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Lung cancer screening: New evidence, updated guidance
CASE
A 51-year-old man presents to your office to discuss lung cancer screening. He has a history of hypertension and prediabetes. His father died of lung cancer 5 years ago, at age 77. The patient stopped smoking soon thereafter; prior to that, he smoked 1 pack of cigarettes per day for 20 years. He wants to know if he should be screened for lung cancer.
The relative lack of symptoms during the early stages of lung cancer frequently results in a delayed diagnosis. This, and the speed at which the disease progresses, underscores the need for an effective screening modality. More than half of people with lung cancer die within 1 year of diagnosis.1 Excluding skin cancer, lung cancer is the second most commonly diagnosed cancer, and more people die of lung cancer than of colon, breast, and prostate cancers combined.2 In 2022, it was estimated that there would be 236,740 new cases of lung cancer and 130,180 deaths from lung cancer.1,2 The average age at diagnosis is 70 years.2
Screening modalities: Only 1 has demonstrated mortality benefit
In 1968, Wilson and Junger3 outlined the characteristics of the ideal screening test for the World Health Organization: it should limit risk to the patient, be sensitive for detecting the disease early in its course, limit false-positive results, be acceptable to the patient, and be inexpensive to the health system.3 For decades, several screening modalities for lung cancer were trialed to fit the above guidance, but many of them fell short of the most important outcome: the impact on mortality.
Sputum cytology. The use of sputum cytology, either in combination with or without chest radiography, is not recommended. Several randomized controlled trials (RCTs) have failed to demonstrate improved lung cancer detection or mortality reduction in patients screened with this modality.4
Chest radiography (CXR). Several studies have assessed the efficacy of CXR as a screening modality. The best known was the Prostate, Lung, Colon, Ovarian (PLCO) Trial.5 This multicenter RCT enrolled more than 154,000 participants, half of whom received CXR at baseline and then annually for 3 years; the other half continued usual care (no screening). After 13 years of follow-up, there were no significant differences in lung cancer detection or mortality rates between the 2 groups.5
Low-dose computed tomography (LDCT). Several major medical societies recommend LDCT to screen high-risk individuals for lung cancer (TABLE 16-10). Results from 2 major RCTs have guided these recommendations.
The National Lung Screening Trial (NLST) was a multicenter RCT comparing 2 screening tests for lung cancer.11 Approximately 54,000 high-risk participants were enrolled between 2002 and 2004 and were randomized to receive annual screening with either LDCT or single-view CXR. The trial was discontinued prematurely when investigators noted a 20% reduction in lung cancer mortality in the LDCT group vs the CXR group.12 This equates to 3 fewer deaths for every 1000 people screened with LDCT vs CXR. There was also a 6% reduction in all-cause mortality noted in the LDCT vs the CXR group.12
Continue to: The NELSON trial...
The NELSON trial, conducted between 2005 and 2015, studied more than 15,000 current or former smokers ages 50 to 74 years and compared LDCT screening at various intervals to no screening.13 After 10 years, lung cancer–related mortality was reduced by 24% (or 1 less death per 1000 person-years) in men who were screened vs their unscreened counterparts.13 In contrast to the NLST, in the NELSON trial, no significant difference in all-cause mortality was observed. Subgroup analysis of the relatively small population of women included in the NELSON trial suggested a 33% reduction in 10-year mortality; however, the difference was nonsignificant between the screened and unscreened groups.13
Each of these landmark studies had characteristics that could limit the results' generalizability to the US population. In the NELSON trial, more than 80% of the study participants were male. In both trials, there was significant underrepresentation of Black, Asian, Hispanic, and other non-White people.12,13 Furthermore, participants in these studies were of higher socioeconomic status than the general US screening-eligible population.
At this time, LDCT is the only lung cancer screening modality that has shown benefit for both disease-related and all-cause mortality, in the populations that were studied. Based on the NLST, the number needed to screen (NNS) with LDCT to prevent 1 lung cancer–related death is 308. The NNS to prevent 1 death from any cause is 219.6
Updated evidence has led to a consensus on screening criteria
Many national societies endorse annual screening with LDCT in high-risk individuals (TABLE 16-10). Risk assessment for the purpose of lung cancer screening includes a detailed review of smoking history and age. The risk of lung cancer increases with advancing age and with cumulative quantity and duration of smoking, but decreases with increasing time since quitting. Therefore, a detailed smoking history should include total number of pack-years, current smoking status, and, if applicable, when smoking cessation occurred.
In 2021, the US Preventive Services Task Force (USPSTF) updated their 2013 lung cancer screening recommendations, expanding the screening age range and lowering the smoking history threshold for triggering initiation of screening.6 The impetus for the update was emerging evidence from systematic reviews, RCTs, and the Cancer Intervention and Surveillance Modeling Network (CISNET) that could help to determine the optimal age for screening and identify high-risk groups. For example, the NELSON trial, combined with results from CISNET modeling data, showed an empirical benefit for screening those ages 50 to 55 years.6
Continue to: As a result...
As a result, the USPSTF now recommends annual lung cancer screening with LDCT for any adult ages 50 to 80 years who has a 20-pack-year smoking history and currently smokes or has quit within the past 15 years.6 Screening should be discontinued once a person has not smoked for 15 years, develops a health problem that substantially limits life expectancy, or is not willing to have curative lung surgery.6
Expanding the screening eligibility may also address racial and gender disparities in health care. Black people and women who smoke have a higher risk for lung cancer at a lower intensity of smoking.6
Following the USPSTF update, the American College of Chest Physicians and the Centers for Medicare and Medicaid Services published updated guidance that aligns with USPSTF’s recommendations to lower the age and pack-year qualifications for initiating screening.7,10 The American Cancer Society is currently reviewing its 2018 guidelines on lung cancer screening.14TABLE 16-10 summarizes the guidance on lung cancer screening from these medical societies.
Effective screening could save lives (and money)
A smoker’s risk for lung cancer is 20 times higher than that of a nonsmoker15,16; 55% of lung cancer deaths in women and 70% in men are attributed to smoking.17 Once diagnosed with lung cancer, more than 50% of people will die within 1 year.1 This underpins the need for a lung cancer screening modality that reduces mortality. Large RCTs, including the NLST and NELSONtrials, have shown that screening high-risk individuals with LDCT can significantly reduce lung cancer–related death when compared to no screening or screening with CXR alone.11,13
There is controversy surrounding the cost benefit of implementing a nationwide lung cancer screening program. However, recent use of microsimulation models has shown LDCT to be a cost-effective strategy, with an average cost of $81,000 per quality-adjusted life-year, which is below the threshold of $100,000 to be considered cost effective.18 Expanding the upper age limit for screening leads to a greater reduction in mortality but increases treatment costs and overdiagnosis rates, and overall does not improve quality-adjusted life-years.18
Continue to: Potential harms
Potential harms: False-positives and related complications
Screening for lung cancer is not without its risks. Harms from screening typically result from false-positive test results leading to overdiagnosis, anxiety and distress, unnecessary invasive tests or procedures, and increased costs.19TABLE 26,19-23 lists specific complications from lung cancer screening with LDCT.
The false-positive rate is not trivial. For every 1000 patients screened, 250 people will have a positive LDCT finding but will not have lung cancer.19 Furthermore, about 1 in every 2000 individuals who screen positive, but who do not have lung cancer, die as a result of complications from the ensuing work-up.6
Annual LDCT screening increases the risk of radiation-induced cancer by approximately 0.05% over 10 years.21 The absolute risk is generally low but not insignificant. However, the mortality benefits previously outlined are significantly more robust in both absolute and relative terms vs the 10-year risk of radiation-induced cancer.
