Choosing Wisely® is an initiative of the American Board of Internal Medicine and is supported by multiple medical societies, including the American Medical Society for Sports Medicine. Each society was asked to contribute five diagnostic tests or treatments that both physicians and patients shoulder question. The highlight this issue is the American College of Occupational and Environmental Medicine’s “number 4” recommendation:

Don’t routinely order X-ray for diagnosis of plantar fasciitis/heel pain in employees who stand or walk at work, as the diagnosis is in most cases evident from the worker’s history and physical examination. X-ray is not recommended except in cases where a serious underlying medical condition is suspected, such as fracture or infection.

Plantar fasciitis is a disorder of the insertion of the plantar fascia as it inserts on the calcaneus (heel bone), causing pain in the heel and bottom of the foot. It is usually most severe following a period of rest, such as when waking up and taking the first steps of the day and can worsen with dorsiflexion of the foot and toes. The pain typically improves with walking or other activities, and may resolve through course of the day.

The underlying cause of plantar fasciitis is not fully understood, however it is thought that microtears, tissue breakdown and scarring play a larger role than inflammatory processes. Risk factors include jobs or activities which require long periods of standing, a period of rapid increase in activity level, obesity, high arches and excessive pronation of the foot while walking. Tightness in the Achilles tendon and poorly fitting shoes have also been identified as risk factors.

The diagnosis can be made with a history and physical exam alone. During the exam, the patient will be tender along the inside part of the heel and into the sole of the foot. X-ray evaluation typically is not necessary, unless there is a suspicion for a more serious problem that might be revealed on imaging. These include fracture (broken bone) or infection, though with a history typical of plantar fasciitis and in the absence of trauma or infectious symptoms, these are far less likely.

Heel spurs are occasionally seen in conjunction with plantar fasciitis and can be found in up to 10% of the population. Only five percent of those with heel spurs have foot pain however, and the pain from plantar fasciitis is not a result of spurring. The presence of a heel spur does not affect management of the patient and therefore is not a reason to obtain X-rays in a patient with suspected plantar fasciitis.

Initial treatment of plantar fasciitis usually involves conservative methods, including rest, medications and a stretching program. Ice massage or rolling on a frozen water bottle, can also be effective. Formal physical therapy, orthotics (shoe inserts) and night splints can also be considered. Injections may be effective in some cases, however repeat injections should be limited due to the risk of side effects. Surgery can be considered in prolonged cases but is usually not necessary.

Visit https://www.amssm.org/Content/pdf%20files/Choosing_Wisely.pdf and http://www.choosingwisely.org/wp-content/uploads/2015/02/ACOEMChoosing-Wisely-List.pdf for more information on this campaign.

AMSSM Member Authors
Benjamin Oshlag, MD