Patient Presentation
A 12-year-old female came to clinic with a 2-3 week history of right heel pain. She had started running about 1 month ago and had slowly increasing heel pain since then. She said the pain was worse after running and when initially getting up in the morning. Recently she also noticed that it was painful after she was sitting for a period of time. After getting up and moving though the pain got better. Her mother was worried because she was limping first thing in the morning. The patient had purchased new shoes for running and was running on concrete sidewalks. They had not tried stretching, antipyretics or ice for pain relief. The past medical history was non-contributory.

The pertinent physical exam showed a happy individual in no distress. Her vital signs were normal and she was not overweight. She had full range of motion in her ankle, forefoot and toes, but had less bilateral flexibility when her Achilles tendons were stretched. Pain could not be elicited by palpation or forefoot extension while seated. However, when standing the patient pointed to medial heel pain with standing that increased with forefoot extension. She had no pain at the Achilles insertion. No pain could be elicited in any other areas of the foot.

The diagnosis of plantar fasciitis was made. The pediatrician looked at her shoes and did not see excessive wear or an abnormal wear pattern. She recommended that the girl make sure to warm up well before running and to run on softer terrain. “You can also get a heel cup to give a little more support when you are running,” she advised. “I’ll also show you a couple of stretches that you can do to help stretch the shock absorber in your foot called the plantar fascia,” she explained. “Good support, stretching and ice, over a few weeks usually helps people a lot,” she explained.

Discussion
The plantar fascia consists of 3 bands of dense connective tissue that originates in the medical calcaneal tubercle and inserts into the base of each of the 5 proximal phalyanxes in a fan-shaped distribution. It acts as a shock absorber and reinforces the medial longitudinal arch as the foot undergoes forward propulsion. The -itis in plantar fasciitis (PF) is a misnomer as it is not an acute inflammation but is a chronic degenerative process involving the plantar fascia aponeurosis of the foot usually at the medial tubercle of the calcaneous. Repetitive strain seems to cause microtearing which then causes a repair response where there can be thickening and fibrosis of the plantar fascia. Plantar fasciosis is a more accurate term to describe the pathology as it is currently understood.

About 1 million visits occur each year for PF in the US. It is most common in the 45-64 year old age group and least common in the pediatric age group. However it does occur as a chronic overuse syndrome for pediatric patients particularly those that are deconditioned, starting new exercise regimens, exercising on a hard surface or are obese. These are risk factors for all age groups and other risk factors include standing for long time periods, sedentary individuals, military personnel or long-distance runners. Additional risk factors include pes planus, pes cavus, shortened Achilles tendon, limited ankle dorsiflexion, weak foot or plantar flexor muscles, and overpronation. Environmental risk factors include deconditioning, working/exercising on a hard surface, prolonged weight bearing, walking barefoot, poor footwear, and inadequate stretching. Females may or may not be at increased risk.

The differential diagnosis includes posterior tibial nerve impingement (tarsal tunnel syndrome that has paraesthesa with dorsiflexion), fascial rupture, calcaneal fractures, calcaneal apophysitis (a review can be found here), Achilles tendonitis, arthritis, bursitis or fat pad contusion.

Diagnosis is usually clinical with a history that classically includes medial heal pain with first steps in the morning that improves with movement throughout the day or improves with rest. This scenario may repeat itself after sitting for a prolonged period. The pain is worsened after long periods of standing or over the course of the day with excessive movement. The pain is reproducible with dorisflexion of the foot.

Learning Point
PF treatment is usually conservative but it can take a long time. Fortunately 85-90% of patients have successful treatment. It is estimated that the stretching routines must be done for at least 1/2 of the time that the patient has had symptoms to have relief or at least ~6-8 weeks.

Conservative treatment includes:

• Using good footwear with arch and heel cushioning- not walking barefooted or in sandals
• Over the counter orthotics – heel or full-foot premade orthotics can provide additional arch and heel cushioning and support.
• Rest and modification of activities
• Use a thick mat if patient has to stand for a long time in one area
• Stretching of foot, ankle and calves as a treatment and in general before exercise
• Massage
• Pain control – Ice and/or anti-pyretics / non-steroid anti-inflammatory drugs
• Weight loss

Additional treatments after usually 6-8 weeks can include:

• Physical therapy
• Corticosteroid injection (has a 10% risk of plantar fascial rupture)
• Anterior night splint
• Other treatments can include extracorporal shock wave therapy or ultrasound therapy, osteopathic manipulative therapy

If still no improvement after an additional 6-8 weeks:

• Orthopaedic consultation
• Fasciotomy

Stretching before first steps in the morning or after sitting for a period of time can really help. Stretching is the best treatment.
Stretching daily can include:

• Calf and ankle stretches – a towel is wrapped around the ball of the foot and then dorsiflexed. Each stretch is 30 seconds. Rest 30 seconds in between. Do each stretch 3 times. Do this 2-3 times/day.
• Plantar fascial stretch – ankle and foot are dorsiflex and all toes are gently extended with the hand. The plantar area is massaged with the other hand. Each stretch is 30 seconds. Rest 60 seconds in between. Do each stretch 3 times. Do this 2-3 times/day.
• Rolling plantar fascia – roll a ball, small can, or frozen water bottle back and forth. Roll for 60 seconds. Rest 30 seconds in between. Do each stretch 2-3 times/day.
• Towel pick up – a paper towel is picked up and dropped by the toes. Do this for 120 seconds once a day.
• Wall push – with the ball of the foot on the base of a wall and the heel on the ground, the patient leans into the wall. Each stretch is 10 seconds. Rest 10 seconds in between. Do each stretch for 2 minutes at least 2 times a day or even every hour.
• Achilles tendon stretch – while standing on step, drop heel off the back of the step, keeping knees straight and also repeat with knee slightly bent. Each stretch is 30 seconds. Rest 30 seconds in between. Do each stretch 3 times. Do this 2-3 times/day.

Questions for Further Discussion
1. How common is plantar fasciitis in cultures who use less footwear?
2. What are indications for imaging with plantar fasciitis?

Related Cases

Disease: Plantar fasciitis | Heel Injuries and Disorders

Symptom/Presentation: Foot Pain

Specialty: Orthopaedic Surgery and Sports Medicine | Physical Medicine and Rehabilitation / Physical Therapy

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Heel Injuries and Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

American Physical Therapy Association. Physical Therapist’s Guide to Plantar Fasciitis. Available from the Internet at https://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=a2395ee9-08bb-47cc-9edc-1943e2fdbf2e
(rev. 8/28/11, cited 7/3/18).

Schwartz EN, Su J. Plantar fasciitis: a concise review. Perm J. 2014 Winter;18(1):e105-7.

Thompson JV, Saini SS, Reb CW, Daniel JN. Diagnosis and management of plantar fasciitis. J Am Osteopath Assoc. 2014 Dec;114(12):900-6.

Pollack A, Britt H. Plantar fasciitis in Australian general practice. Aust Fam Physician. 2015 Mar;44(3):90-1.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa