Epidemiology Plantar fasciitis (Heel pain)

Epidemiology Plantar fasciitis (Heel pain)

Plantar fasciitis Plantar fasciitis is an overload injury.1 Frequent load of the fascia can lead to micro failures which can eventually lead to inflammation and degeneration of the connective tissue in the fascia of the plantar surface.1

Plantar fasciitis is the most common disorder of the heel to the plantar surface.2

Incidence / Prevalence Plantar fasciitis is the most common cause of heel pain with a lifetime prevalence of 10%, accounting for eleven to 15% of all foot symptoms, and affecting two million people in the United States alone.13-16
Sex Man are most susceptible to gain plantar fasciitis17
Age Occurs mainly in middle and older age3
Pain location Ankle / Foot
Pain sensation / Symptoms The heel pain is at its worst in the morning just after waking up and the first few steps.8-13 This heel pain is therefore also called starting pain. At the end of the day, at times, there is a dull pain on the inside of the heel, which is further reduced at rest. When one goes walking again the heel pain will play up again. The heel may be red and slightly swollen. On the plantar surface, near the center line, there is a point that is particularly sensitive when pressed upon. If the condition is long term often occurs a calcification in the insertion of the fascia at the heel bone, which bears the name heel spurs. However, this is not the cause of the pain or the disease but is a result of the inflammation processes.2
History of injury In Plantar fasciitis no trauma is preceded.22

The endogenous factors (biomechanical disorders) that cause the plantar fasciitis
relate to pes planus, pes cavus, decreased mobility in the subtalar joint and a too short Achilles tendon.18 With age degenerative changes of the fatty tissue that is located between the plantar aspect of the calcaneus and the skin (lipoatrophy) arise. The loss of function of this fatty tissue can easily lead to bruising of the posteroplantaire part of the calcaneus when running. Eventually microfractures and/or periosteal irritation can occur.

Prognosis The disease is self-limiting: it usually corrects itself with a natural course of about 1 to 2 years.4 Examination of Wolgin4 showed that 80% of patients treated conservatively were completely pain free after 4 years. Twenty percent still keeps pain. Another study by Davis5 showed that 10% of the patients treated with conservative therapy of them have no benefit. They keep pain.
Risk factors Overloading in athletic sports19 and military20, overweight and increase in body mass index are common causes.20 Professions that require a lot of standing or walking, especially if the person was not used to it before.22
  1. Lefevre F.: Extracorporeal Shock Wave Treatment for Chronic Plantar Fasciitis. Assessment Program Volume 19, No. 18 March 2005.
  2. Singh D, Angel J, Bentley G, Trevino SG. Fortnightly review. Plantar fasciitis. BMJ. 1997; 315:172-5
  3. Crawford F.: Interventions for treating plantar heel pain. Cochrane Database Syst Rev (3):CD000416, 2003.
  4. Wolgin M.: Conservative treatment of plantar heel pain: long-term follow-up. Foot Ankle Int 15:97-102, 1994.
  5. Davis PF.: Painful heel syndrome: results of non-operative treatment. Foot Ankle Int, 15:531-535, 1994.
  6. Lemont H.: Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. May-Jun;93(3):234-7, 2003.
  7. Boyle RA.: Endoscopic plantar fascia release: a case series. Foot Ankle Int 24:176-9, 2003
  8. DiGiovanni BF, et al. Tissue-specific plantar fascia stretching exercise enhances outcomes in patients with chronic heel pain: a prospective, randomized study. J Bone Joint Surg. 2003;85A(7):1270-1277.
  9. Crawford F, Snaith M. How effective is therapeutic ultrasound in the treatment of heel pain? Ann Rheum Dis. 1996;55:265-267.
  10. Batt ME, Tanji JL, Skattum N. Plantar fasciitis: a prospective randomized clinical trial of the tension night splint. Clin J Sports Med. 1996;6(3):158-162.
  11. Lynch DM, et al. Conservative treatment of plantar fasciitis: a prospective study. J Am Pod Med Assoc. 1998;88(8):375-380.
  12. Caselli MA, et al. Evaluation of magnetic foil and PPT Insoles® in the treatment of heel pain. J Am Pod Med Assoc. 1997;87(1):11-16.
  13. Martin JE, et al. Mechanical treatment of plantar fasciitis: a prospective study. J Am Pod Med Assoc. 2001;91(2):55-62.
  14. Pfeffer G, et al. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int. 1999;20(4):214-221.
  15. Buchbinder R. Plantar fasciitis. N Engl J Med. 2004;350(32):2159-2166.
  16. Landorf KB, Keenan AM, Herbert RD. Effectiveness of different types of foot orthoses for the treatment of plantar fasciitis. J Am Pod Med Assoc. 2004;94(6):542-549.
  17. Book: Voet en enkelpijn; prof.dr.R. Cailliet,1997
  18. Tracy Aldridge, M.D., Diagnosing Heel Pain in Adults. Am Fam Physician 2005 July;70(2)
  19. Kibler WB, Goldberg C, Chandler TJ. Functional biomechanical deficits in running athletes with plantar fasciitis. Am J Sports Med. 1991;19:66-71
  20. Daniel L. Riddle, Matthew Pulisic, Peter Pidcoe, Robert E. Johnson. Risc factors for plantar fasciitis: a matched case-control study. J Bone Joint SurgAm. 2003;85:872-877
  21. Sadat-Ali M. Plantar fasciitis/calcaneal spur among security forces personnel. Mil Med.


  1. Barret SL, O’Malley R. Plantar fasciitis and other causes of heel pain. American family physiscian. 59(8), april 1999


Physical examination

There is no gold standard for the diagnosis of plantar fasciitis. A pronation of the foot is usually seen at plantar fasciitis.1 The functional assessment is negative. Upon palpation, there is a strong pain present at the site of the disorder while holding pressure.2 The pain will increase at passive dorsiflexion of the toes.3
Red Flags
A trauma means a red flag. When complaints arise from trauma, the potential exists for a (partial) rupture of the plantar fascia. In case of a rupture, however, pain is more commonly indicated at the medial arch than at the plantar surface of the heel. However, it is not impossible that the patient at that spot indicates pain. As a result of trauma, there may also be a (stress) fracture of the calcaneus. The symptoms often mimic the symptoms of Plantar fasciitis. However, when a patient has a fracture of the calcaneus, it will also indicate pain when pressure on the medial and lateral side of the calcaneus is given (axial pressure pain).
The main issue regarding physical medicine and rehabilitation for plantar fasciitis is that chronic plantar pain leads to increased limping; this can produce an antalgic gait pattern that may hinder and possibly decrease mobility to levels that are unacceptable for the performance of activities of daily living (ADLs), including work and recreation.
How is plantar fasciitis examined and diagnosed?
Diagnosis is generally straightforward, but an examination must be done to rule out other possible causes of foot/heel pain (which would require different treatment) such as fracture, bursitis, and nerve entrapments that mimic plantar fasciitis. Diagnosis is based on the description of the pain and examination which should not only include the area of pain but also the biomechanics of the feet and legs. Furthermore, other factors should be explored, such as, training/exercise program, footwear, body weight, previous injuries, walking/running gait, etc.
Are special tests (like X-rays or MRI) needed?
No. The diagnosis is made based on the presentation of the symptoms and special diagnostic tests are rarely indicated. X-rays do not show the plantar fascia. With x-rays often times heel spurs (a small growth of bone) is seen in the heel with plantar fasciitis but these are generally not the cause of pain and of minimal importance to plantar fasciitis. Ultrasound imaging or magnetic resonance imaging (MRI) may show thickening of the fascia, which support the diagnosis, however, such findings do not change treatment and therefore probably not the prognosis either.
  1. Barret SL, O’Malley R. Plantar fasciitis and other causes of heel pain. American family physiscian. 59(8), april 1999
  2. Dos Winkel, Geert Aufdemkampe. Orthopedische geneeskunde en manuele therapie. Deel 1:extremiteiten. 2001
  3. Tracy Aldridge, M.D., Diagnosing Heel Pain in Adults. Am Fam Physician 2005 July;70(2)


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