Lastly, it is important to note that the NELSON trial and NLST included a limited number of LDCT scans. Current guidelines for lung cancer screening with LDCT, including those from the USPSTF, recommend screening annually. We do not know the cumulative harm of annual LDCT over a 20- or 30-year period for those who would qualify (ie, current smokers).
If you screen, you must be able to act on the results
Effective screening programs should extend beyond the LDCT scan itself. The studies that have shown a benefit of LDCT were done at large academic centers that had the appropriate radiologic, pathologic, and surgical infrastructure to interpret and act on results and offer further diagnostic or treatment procedures.
Continue to: Prior to screening...
Prior to screening for lung cancer with LDCT, documentation of shared decision-making between the patient and the clinician is necessary.7 This discussion should include the potential benefits and harms of screening, potential results and likelihood of follow-up diagnostic testing, the false-positive rate of LDCT lung cancer screening, and cumulative radiation exposure. In addition, screening should be considered only if the patient is willing to be screened annually, is willing to pursue follow-up scans and procedures (including lung biopsy) if deemed necessary, and does not have comorbid conditions that significantly limit life expectancy.
Smoking cessation: The most important change to make
Smoking cessation is the single most important risk-modifying behavior to reduce one’s chance of developing lung cancer. At age 40, smokers have a 2-fold increase in all-cause mortality compared to age-matched nonsmokers. This rises to a 3-fold increase by the age of 70.16
Smoking cessation reduces the risk of lung cancer by 20% after 5 years, 30% to 50% after 10 years, and up to 70% after 15 years.24 In its guidelines, the American Thoracic Society recommends varenicline (Chantix) for all smokers to assist with smoking cessation.25
CASE
This 51-year-old patient with at least a 20-pack-year history of smoking should be commended for giving up smoking. Based on the USPSTF recommendations, he should be screened annually with LDCT for the next 10 years.
Screening to save more lives
The results of 2 large multicenter RCTs have led to the recent recommendation for lung cancer screening of high-risk adults with the use of LDCT. Screening with LDCT has been shown to reduce disease-related mortality and likely be cost effective in the long term.
Screening with LDCT should be part of a multidisciplinary system that has the infrastructure not only to perform the screening, but also to diagnose and appropriately follow up and treat patients whose results are concerning. The risk of false-positive results leading to increased anxiety, overdiagnosis, and unnecessary procedures points to the importance of proper patient selection, counseling, and shared decision-making. Smoking cessation remains the most important disease-modifying behavior one can make to reduce their risk for lung cancer.
CORRESPONDENCE
Carlton J. Covey, MD, 101 Bodin Circle, David Grant Medical Center, Travis Air Force Base, Fairfield, CA, 94545; carlcovey24@gmail.com
1. National Cancer Institute. Cancer Stat Facts: lung and bronchus cancer. Accessed October 12, 2022. https://seer.cancer.gov/statfacts/html/lungb.html
2. American Cancer Society. Key statistics for lung cancer. Accessed October 12, 2022. https://www.cancer.org/cancer/lung-cancer/about/key-statistics.html
3. Wilson JMG, Junger G. Principles and Practice of Screening for Disease. World Health Organization; 1968:21-25, 100. https://apps.who.int/iris/handle/10665/37650
4. Humphrey LL, Teutsch S, Johnson M. Lung cancer screening with sputum cytologic examination, chest radiography, and computed tomography: an update for the United States preventive services task force. Ann Intern Med. 2004;140:740-753. doi: 10.7326/0003-4819-140-9-200405040-00015
5. Oken MM, Hocking WG, Kvale PA, et al. Screening by chest radiograph and lung cancer mortality: the Prostate, Lung, Colorectal, and Ovarian (PLCO) randomized trial. JAMA. 2011;306:1865-1873. doi: 10.1001/jama.2011.1591
6. US Preventive Services Task Force. Screening for lung cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325:962-970. doi: 10.1001/jama.2021.1117
7. Centers for Medicare & Medicaid Services. Screening for lung cancer with low dose computed tomography (LDCT) (CAG-00439R). Accessed October 14, 2022. www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=304
8. Smith RA, Andrews KS, Brooks D, et al. Cancer screening in the United States, 2018: a review of current American Cancer Society guidelines and current issues in cancer screening. CA Cancer J Clin. 2018;68:297-316. doi: 10.3322/caac.21446
9. American Academy of Family Physicians. AAFP updates recommendation on lung cancer screening. Published April 6, 2021. Accessed October 12, 2022. www.aafp.org/news/health-of-the-public/20210406lungcancer.html
10. Mazzone PJ, Silvestri GA, Souter LH, et al. Screening for lung cancer: CHEST Guideline and Expert Panel Report. CHEST. 2021;160:E427-E494. doi: 10.1016/j.chest.2021.06.063
11. The National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395-409. doi: 10.1056/NEJMoa1102873
12. The National Lung Screening Trial Research Team. Results of initial low-dose computed tomographic screening for lung cancer. N Engl J Med. 2013;368:1980-1991. doi: 10.1056/NEJMoa1209120
13. de Koning HJ, van der Aalst CM, et al. Reduced lung-cancer mortality with volume CT screening in a randomized trial. N Engl J Med. 2020;382:503-513. doi: 10.1056/NEJMoa1911793
14. American Cancer Society. Lung cancer screening guidelines. Accessed October 14, 2022. www.cancer.org/health-care-professionals/american-cancer-society-prevention-early-detection-guidelines/lung-cancer-screening-guidelines.html
15. Pirie K, Peto R, Reeves GK, et al. The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK. Lancet. 2013;381:133-141. doi: 10.1016/S0140-6736(12)61720-6
16. Doll R, Peto R, Boreham J, et al. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ. 2004;328:1519. doi: 10.1136/bmj.38142.554479.AE
17. O’Keefe LM, Gemma T, Huxley R, et al. Smoking as a risk factor for lung cancer in women and men: a systematic review and meta-analysis. BMJ Open. 2018;8:e021611. doi: 10.1136/bmjopen-2018-021611
18. Criss SD, Pianpian C, Bastani M, et al. Cost-effectiveness analysis of lung cancer screening in the United States: a comparative modeling study. Ann Intern Med. 2019;171:796-805. doi: 10.7326/M19-0322
19. Lazris A, Roth RA. Lung cancer screening: pros and cons. Am Fam Physician. 2019;99:740-742.
20. Ali MU, Miller J, Peirson L, et al. Screening for lung cancer: a systematic review and meta-analysis. Prev Med. 2016;89:301-314. doi: 10.1016/j.ypmed.2016.04.015
21. Rampinelli C, De Marco P, Origgi D, et al. Exposure to low dose computed tomography for lung cancer screening and risk of cancer: secondary analysis of trial data and risk-benefit analysis. BMJ. 2017;356:j347. doi: 10.1136/bmj.j347
22. Manser RL, Lethaby A, Irving LB, et al. Screening for lung cancer. Cochrane Database Syst Rev. 2013;CD001991. doi: 10.1002/14651858.CD001991.pub3
23. Mazzone PJ, Silvestri GA, Patel S, et al. Screening for lung cancer: CHEST guideline and expert panel report. CHEST. 2018;153:954-985. doi: 10.1016/j.chest.2018.01.016
24. US Public Health Service Office of the Surgeon General; National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking. and Health. Smoking Cessation: A Report of the Surgeon General. US Department of Health and Human Services; 2020. www.ncbi.nlm.nih.gov/books/NBK555591/
25. Leone FT, Zhang Y, Evers-Casey S, et al, on behalf of the American Thoracic Society Assembly on Clinical Problems. Initiating pharmacologic treatment in tobacco-dependent adults: an official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2020;202:e5-e31. doi: 10.1164/rccm.202005-1982ST
CASE
A 51-year-old man presents to your office to discuss lung cancer screening. He has a history of hypertension and prediabetes. His father died of lung cancer 5 years ago, at age 77. The patient stopped smoking soon thereafter; prior to that, he smoked 1 pack of cigarettes per day for 20 years. He wants to know if he should be screened for lung cancer.
The relative lack of symptoms during the early stages of lung cancer frequently results in a delayed diagnosis. This, and the speed at which the disease progresses, underscores the need for an effective screening modality. More than half of people with lung cancer die within 1 year of diagnosis.1 Excluding skin cancer, lung cancer is the second most commonly diagnosed cancer, and more people die of lung cancer than of colon, breast, and prostate cancers combined.2 In 2022, it was estimated that there would be 236,740 new cases of lung cancer and 130,180 deaths from lung cancer.1,2 The average age at diagnosis is 70 years.2
Screening modalities: Only 1 has demonstrated mortality benefit
In 1968, Wilson and Junger3 outlined the characteristics of the ideal screening test for the World Health Organization: it should limit risk to the patient, be sensitive for detecting the disease early in its course, limit false-positive results, be acceptable to the patient, and be inexpensive to the health system.3 For decades, several screening modalities for lung cancer were trialed to fit the above guidance, but many of them fell short of the most important outcome: the impact on mortality.
Sputum cytology. The use of sputum cytology, either in combination with or without chest radiography, is not recommended. Several randomized controlled trials (RCTs) have failed to demonstrate improved lung cancer detection or mortality reduction in patients screened with this modality.4
Chest radiography (CXR). Several studies have assessed the efficacy of CXR as a screening modality. The best known was the Prostate, Lung, Colon, Ovarian (PLCO) Trial.5 This multicenter RCT enrolled more than 154,000 participants, half of whom received CXR at baseline and then annually for 3 years; the other half continued usual care (no screening). After 13 years of follow-up, there were no significant differences in lung cancer detection or mortality rates between the 2 groups.5
Low-dose computed tomography (LDCT). Several major medical societies recommend LDCT to screen high-risk individuals for lung cancer (TABLE 16-10). Results from 2 major RCTs have guided these recommendations.
The National Lung Screening Trial (NLST) was a multicenter RCT comparing 2 screening tests for lung cancer.11 Approximately 54,000 high-risk participants were enrolled between 2002 and 2004 and were randomized to receive annual screening with either LDCT or single-view CXR. The trial was discontinued prematurely when investigators noted a 20% reduction in lung cancer mortality in the LDCT group vs the CXR group.12 This equates to 3 fewer deaths for every 1000 people screened with LDCT vs CXR. There was also a 6% reduction in all-cause mortality noted in the LDCT vs the CXR group.12
Continue to: The NELSON trial...
The NELSON trial, conducted between 2005 and 2015, studied more than 15,000 current or former smokers ages 50 to 74 years and compared LDCT screening at various intervals to no screening.13 After 10 years, lung cancer–related mortality was reduced by 24% (or 1 less death per 1000 person-years) in men who were screened vs their unscreened counterparts.13 In contrast to the NLST, in the NELSON trial, no significant difference in all-cause mortality was observed. Subgroup analysis of the relatively small population of women included in the NELSON trial suggested a 33% reduction in 10-year mortality; however, the difference was nonsignificant between the screened and unscreened groups.13
Each of these landmark studies had characteristics that could limit the results' generalizability to the US population. In the NELSON trial, more than 80% of the study participants were male. In both trials, there was significant underrepresentation of Black, Asian, Hispanic, and other non-White people.12,13 Furthermore, participants in these studies were of higher socioeconomic status than the general US screening-eligible population.
At this time, LDCT is the only lung cancer screening modality that has shown benefit for both disease-related and all-cause mortality, in the populations that were studied. Based on the NLST, the number needed to screen (NNS) with LDCT to prevent 1 lung cancer–related death is 308. The NNS to prevent 1 death from any cause is 219.6
Updated evidence has led to a consensus on screening criteria
Many national societies endorse annual screening with LDCT in high-risk individuals (TABLE 16-10). Risk assessment for the purpose of lung cancer screening includes a detailed review of smoking history and age. The risk of lung cancer increases with advancing age and with cumulative quantity and duration of smoking, but decreases with increasing time since quitting. Therefore, a detailed smoking history should include total number of pack-years, current smoking status, and, if applicable, when smoking cessation occurred.
In 2021, the US Preventive Services Task Force (USPSTF) updated their 2013 lung cancer screening recommendations, expanding the screening age range and lowering the smoking history threshold for triggering initiation of screening.6 The impetus for the update was emerging evidence from systematic reviews, RCTs, and the Cancer Intervention and Surveillance Modeling Network (CISNET) that could help to determine the optimal age for screening and identify high-risk groups. For example, the NELSON trial, combined with results from CISNET modeling data, showed an empirical benefit for screening those ages 50 to 55 years.6
Continue to: As a result...
As a result, the USPSTF now recommends annual lung cancer screening with LDCT for any adult ages 50 to 80 years who has a 20-pack-year smoking history and currently smokes or has quit within the past 15 years.6 Screening should be discontinued once a person has not smoked for 15 years, develops a health problem that substantially limits life expectancy, or is not willing to have curative lung surgery.6
Expanding the screening eligibility may also address racial and gender disparities in health care. Black people and women who smoke have a higher risk for lung cancer at a lower intensity of smoking.6
Following the USPSTF update, the American College of Chest Physicians and the Centers for Medicare and Medicaid Services published updated guidance that aligns with USPSTF’s recommendations to lower the age and pack-year qualifications for initiating screening.7,10 The American Cancer Society is currently reviewing its 2018 guidelines on lung cancer screening.14TABLE 16-10 summarizes the guidance on lung cancer screening from these medical societies.
Effective screening could save lives (and money)
A smoker’s risk for lung cancer is 20 times higher than that of a nonsmoker15,16; 55% of lung cancer deaths in women and 70% in men are attributed to smoking.17 Once diagnosed with lung cancer, more than 50% of people will die within 1 year.1 This underpins the need for a lung cancer screening modality that reduces mortality. Large RCTs, including the NLST and NELSONtrials, have shown that screening high-risk individuals with LDCT can significantly reduce lung cancer–related death when compared to no screening or screening with CXR alone.11,13
There is controversy surrounding the cost benefit of implementing a nationwide lung cancer screening program. However, recent use of microsimulation models has shown LDCT to be a cost-effective strategy, with an average cost of $81,000 per quality-adjusted life-year, which is below the threshold of $100,000 to be considered cost effective.18 Expanding the upper age limit for screening leads to a greater reduction in mortality but increases treatment costs and overdiagnosis rates, and overall does not improve quality-adjusted life-years.18
Continue to: Potential harms
Potential harms: False-positives and related complications
Screening for lung cancer is not without its risks. Harms from screening typically result from false-positive test results leading to overdiagnosis, anxiety and distress, unnecessary invasive tests or procedures, and increased costs.19TABLE 26,19-23 lists specific complications from lung cancer screening with LDCT.
The false-positive rate is not trivial. For every 1000 patients screened, 250 people will have a positive LDCT finding but will not have lung cancer.19 Furthermore, about 1 in every 2000 individuals who screen positive, but who do not have lung cancer, die as a result of complications from the ensuing work-up.6
Annual LDCT screening increases the risk of radiation-induced cancer by approximately 0.05% over 10 years.21 The absolute risk is generally low but not insignificant. However, the mortality benefits previously outlined are significantly more robust in both absolute and relative terms vs the 10-year risk of radiation-induced cancer.
Lastly, it is important to note that the NELSON trial and NLST included a limited number of LDCT scans. Current guidelines for lung cancer screening with LDCT, including those from the USPSTF, recommend screening annually. We do not know the cumulative harm of annual LDCT over a 20- or 30-year period for those who would qualify (ie, current smokers).
If you screen, you must be able to act on the results
Effective screening programs should extend beyond the LDCT scan itself. The studies that have shown a benefit of LDCT were done at large academic centers that had the appropriate radiologic, pathologic, and surgical infrastructure to interpret and act on results and offer further diagnostic or treatment procedures.
Continue to: Prior to screening...
Prior to screening for lung cancer with LDCT, documentation of shared decision-making between the patient and the clinician is necessary.7 This discussion should include the potential benefits and harms of screening, potential results and likelihood of follow-up diagnostic testing, the false-positive rate of LDCT lung cancer screening, and cumulative radiation exposure. In addition, screening should be considered only if the patient is willing to be screened annually, is willing to pursue follow-up scans and procedures (including lung biopsy) if deemed necessary, and does not have comorbid conditions that significantly limit life expectancy.
Smoking cessation: The most important change to make
Smoking cessation is the single most important risk-modifying behavior to reduce one’s chance of developing lung cancer. At age 40, smokers have a 2-fold increase in all-cause mortality compared to age-matched nonsmokers. This rises to a 3-fold increase by the age of 70.16
Smoking cessation reduces the risk of lung cancer by 20% after 5 years, 30% to 50% after 10 years, and up to 70% after 15 years.24 In its guidelines, the American Thoracic Society recommends varenicline (Chantix) for all smokers to assist with smoking cessation.25
CASE
This 51-year-old patient with at least a 20-pack-year history of smoking should be commended for giving up smoking. Based on the USPSTF recommendations, he should be screened annually with LDCT for the next 10 years.
Screening to save more lives
The results of 2 large multicenter RCTs have led to the recent recommendation for lung cancer screening of high-risk adults with the use of LDCT. Screening with LDCT has been shown to reduce disease-related mortality and likely be cost effective in the long term.
Screening with LDCT should be part of a multidisciplinary system that has the infrastructure not only to perform the screening, but also to diagnose and appropriately follow up and treat patients whose results are concerning. The risk of false-positive results leading to increased anxiety, overdiagnosis, and unnecessary procedures points to the importance of proper patient selection, counseling, and shared decision-making. Smoking cessation remains the most important disease-modifying behavior one can make to reduce their risk for lung cancer.
CORRESPONDENCE
Carlton J. Covey, MD, 101 Bodin Circle, David Grant Medical Center, Travis Air Force Base, Fairfield, CA, 94545; carlcovey24@gmail.com
CASE
A 51-year-old man presents to your office to discuss lung cancer screening. He has a history of hypertension and prediabetes. His father died of lung cancer 5 years ago, at age 77. The patient stopped smoking soon thereafter; prior to that, he smoked 1 pack of cigarettes per day for 20 years. He wants to know if he should be screened for lung cancer.
The relative lack of symptoms during the early stages of lung cancer frequently results in a delayed diagnosis. This, and the speed at which the disease progresses, underscores the need for an effective screening modality. More than half of people with lung cancer die within 1 year of diagnosis.1 Excluding skin cancer, lung cancer is the second most commonly diagnosed cancer, and more people die of lung cancer than of colon, breast, and prostate cancers combined.2 In 2022, it was estimated that there would be 236,740 new cases of lung cancer and 130,180 deaths from lung cancer.1,2 The average age at diagnosis is 70 years.2
Screening modalities: Only 1 has demonstrated mortality benefit
In 1968, Wilson and Junger3 outlined the characteristics of the ideal screening test for the World Health Organization: it should limit risk to the patient, be sensitive for detecting the disease early in its course, limit false-positive results, be acceptable to the patient, and be inexpensive to the health system.3 For decades, several screening modalities for lung cancer were trialed to fit the above guidance, but many of them fell short of the most important outcome: the impact on mortality.
Sputum cytology. The use of sputum cytology, either in combination with or without chest radiography, is not recommended. Several randomized controlled trials (RCTs) have failed to demonstrate improved lung cancer detection or mortality reduction in patients screened with this modality.4
Chest radiography (CXR). Several studies have assessed the efficacy of CXR as a screening modality. The best known was the Prostate, Lung, Colon, Ovarian (PLCO) Trial.5 This multicenter RCT enrolled more than 154,000 participants, half of whom received CXR at baseline and then annually for 3 years; the other half continued usual care (no screening). After 13 years of follow-up, there were no significant differences in lung cancer detection or mortality rates between the 2 groups.5
Low-dose computed tomography (LDCT). Several major medical societies recommend LDCT to screen high-risk individuals for lung cancer (TABLE 16-10). Results from 2 major RCTs have guided these recommendations.
The National Lung Screening Trial (NLST) was a multicenter RCT comparing 2 screening tests for lung cancer.11 Approximately 54,000 high-risk participants were enrolled between 2002 and 2004 and were randomized to receive annual screening with either LDCT or single-view CXR. The trial was discontinued prematurely when investigators noted a 20% reduction in lung cancer mortality in the LDCT group vs the CXR group.12 This equates to 3 fewer deaths for every 1000 people screened with LDCT vs CXR. There was also a 6% reduction in all-cause mortality noted in the LDCT vs the CXR group.12
Continue to: The NELSON trial...
The NELSON trial, conducted between 2005 and 2015, studied more than 15,000 current or former smokers ages 50 to 74 years and compared LDCT screening at various intervals to no screening.13 After 10 years, lung cancer–related mortality was reduced by 24% (or 1 less death per 1000 person-years) in men who were screened vs their unscreened counterparts.13 In contrast to the NLST, in the NELSON trial, no significant difference in all-cause mortality was observed. Subgroup analysis of the relatively small population of women included in the NELSON trial suggested a 33% reduction in 10-year mortality; however, the difference was nonsignificant between the screened and unscreened groups.13
Each of these landmark studies had characteristics that could limit the results' generalizability to the US population. In the NELSON trial, more than 80% of the study participants were male. In both trials, there was significant underrepresentation of Black, Asian, Hispanic, and other non-White people.12,13 Furthermore, participants in these studies were of higher socioeconomic status than the general US screening-eligible population.
At this time, LDCT is the only lung cancer screening modality that has shown benefit for both disease-related and all-cause mortality, in the populations that were studied. Based on the NLST, the number needed to screen (NNS) with LDCT to prevent 1 lung cancer–related death is 308. The NNS to prevent 1 death from any cause is 219.6
Updated evidence has led to a consensus on screening criteria
Many national societies endorse annual screening with LDCT in high-risk individuals (TABLE 16-10). Risk assessment for the purpose of lung cancer screening includes a detailed review of smoking history and age. The risk of lung cancer increases with advancing age and with cumulative quantity and duration of smoking, but decreases with increasing time since quitting. Therefore, a detailed smoking history should include total number of pack-years, current smoking status, and, if applicable, when smoking cessation occurred.
In 2021, the US Preventive Services Task Force (USPSTF) updated their 2013 lung cancer screening recommendations, expanding the screening age range and lowering the smoking history threshold for triggering initiation of screening.6 The impetus for the update was emerging evidence from systematic reviews, RCTs, and the Cancer Intervention and Surveillance Modeling Network (CISNET) that could help to determine the optimal age for screening and identify high-risk groups. For example, the NELSON trial, combined with results from CISNET modeling data, showed an empirical benefit for screening those ages 50 to 55 years.6
Continue to: As a result...
As a result, the USPSTF now recommends annual lung cancer screening with LDCT for any adult ages 50 to 80 years who has a 20-pack-year smoking history and currently smokes or has quit within the past 15 years.6 Screening should be discontinued once a person has not smoked for 15 years, develops a health problem that substantially limits life expectancy, or is not willing to have curative lung surgery.6
Expanding the screening eligibility may also address racial and gender disparities in health care. Black people and women who smoke have a higher risk for lung cancer at a lower intensity of smoking.6
Following the USPSTF update, the American College of Chest Physicians and the Centers for Medicare and Medicaid Services published updated guidance that aligns with USPSTF’s recommendations to lower the age and pack-year qualifications for initiating screening.7,10 The American Cancer Society is currently reviewing its 2018 guidelines on lung cancer screening.14TABLE 16-10 summarizes the guidance on lung cancer screening from these medical societies.
Effective screening could save lives (and money)
A smoker’s risk for lung cancer is 20 times higher than that of a nonsmoker15,16; 55% of lung cancer deaths in women and 70% in men are attributed to smoking.17 Once diagnosed with lung cancer, more than 50% of people will die within 1 year.1 This underpins the need for a lung cancer screening modality that reduces mortality. Large RCTs, including the NLST and NELSONtrials, have shown that screening high-risk individuals with LDCT can significantly reduce lung cancer–related death when compared to no screening or screening with CXR alone.11,13
There is controversy surrounding the cost benefit of implementing a nationwide lung cancer screening program. However, recent use of microsimulation models has shown LDCT to be a cost-effective strategy, with an average cost of $81,000 per quality-adjusted life-year, which is below the threshold of $100,000 to be considered cost effective.18 Expanding the upper age limit for screening leads to a greater reduction in mortality but increases treatment costs and overdiagnosis rates, and overall does not improve quality-adjusted life-years.18
Continue to: Potential harms
Potential harms: False-positives and related complications
Screening for lung cancer is not without its risks. Harms from screening typically result from false-positive test results leading to overdiagnosis, anxiety and distress, unnecessary invasive tests or procedures, and increased costs.19TABLE 26,19-23 lists specific complications from lung cancer screening with LDCT.
The false-positive rate is not trivial. For every 1000 patients screened, 250 people will have a positive LDCT finding but will not have lung cancer.19 Furthermore, about 1 in every 2000 individuals who screen positive, but who do not have lung cancer, die as a result of complications from the ensuing work-up.6
Annual LDCT screening increases the risk of radiation-induced cancer by approximately 0.05% over 10 years.21 The absolute risk is generally low but not insignificant. However, the mortality benefits previously outlined are significantly more robust in both absolute and relative terms vs the 10-year risk of radiation-induced cancer.
Lastly, it is important to note that the NELSON trial and NLST included a limited number of LDCT scans. Current guidelines for lung cancer screening with LDCT, including those from the USPSTF, recommend screening annually. We do not know the cumulative harm of annual LDCT over a 20- or 30-year period for those who would qualify (ie, current smokers).
If you screen, you must be able to act on the results
Effective screening programs should extend beyond the LDCT scan itself. The studies that have shown a benefit of LDCT were done at large academic centers that had the appropriate radiologic, pathologic, and surgical infrastructure to interpret and act on results and offer further diagnostic or treatment procedures.
Continue to: Prior to screening...
Prior to screening for lung cancer with LDCT, documentation of shared decision-making between the patient and the clinician is necessary.7 This discussion should include the potential benefits and harms of screening, potential results and likelihood of follow-up diagnostic testing, the false-positive rate of LDCT lung cancer screening, and cumulative radiation exposure. In addition, screening should be considered only if the patient is willing to be screened annually, is willing to pursue follow-up scans and procedures (including lung biopsy) if deemed necessary, and does not have comorbid conditions that significantly limit life expectancy.
Smoking cessation: The most important change to make
Smoking cessation is the single most important risk-modifying behavior to reduce one’s chance of developing lung cancer. At age 40, smokers have a 2-fold increase in all-cause mortality compared to age-matched nonsmokers. This rises to a 3-fold increase by the age of 70.16
Smoking cessation reduces the risk of lung cancer by 20% after 5 years, 30% to 50% after 10 years, and up to 70% after 15 years.24 In its guidelines, the American Thoracic Society recommends varenicline (Chantix) for all smokers to assist with smoking cessation.25
CASE
This 51-year-old patient with at least a 20-pack-year history of smoking should be commended for giving up smoking. Based on the USPSTF recommendations, he should be screened annually with LDCT for the next 10 years.
Screening to save more lives
The results of 2 large multicenter RCTs have led to the recent recommendation for lung cancer screening of high-risk adults with the use of LDCT. Screening with LDCT has been shown to reduce disease-related mortality and likely be cost effective in the long term.
Screening with LDCT should be part of a multidisciplinary system that has the infrastructure not only to perform the screening, but also to diagnose and appropriately follow up and treat patients whose results are concerning. The risk of false-positive results leading to increased anxiety, overdiagnosis, and unnecessary procedures points to the importance of proper patient selection, counseling, and shared decision-making. Smoking cessation remains the most important disease-modifying behavior one can make to reduce their risk for lung cancer.
