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Diagnosis and treatment of plantar fasciitis in the military
Brett D. Owens, MD, answers 4 Questions about studying this ailment in a unique population.
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Over the years, I have found plantar fasciitis has been one of the more frustrating entities to treat in orthopedic patients. It can be quite refractory to treatments and frustrating symptoms may persist for inpatient individuals. The good news is it usually gets better, but it may take longer than the patient may like. This month I have turned to Brett D. Owens, MD, to share his insights from studying military personnel with plantar fasciitis.
— Douglas W. Jackson, MD
Chief Medical Editor
Douglas W. Jackson, MD: What symptoms and physical findings are necessary to make a diagnosis of plantar fasciitis?
Brett D. Owens, MD: A good patient history is helpful. Patients with plantar fasciitis classically describe heel pain associated with their first steps upon arising from bed. They may also note pain at the end of the day that was worsened by extended periods of standing. Athletes note pain associated with increased activity levels, such as a long run.
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Physical examination typically shows tenderness with palpation of the plantar fascia origin at the medial calcaneal tubercle. Patients may have decreased ankle dorsiflexion secondary to a tight Achilles tendon, which may lead to a compensatory pronation of the foot.
It is important to rule out other causes of plantar heel pain. For example, central fat pad atrophy occurs in elderly patients with pain in the central heel; however, they usually do not complain of pain upon first weight-bearing in the morning. Tarsal tunnel syndrome is described as sharp or burning pain along the distribution of the tibial nerve posterior and inferior to the medial malleolus. Similarly, compression of the first branch of the lateral plantar nerve (Baxter’s Nerve) can mimic plantar fasciitis, causing pain more proximally. Finally, a calcaneal stress fracture can be confirmed on examination with use of the squeeze test, which produces tenderness on mediolateral compression of the calcaneus.
Jackson: In your military population, what are some of the risk fractors your recent study documented to be associated with plantar fasciitis?
Owens: We utilized a large military database to determine the incidence rate and demographic risk factors for this common entity. The largest effect we noted was increased age, with the greater than 40 year old group having a 3.4-times higher incidence than the 20 to 24 years-old group.
The next largest effect was gender, where we found that the rate in female service members was twice that of men. We found a slightly higher incidence among black service members compared to those of white service members. We also found that junior enlisted personnel and those in the Army and Marines were at higher risk for plantar fasciitis — with these categories probably having higher activity levels than senior officers and other branches of service.
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Image: Owens BD |
Jackson: What is the usual natural history of plantar fasciitis in the military population?
Owens: We do not have a complete understanding of the natural history of plantar fasciitis in the military population, as this has not been studied to our knowledge. There are activity requirements that may alter the natural history in this unique population. Service members are subjected to austere activity and load conditions that increase their risk for a degenerative process such as plantar fasciitis — especially in a deployed or combat environment. A typical “fighting load” often exceeds 40 lbs, much of which is born via a shoulder-born pack and waist harnesses. It is often not possible to modify a service member’s load or activity to alleviate symptoms. For this reason, more cases or refractory fasciitis may develop. Certainly some patients require surgical intervention and some cannot perform the duties required by their job, resulting in medical separation from the service.
Jackson: What treatments are currently employed in the military population and are those treatments better then avoiding aggravating activities and the passage of time?
Owens: In the U. S. military population, patients are primarily treated with nonoperative management for plantar fasciitis. This includes the use of NSAID medications, instruction on the performance of Achilles tendon- and plantar fascia-specific stretching, physical therapy, and/or shoe inserts. A short trial of immobilization and protected weight-bearing is often helpful, if possible, depending upon the operational situation. In deployed or combat situations, corticosteroid injections may provide temporary relief when activity modification may not be possible.
Those service members who are recalcitrant to nonoperative management for a minimum of 6 months are considered candidates for surgical intervention with a partial plantar fasciectomy. It is difficult to say whether these treatment modalities are better than avoiding aggravating activities and allowing the passage of time — but this option often is not feasible in our unique patient population.
Editor’s note: The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of Defense or United States government.
Reference:
- Scher DL, Belmont PJ, Mountcastle SB, Bear R, Orr J, Owens BD. The Incidence of Plantar Fasciitis in the United States Military Servicemembers. J Bone Joint Surg (Am). 2009;91:2867-2872.
- Brett D. Owens, MD, is an associate professor with the Uniformed Services University of Health Sciences, John A. Feagin, Jr. Sports Medicine Fellowship at Keller Army Hospital, West Point, NY 10996. He can be reached at b.owens@us.army.mil.