Research-Based Clinical Presentation
Patient’s chief complaint is usually an insidious onset of pain, often described as sharp, pinpointed to the plantar aspect of the heel at the aponeurosis insertion (calcaneal tubercle).  Pain may also be reported in the medial longitudinal arch.  The pain is usually greatest with the first few steps in the morning and during weight bearing activities.  The pain can be so severe at times as to cause an antalgic gait.(2)  Pain usually decreases as the tissue warms up, but may easily return again after long periods of standing, physical activity, or upon standing after long periods of sitting.  Although there are no activity limitation measures specifically for plantar fasciitis, clinicians can use the following questions to get an idea of what acitivities are limited in clients.(2)

  · Over the previous 24 hours, what percentage of time did you experience heel pain?
· After lying down or sitting for a prolonged period of time, what is your level of pain upon the first few steps?
· What is your level of pain in single-leg standing?
· What is your level of pain after prolonged standing for 30 minutes?
· What is your level of pain after walking 1000 meters?

The Foot and Ankle Ability Measure (FAAM)-aka Foot and Ankle Disability Index (FADI), which has been validated in physical therapy practice, can also be used as a functional outcome measure for patients with PF.(2) Have the patient fill out the questionnaire before beginning their treatment, after their first series of visits and at the end of their course of treatment.  On observation of the patient in standing, pronation of the subtalar joint is common, which is often accompanied by a slight drop in the navicular bone and calcaneal eversion.(11) Tightness of the Achilles tendon (with dorsiflexion at the ankle limited by 5° or more) is found in almost 80 percent of patients with PF.(1)  It is appropriate to measure talocrural dorsiflexion range of motion as a possible impairment of body function.(2)  On palpation, both the insertion of the aponeurosis and the medial longitudinal arch are usually tender.  Pain may also be experienced on palpation of the plantar surface of the calcaneus.  Along with pain, an increase in palpable tension is often present in the plantar fascia, with thickening and nodulation of the fascia in chronic cases.  Pain might be reproduced by passive and/or active toe extension.(11)  The Windlass Test is an appropriate special test for impairment of the fascia and ligaments of the foot.(15) With the patient sitting, the examiner stabilizes the ankle in neutral with one hand and then, with the other hand, extends the first metatarsophalangeal joint while allowing the interphalangeal joint to flex.  Passive extension of the first metatarsophalangeal joint is continued until end range or until the patient’s pain is reproduced.  Reproduction of pain indicates a positive test for plantar fascia impairment.

The Windlass Test for impairment of the plantar fascia.

In diagnosis, other possible causes of the heel pain should be ruled out.  For example, in the case of a calcaneal stress fracture or nerve entrapment, pain would actually increase with more walking, rather than diminish after the first few steps.(11)   Nocturnal pain should raise suspicion of other causes of heel pain, such as tumors, infections, and neuralgia (including tarsal tunnel syndrome).(12)   PF is usually unilateral, but up to 30 percent of cases have a bilateral presentation.  Bilateral disease in young patients may indicate Reiter’s syndrome.  Patients should also be questioned about other features of seronegative arthritides (ie. presence of arthritis not related to rheumatoid arthritis).(13)  PF can be associated with psoriatic arthropathy, ankylosing spondylitis and enteropathic spondyloarthropathy.(2)  Diagnostic imaging is rarely indicated for initial evaluation and treatment, but may be helpful in certain cases to rule out other causes of heel pain.  Plain radiographs can rule out calcaneal stress fracture and may detect an underlying spondyloarthropathy.(12)  Bone scans and magnetic resonance imaging (MRI) may also serve useful, but are not routinely used.(12)
In prognosis, most cases of PF do not require surgery or invasive procedures to stop pain and reverse damage.  Conservative treatments are usually all that is required.  However, every patient’s body responds to plantar fasciitis treatment differently and recovery times vary.  The clinical outcome is positive for 80 percent of patients, who reported resolution of symptoms within 12 months.(14)  Surgery should only be considered for patients with considerable disability for whom conservative treatment has not helped after at least 12 months.

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