CORRESPONDENCE
Carlton J. Covey, MD, 101 Bodin Circle, David Grant Medical Center, Travis Air Force Base, Fairfield, CA, 94545; carlcovey24@gmail.com
1. National Cancer Institute. Cancer Stat Facts: lung and bronchus cancer. Accessed October 12, 2022. https://seer.cancer.gov/statfacts/html/lungb.html
2. American Cancer Society. Key statistics for lung cancer. Accessed October 12, 2022. https://www.cancer.org/cancer/lung-cancer/about/key-statistics.html
3. Wilson JMG, Junger G. Principles and Practice of Screening for Disease. World Health Organization; 1968:21-25, 100. https://apps.who.int/iris/handle/10665/37650
4. Humphrey LL, Teutsch S, Johnson M. Lung cancer screening with sputum cytologic examination, chest radiography, and computed tomography: an update for the United States preventive services task force. Ann Intern Med. 2004;140:740-753. doi: 10.7326/0003-4819-140-9-200405040-00015
5. Oken MM, Hocking WG, Kvale PA, et al. Screening by chest radiograph and lung cancer mortality: the Prostate, Lung, Colorectal, and Ovarian (PLCO) randomized trial. JAMA. 2011;306:1865-1873. doi: 10.1001/jama.2011.1591
6. US Preventive Services Task Force. Screening for lung cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325:962-970. doi: 10.1001/jama.2021.1117
7. Centers for Medicare & Medicaid Services. Screening for lung cancer with low dose computed tomography (LDCT) (CAG-00439R). Accessed October 14, 2022. www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=304
8. Smith RA, Andrews KS, Brooks D, et al. Cancer screening in the United States, 2018: a review of current American Cancer Society guidelines and current issues in cancer screening. CA Cancer J Clin. 2018;68:297-316. doi: 10.3322/caac.21446
9. American Academy of Family Physicians. AAFP updates recommendation on lung cancer screening. Published April 6, 2021. Accessed October 12, 2022. www.aafp.org/news/health-of-the-public/20210406lungcancer.html
10. Mazzone PJ, Silvestri GA, Souter LH, et al. Screening for lung cancer: CHEST Guideline and Expert Panel Report. CHEST. 2021;160:E427-E494. doi: 10.1016/j.chest.2021.06.063
11. The National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395-409. doi: 10.1056/NEJMoa1102873
12. The National Lung Screening Trial Research Team. Results of initial low-dose computed tomographic screening for lung cancer. N Engl J Med. 2013;368:1980-1991. doi: 10.1056/NEJMoa1209120
13. de Koning HJ, van der Aalst CM, et al. Reduced lung-cancer mortality with volume CT screening in a randomized trial. N Engl J Med. 2020;382:503-513. doi: 10.1056/NEJMoa1911793
14. American Cancer Society. Lung cancer screening guidelines. Accessed October 14, 2022. www.cancer.org/health-care-professionals/american-cancer-society-prevention-early-detection-guidelines/lung-cancer-screening-guidelines.html
15. Pirie K, Peto R, Reeves GK, et al. The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK. Lancet. 2013;381:133-141. doi: 10.1016/S0140-6736(12)61720-6
16. Doll R, Peto R, Boreham J, et al. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ. 2004;328:1519. doi: 10.1136/bmj.38142.554479.AE
17. O’Keefe LM, Gemma T, Huxley R, et al. Smoking as a risk factor for lung cancer in women and men: a systematic review and meta-analysis. BMJ Open. 2018;8:e021611. doi: 10.1136/bmjopen-2018-021611
18. Criss SD, Pianpian C, Bastani M, et al. Cost-effectiveness analysis of lung cancer screening in the United States: a comparative modeling study. Ann Intern Med. 2019;171:796-805. doi: 10.7326/M19-0322
19. Lazris A, Roth RA. Lung cancer screening: pros and cons. Am Fam Physician. 2019;99:740-742.
20. Ali MU, Miller J, Peirson L, et al. Screening for lung cancer: a systematic review and meta-analysis. Prev Med. 2016;89:301-314. doi: 10.1016/j.ypmed.2016.04.015
21. Rampinelli C, De Marco P, Origgi D, et al. Exposure to low dose computed tomography for lung cancer screening and risk of cancer: secondary analysis of trial data and risk-benefit analysis. BMJ. 2017;356:j347. doi: 10.1136/bmj.j347
22. Manser RL, Lethaby A, Irving LB, et al. Screening for lung cancer. Cochrane Database Syst Rev. 2013;CD001991. doi: 10.1002/14651858.CD001991.pub3
23. Mazzone PJ, Silvestri GA, Patel S, et al. Screening for lung cancer: CHEST guideline and expert panel report. CHEST. 2018;153:954-985. doi: 10.1016/j.chest.2018.01.016
24. US Public Health Service Office of the Surgeon General; National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking. and Health. Smoking Cessation: A Report of the Surgeon General. US Department of Health and Human Services; 2020. www.ncbi.nlm.nih.gov/books/NBK555591/
25. Leone FT, Zhang Y, Evers-Casey S, et al, on behalf of the American Thoracic Society Assembly on Clinical Problems. Initiating pharmacologic treatment in tobacco-dependent adults: an official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2020;202:e5-e31. doi: 10.1164/rccm.202005-1982ST
1. National Cancer Institute. Cancer Stat Facts: lung and bronchus cancer. Accessed October 12, 2022. https://seer.cancer.gov/statfacts/html/lungb.html
2. American Cancer Society. Key statistics for lung cancer. Accessed October 12, 2022. https://www.cancer.org/cancer/lung-cancer/about/key-statistics.html
3. Wilson JMG, Junger G. Principles and Practice of Screening for Disease. World Health Organization; 1968:21-25, 100. https://apps.who.int/iris/handle/10665/37650
4. Humphrey LL, Teutsch S, Johnson M. Lung cancer screening with sputum cytologic examination, chest radiography, and computed tomography: an update for the United States preventive services task force. Ann Intern Med. 2004;140:740-753. doi: 10.7326/0003-4819-140-9-200405040-00015
5. Oken MM, Hocking WG, Kvale PA, et al. Screening by chest radiograph and lung cancer mortality: the Prostate, Lung, Colorectal, and Ovarian (PLCO) randomized trial. JAMA. 2011;306:1865-1873. doi: 10.1001/jama.2011.1591
6. US Preventive Services Task Force. Screening for lung cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325:962-970. doi: 10.1001/jama.2021.1117
7. Centers for Medicare & Medicaid Services. Screening for lung cancer with low dose computed tomography (LDCT) (CAG-00439R). Accessed October 14, 2022. www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=304
8. Smith RA, Andrews KS, Brooks D, et al. Cancer screening in the United States, 2018: a review of current American Cancer Society guidelines and current issues in cancer screening. CA Cancer J Clin. 2018;68:297-316. doi: 10.3322/caac.21446
9. American Academy of Family Physicians. AAFP updates recommendation on lung cancer screening. Published April 6, 2021. Accessed October 12, 2022. www.aafp.org/news/health-of-the-public/20210406lungcancer.html
10. Mazzone PJ, Silvestri GA, Souter LH, et al. Screening for lung cancer: CHEST Guideline and Expert Panel Report. CHEST. 2021;160:E427-E494. doi: 10.1016/j.chest.2021.06.063
11. The National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395-409. doi: 10.1056/NEJMoa1102873
12. The National Lung Screening Trial Research Team. Results of initial low-dose computed tomographic screening for lung cancer. N Engl J Med. 2013;368:1980-1991. doi: 10.1056/NEJMoa1209120
13. de Koning HJ, van der Aalst CM, et al. Reduced lung-cancer mortality with volume CT screening in a randomized trial. N Engl J Med. 2020;382:503-513. doi: 10.1056/NEJMoa1911793
14. American Cancer Society. Lung cancer screening guidelines. Accessed October 14, 2022. www.cancer.org/health-care-professionals/american-cancer-society-prevention-early-detection-guidelines/lung-cancer-screening-guidelines.html
15. Pirie K, Peto R, Reeves GK, et al. The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK. Lancet. 2013;381:133-141. doi: 10.1016/S0140-6736(12)61720-6
16. Doll R, Peto R, Boreham J, et al. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ. 2004;328:1519. doi: 10.1136/bmj.38142.554479.AE
17. O’Keefe LM, Gemma T, Huxley R, et al. Smoking as a risk factor for lung cancer in women and men: a systematic review and meta-analysis. BMJ Open. 2018;8:e021611. doi: 10.1136/bmjopen-2018-021611
18. Criss SD, Pianpian C, Bastani M, et al. Cost-effectiveness analysis of lung cancer screening in the United States: a comparative modeling study. Ann Intern Med. 2019;171:796-805. doi: 10.7326/M19-0322
