A18.
 American College of Radiology (ACR). Chronic Foot Pain: ACR Appropriateness Criteria. Reston, VA: ACR; 2008.
 National Institute for Health and Clinical Excellence (NICE). Extracorporeal shockwave therapy for refractory plantar fasciitis. London: NICE; 2009.
Further information was provided by the following references including practice-based knowledge: [5-8].
MSK Interface provide assessment, diagnostic and treatment of a wide variety of musculoskeletal conditions. This includes both simple and complex problems that may traditionally have been referred direct to orthopaedics.
Primarily the role is assessment of non-surgical cases or assessing and triaging those patients where the need for surgery is not obvious.
Treatments include an injection service, exercise therapy, self-management programs and referral on for physiotherapy, podiatry and surgical appliances as required.
Diagnostics includes access to MRI and ultrasound when deemed clinically relevant by the clinician
the process should be repeated six times, at least twice a day
this should be used with caution as it can increase pain
chair stretches for Achilles tendon and plantar fascia :
this process can be repeated about ten times in a session, and the whole routine repeated five or six times a day
dynamic stretches for plantar fascia [1-3]:
rolling the foot on a golf ball or pediroller (ridged massage bar) whilst seated, holding under the thighs, with toes up and gently rolling back and forth for 1 min repeating 3 times on each leg. This should be repeated at least twice a day
padding and strapping [1-3]
Usually patients have a symptomatic improvement after 6-12 weeks of initial treatment [1,2].
Consider referral to a podiatrist if the patient has not responded after 6-12 weeks of treatment and if there is a suggestion of obvious biomechanical abnormality .
Consider referral to an orthopaedic foot and ankle surgeon if the patient has not responded after 6-12 weeks of treatment and there is suspicion of fracture or nerve entrapment .
Consider referral to a rheumatologist if the patient has not responded after 6-12 weeks of treatment and there is suspicion of rheumatological condition .
NB: There is limited evidence that physiotherapy is beneficial beyond stretching exercises . However, patients usually find it difficult to understand this until shown to them by a physiotherapist .
when conservative measures and interventions provided by a podiatrist or physiotherapist have proved inadequate [1,2]; or
if symptoms are severe 
if symptoms are having a significant impact on quality of life 
for people in particular occupations, eg athletes, or people whose job entails standing or walking for prolonged period 
injections should be administered by an experienced clinician and ideally under ultrasound guidance 
there is little consensus from specialists regarding optimal use of corticosteroid injections for plantar fasciitis [1,6]
discuss the benefits and possible harms with the person before administration 
be aware that observational studies have found a high rate of plantar fascia rupture (and other complications including atrophy of the fat pad) associated with corticosteroid injections; which can lead to chronic disability in some patients 
the most common mistake made during the administration of corticosteroid injections is to insert the injection directly into the medial tuberosity and not into the junction of the plantar aponeurosis. It is recommended to use a medical approach and avoid superficial placement of the steriod injection into the fat pad. 
consider repeating the treatment if symptoms return only if initial treatment was clearly beneficial :
do not repeat if symptoms do not improve initially with the first dose − consider alternative diagnosis
wait a minimum of 6 weeks before repeating administration
consider referral if patient requires three or more doses
customised functional foot orthoses [3,6]:
decreases pain associated with plantar fasciitis
may also provide added benefit in terms of increased functional ability
physical therapy 
cast or boot immobilization for 4 to 6 weeks 
The majority of patients will demonstrate improvement 2-3 months after commencing second-line treatment (ie 4-6 months after first-line treatment commenced) .
If characteristic symptoms and signs are not consistent with plantar fasciitis, consider :
calcaneal stress fracture − typically presents with diffuse, warm swelling, and can be diagnosed by squeezing the calcaneum, inducing pain :
diagnosis is confirmed by radiography (although changes may be subtle or even absent)
Achilles tendinopathy − may present with tenderness on palpation, and pain radiating up the calf with extension of the foot, or standing on tiptoes (complete rupture causes severe pain and loss of foot stability):
flexor hallucis or posterior tibial tendinopathy may also mimic plantar fasciitis
fat pad atrophy − causes centralized heel pain, and a flattened atrophied surface may be felt on palpation 
sub-calcaneal bursitis − typically affects obese people or athletes, and presents as posterior heel pain under the fat pad of the calcaneum
Less common causes of heel pain include, but are not limited to:
neurological causes :
tarsal tunnel syndrome, which is detected by a positive 'Tinel's sign' on a dorsiflexed, everted foot (often missed in primary care) 
S1 radiculopathy causes pain that radiates throughout the leg − it can be ruled out by a comprehensive neurological examination 
nerve entrapment, eg lateral and medial plantar nerves can mimic plantar fasciitis, but tends not to specifically affect the medial tuberosity:
in particular, the first branch of the lateral plantar nerve may present with tenderness on the medial side of the edge of the heel, with pain radiating to the lateral side of the heel
peripheral neuropathy lacks a specific focal area of pain and sensations may still be felt at rest
other musculoskeletal causes :
plantar fascia rupture, presenting as a sudden onset of pain:
there may be a palpable gap and evidence of collapse in the medial and longitudinal arches
plantar fibromatosis − causes pain in the mid-section of the plantar fascia and palpable nodules
bone contusion − typically affects obese people or athletes, and presents as posterior heel pain under the fat pad of the calcaneum
infection (osteomyelitis or subtalar pyoarthrosis) is rare in the absence of an open wound:
it presents with a red, hot, swelling and systemic illness
subtalar arthritis − usually presents with pain felt in the subtalar joint, ie deep within the heel upon weight bearing
inflammatory arthropathies and gout can be ruled out by appropriate investigations
neoplasm and vascular insufficiency are very rare causes of heel pain − however, should be considered in recalcitrant cases
trauma, eg fracture or stress fracture 
Patients should possess chronic symptoms and undergo treatment for at least 6 months prior to consideration for third-line treatment options :
plantar fasciotomy :
an open or endoscopic approach could be employed, however, current practise favours an endoscopic approach 
in most cases, removal of the plantar heel spur does not seem to add to the success of the outcome in the surgical treatment of plantar heel pain
extracorporeal shock wave therapy (ESWT) :
ESWT is a noninvasive treatment used to pass acoustic shockwaves through the skin to the affected area
ultrasound guidance can be used to assist with positioning of the device
ESWT may be applied in one or several sessions:
local anaesthesia may be used because high-energy ESWT can be painful
different energies can be used and there is evidence that local anaesthesia may influence the outcome of ESWT
the mechanism by which this therapy might have an effect on tendinopathy is unknown
if offering treatment with ESWT:
obtain fully informed consent − ensure that the patient understands the uncertainty about the efficacy of ESWT; provide clear written information
audit and review all outcomes of ESWT
inform the clinical governance leads in the trust
consider the resource implications in relation to the treatment effects 
The MSK referral form is available as an EMIS template. Referrals to NSCP MSK service are done via Manager Referrals in EMIS
Consider the following:
in patients who have demonstrated improvement, continue first- and second-line treatment until there is resolution of symptoms [1,2]
only repeat corticosteroid injections if initial treatment was clearly beneficial, however :
wait a minimum of 6 weeks before repeating
consider alternate diagnosis if more than 2 corticosteroid injections are required
If symptoms are improving, continue first-line treatment until symptoms are resolved .