Plantar fasciitis is the most common cause of chronic heel pain observed in up to 10% of the general population. A survey among professional team physicians and trainers in 1995 found plantar fasciitis to be among the top five causes of foot and ankle injuries in professional athletes (6). Another study estimated that about one million patient visits per year are for plantar fasciitis (7). It mainly occurs in middle-aged females and male runners younger than 20 years old, although all ages can be affected. The male to female ratio is 1:2 with obesity concomitantly present in 40% of affected males and 90% of affected females. Mortality is low and is associated with fibrosarcoma of the plantar fascia. This rare tumor has an incidence of 30 per year in the United States. Delayed diagnosis leads to a 5-year survival rate of less than 10%.
Proven risk factors include obesity, sedentary lifestyle, repetitive loading, and a mean age of 40 to 50 years old. Decreased healing response, along with decreased tissue elasticity and repetitive tearing have been implicated in the middle-aged population and may be contributing factors. Other factors implicated in this condition include:
1. Pes cavus with a rigid high medial arch.
2. Shoes with stiff soles or poor arch support.
3. Tight calf muscles.
4. Forefoot pronation.
5. Leg length discrepancy.
6. Excessive tibial torsion.
Prichasuk described the mean calcaneal pitch to be significantly lower in symptomatic patients (16 versus 20.5°) than in asymptomatic patients (7). On lateral foot radiographs, the calcaneal pitch (also known as the calcaneal inclination angle) is the angle formed by intersecting a line drawn from the plantar most surface of the calcaneus to the inferior border of the distal articular surface and the transverse plane. Other conditions associated with increased risk for plantar fasciitis include pregnancy, hypothyroidism, and certain arthropathies.
Training errors are also a common cause of plantar fasciitis. Patients often report a recent increase in intensity, duration, or distance during exercise activities. Plyometrics, graded hill workouts, speed workouts, or running on poorly padded surfaces are also high-risk behaviors. Improper shoes also play a role; lightweight shoes with minimal cushion do not adequately decrease the forces impacting the heel during activity. Because shoes rapidly lose their cushioning properties, frequent shoe replacement appropriate to a patient's activity is advocated (8).
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