19. Lazris A, Roth RA. Lung cancer screening: pros and cons. Am Fam Physician. 2019;99:740-742.
20. Ali MU, Miller J, Peirson L, et al. Screening for lung cancer: a systematic review and meta-analysis. Prev Med. 2016;89:301-314. doi: 10.1016/j.ypmed.2016.04.015
21. Rampinelli C, De Marco P, Origgi D, et al. Exposure to low dose computed tomography for lung cancer screening and risk of cancer: secondary analysis of trial data and risk-benefit analysis. BMJ. 2017;356:j347. doi: 10.1136/bmj.j347
22. Manser RL, Lethaby A, Irving LB, et al. Screening for lung cancer. Cochrane Database Syst Rev. 2013;CD001991. doi: 10.1002/14651858.CD001991.pub3
23. Mazzone PJ, Silvestri GA, Patel S, et al. Screening for lung cancer: CHEST guideline and expert panel report. CHEST. 2018;153:954-985. doi: 10.1016/j.chest.2018.01.016
24. US Public Health Service Office of the Surgeon General; National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking. and Health. Smoking Cessation: A Report of the Surgeon General. US Department of Health and Human Services; 2020. www.ncbi.nlm.nih.gov/books/NBK555591/
25. Leone FT, Zhang Y, Evers-Casey S, et al, on behalf of the American Thoracic Society Assembly on Clinical Problems. Initiating pharmacologic treatment in tobacco-dependent adults: an official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2020;202:e5-e31. doi: 10.1164/rccm.202005-1982ST
PRACTICE RECOMMENDATIONS
› Recommend annual lung cancer screening for all highrisk adults ages 50 to 80 years using low-dose computed tomography. A
› Do not pursue lung cancer screening in patients who quit smoking ≥ 15 years ago, have a health problem that limits their life expectancy, or are unwilling to undergo lung surgery. A
› Recommend varenicline as first-line pharmacotherapy for smokers who would like to quit. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Plantar Fasciitis: How Best to Treat?
› Use plantar fascia specific stretching to decrease pain in patients with plantar fasciitis. A
› Consider recommending prefabricated orthoses, including night splints, to decrease pain. A
› Consider using extracorporeal shock wave therapy for plantar fascial pain. A
Strength of recommendation (SOR)
A. Good-quality patient-oriented evidence
B. Inconsistent or limited-quality patient-oriented evidence
C. Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE A 43-year-old obese woman seeks advice for left heel pain she has had for 2 months. Before the onset of pain, her activity level had increased as part of a weight loss program. Her pain is at its worst in the morning, with her first few steps; it decreases with continued walking and intensifies again after being on her feet all day. There is no history of trauma, and she reports no paresthesias or radiation of the pain. Her medical history is otherwise unremarkable. She has used ibuprofen sparingly, with limited relief.
If you were this patient’s physician, how would you proceed with her care?
Plantar fasciitis (PF) is a common cause of heel pain that affects up to 10% of the US population and accounts for approximately 600,000 outpatient visits annually.1 The plantar fascia is a dense, fibrous membrane spanning the length of the foot. It originates at the medial calcaneal tubercle, attaches to the phalanges, and provides stability and arch support to the foot. The etiology of PF is unknown, but predisposing factors include overtraining, obesity, pes planus, decreased ankle dorsiflexion, and inappropriate footwear.2 Limited dorsiflexion due to tightness of the Achilles tendon strains the plantar fascia and can lead to PF. Histology shows minimal inflammatory changes, and some experts advocate the term plantar fasciosis to counter the misperception that it is primarily an inflammatory condition.3
A patient’s history and physical exam findings are the basis for confirming or dismissing a diagnosis of PF. Radiologic studies, used judiciously, can rule out important alternative diagnoses that should not be overlooked. Multiple treatment options range from conservative to surgical interventions, although studies of the effectiveness of each modality have had conflicting results. Clinical practice guidelines generally advocate a stepwise approach to treatment.
Diagnosis
The differential diagnosis of PF (TABLE) includes significant disorders such as calcaneal stress fracture, entrapment neuropathies (eg, tarsal tunnel syndrome), calcaneal tumor, Paget’s disease, and systemic arthritidies.4,5
What to look for in the history and physical exam
Severe heel pain upon initial weight bearing in the morning or after prolonged periods of inactivity is pathognomonic for PF.2 Initially the pain presents diffusely, but over time it localizes to the area of the medial calcaneal tubercle. Pain typically subsides with activity but may return with prolonged weight bearing, as it did with the patient in the opening case.
Test range of motion of the foot and ankle. Although this is not needed for diagnosing PF, some patients will exhibit limited ankle dorsiflexion, a predisposing factor for PF.4,6 Look for heel pad swelling, inflammation, or atrophy, and palpate the heel, plantar fascia, and calcaneal tubercle. Lastly, evaluate for gait abnormalities and the presence of sensory deficits or hypesthesias.4
The most common exam finding in PF is pain at the medial calcaneal tubercle, which may be exacerbated with passive ankle dorsiflexion or first digit extension.2,4 If paresthesias occur with percussion inferior to the medial malleolus, suspect possible nerve entrapment or tarsal tunnel syndrome. Tenderness with heel compression (squeeze test) may indicate a calcaneal fracture or apophysitis.
Imaging is useful to rule out alternative disorders
Radiologic studies generally do not contribute to the diagnosis or management of PF, but they can assist in ruling out alternative causes of heel pain or in reevaluation if symptoms of PF persist after 3 to 6 months of treatment.
Plain films lack the sensitivity to detect plantar fasciitis. While a plantar calcaneal spur is often seen on radiography, it does not confirm the diagnosis, correlate with severity of symptoms, or predict prognosis.4 Despite this deficiency, plain radiography remains the initial choice of imaging modalities, particularly to rule out other conditions.
Ultrasound accurately diagnoses plantar fasciitis. Plantar fascia thickness of more than 4.0 mm is diagnostic of PF.7 Additionally, a decrease in plantar fascia thickness correlates with a decrease in pain levels, and thus ultrasound can aid in monitoring treatment progress.8 If results of plain films and ultrasound are inconclusive and clinical concern for an alternative diagnosis warrants additional expense, consider arranging for magnetic resonance imaging.9
Noninvasive treatments
Conservative therapies remain the preferred approach to treating PF, successfully managing 85% to 90% of cases.10,11 A 2010 clinical practice guideline from the American College of Foot and Ankle Surgeons recommends conservative treatments such as nonsteroidal inflammatory drugs (NSAIDs), stretching, and prefabricated orthotics for the initial management of plantar heel pain.4 Emphasize to patients that it may take 6 to 12 months for symptoms to resolve.4
Stretching and trigger-point manual therapy are effective
The traditional primary treatment modality for PF has been early initiation of an Achilles-soleus (heel-cord) muscle–stretching program. However, studies have shown that plantar fascia–specific stretching (PFSS) (FIGURE) significantly diminishes or eliminates heel pain when compared with traditional stretching movements, and is useful in treating chronic recalcitrant heel pain.12,13 PFSS has also yielded results superior to low-dose shock wave therapy.14
In a 2011 study, adding myofascial trigger-point manual therapy to a PFSS routine improved self-reported physical function and pain vs stretching alone.15 This manual therapy technique is specialized and should be administered only by trained physical therapists. Data are limited and mixed regarding the effectiveness of deep tissue massage, iontophoresis, or eccentric stretching of the plantar fascia to alleviate plantar fascial pain. Support for therapies such as rest, ice, heat, and massage has largely been anecdotal.
NSAIDs for PF lack good evidence
Nonsteroidal anti-inflammatory drugs (NSAIDs) are often prescribed to treat PF, despite a lack of evidence supporting their use. A small randomized, placebo-controlled double-blind study established a trend toward improvement in pain and disability scores with the use of NSAIDs. However, no statistically significant difference was noted in the measures between the NSAID and placebo groups at 1, 2, and 6 months.16 We found no studies that demonstrate a significant reduction in pain or improvement in function with the use of NSAIDs alone.
Although NSAIDs carry their own risks, they may work for some patients. And studies showing a lack of significant pain reduction may have been underpowered. If patients are willing to accept the risks of NSAID use, it would be reasonable to prescribe a therapeutic trial.
Orthotics and night splints can help, depending on comfort and compliance
Foot orthotics help prevent overpronation and attenuate tensile forces on the plantar fascia. A 2009 meta-analysis confirmed that both prefabricated and custom-made foot orthotics can decrease pain.17 One prospective study showed that 95% of patients had improvement in PF symptoms after 8 weeks of treatment with prefabricated orthotics.18 A Cochrane review found no difference in pain reduction between custom and prefabricated foot orthotics.19 A recent study demonstrated that rocker sole shoes—a type of therapeutic footwear with a more rounded outsole contour—combined with custom orthotics significantly reduced pain during walking compared with either modality alone.20 More research needs to be conducted into the use of rocker sole shoes before recommending them to PF patients.
Night splints help keep the foot and ankle in a neutral position, or slightly dorsiflexed, while patients sleep. Several studies have shown a reduction in pain with the use of night splints alone.17,21,22 Patient comfort and compliance tend to be the limiting factors in their use. Anterior splints are better tolerated than posterior splints.23
Shock wave therapy has better long-term results than steroid injections
Shock waves used to treat PF are thought to invoke extracellular responses that cause neovascularization and induce tissue repair and regeneration. A 2012 review article concluded that most research confirms that extracorporeal shock wave therapy (ESWT) reduces PF pain and improves function in 34% to 88% of cases.24 ESWT is comparable to surgical plantar fasciotomy without the operative risks, and yields better long-term effects in recalcitrant PF compared with corticosteroid injections (CSI).24 Many studies are underway to validate the effectiveness of ESWT. Currently, expense or lack of availability limits its use in some communities.
Invasive treatments
Corticosteroid injections may be used for more than just refractory pain
CSI have historically been reserved for recalcitrant heel pain. However, one systematic review cites evidence in support of CSI for the short-term management of plantar fascia pain.25 Compared with placebo, CSI reduces pain at both 6 and 12 weeks and decreases plantar fascia thickness.26 Additionally, the American College of Foot and Ankle Surgeons lists CSI as an acceptable first-line treatment for PF.4
The most common complication of CSI is postinjection pain. Other complications, such as fat pad atrophy, rarely occur.27 While the evidence is limited, CSI may be part of an initial approach to treating PF in addition to heel-cord or plantar fascia-specific stretching, particularly for patients who desire an expedited return to normal activity.
Platelet-rich plasma therapy holds promise
Platelet-rich plasma (PRP) has been gaining popularity as a treatment for PF pain. PRP is a component of whole blood that is centrifuged to a concentrated state, treated with an activating agent, and injected into the affected area. Theoretically, injected PRP increases the release of reparative growth factors, enhancing the healing process.28 PRP has been shown to be as effective in reducing pain scores as CSI at 3 weeks and 6 months.29 PRP also decreases plantar fascia thickness and improves pain scores and functional ability.30
To date, no trials have compared PRP with placebo injections. Postprocedural pain is the most common risk with PRP. While limited evidence exists, PRP seems to be a relatively safe and effective therapeutic alternative for treating chronic PF.
Surgery only when conservative measures fail
Reserve surgery for those who have not responded adequately after 6 to 12 months of conservative therapy.5 Endoscopic plantar fascia release is superior to traditional open surgery.31 Heel spur resection is no longer routinely practiced. Patients undergoing surgery should expect a return to normal activity in approximately 2 to 3 months, and up to 35% of patients may continue to have symptoms after surgical intervention.2,31
Treatment options in perspective
Treat conservatively at first. Stretching the plantar fascia and heel cord, using prefabricated orthotics, and wearing night splints are backed by firm clinical evidence of benefit. Acute treatment of PF may also include CSI, especially for patients who are athletic or otherwise active and wish to return to full function as soon as possible, and are willing to accept the risks associated with CSI.
ESWT improves pain and function scores and may also relieve pain in patients with recalcitrant PF pain. PRP has limited but promising evidence for patients with chronic PF pain. Surgical intervention remains the last line of therapy and is not always effective at reducing pain.
CASE You prescribe a conservative treatment program of plantar fascia–specific stretches and prefabricated orthoses for the patient in the opening scenario. At one month, her pain drops by 30%. At 6 months, her pain disappears, and she resumes a daily aerobic exercise program to assist in weight loss.
CORRESPONDENCE
Carlton J. Covey, MD, Nellis Family Medicine Residency, 99MDOS/SGOF, 4700 Las Vegas Boulevard N, Las Vegas, NV 89191;
carlton.covey@nellis.af.mil
1. Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int. 2004;25: 303-310.
2. Glazer JL. An approach to the diagnosis and treatment of plantar fasciitis. Phys Sportsmed. 2009;37:74-79.
3. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003;93:234-237.
4. Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heal pain: a clinical practice guideline – revision 2010. J Foot Ankle Surg. 2010;49(suppl):S1-S19.
5. Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treatment. J Am Acad Orthop Surg. 2008;16:338-346.
6. Singh D, Angel J, Bentley G, et al. Fortnightly review: plantar fasciitis. BMJ. 1997;315:172-175.
7. McMillan AM, Landorf KB, Barrett JT, et al. Diagnostic imaging for chronic plantar heel pain: a systematic review and metaanalysis. J Foot Ankle Res. 2009;2:32.
8. Mahowald S, Legge BS, Grady JF. The correlation between plantar fascia thickness and symptoms of plantar fasciitis. J Am Podiatr Med Assoc. 2011;101:385-389.
9. American College of Radiology. ACR appropriateness criteria. Chronic foot pain. Available at: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/ChronicFootPain.pdf. Accessed November 11, 2012.
10. Gill LH. Plantar fasciitis: diagnosis and conservative treatment. J Am Acad Orthop Surg. 1997;5:109-117.
11. Martin RL, Irrgang JJ, Conti SF. Outcome study of subjects with insertional plantar fasciitis. Foot Ankle Int. 1998;19:803-811.
12. DiGiovanni BF, Nawoczenski DA, Malay DP, et al. Plantar fasciaspecific stretching exercise improves outcomes in patients with chronic plantar fasciitis: a prospective clinic trial with two-year follow up. J Bone Joint Surg Am. 2006;88:1775-1781.
13. Sweeting D, Parish B, Hooper L, et al. The effectiveness of manual stretching in the treatment of plantar heel pain: a systemic review. J Foot Ankle Res. 2011;4:1-13.
14. Rompe JD, Cacchio A, Lowell W, et al. Plantar fascia-specific stretching versus radial shock-wave therapy as initial treatment of plantar fasciopathy. J Bone Joint Surg Am. 2010;92:2514-2522.
15. Renan-Ordine R, Alburquerque-Sendin F, Rodriques De Souza DP, et al. Effectiveness of myofascial trigger point manual therapy combined with a self stretching protocol for the management of plantar heel pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2011;41:43-50.
16. Donley BG, Moore T, Sferra J, et al. The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: a randomized, prospective, placebo-controlled study. Foot Ankle Int. 2007;28:20-23.
17. Lee SY, McKeon P, Hertel J. Does the use of orthoses improve selfreported pain and function measures in patients with plantar fasciitis? A meta-analysis. Phys Ther Sport. 2009;10:12-18.
18. Pfeffer G, Bacchetti P, Deland J, et al. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int. 1999;20:214-221.
19. Hawke F, Burns J, Radford JA, et al. Custom-made foot orthoses for the treatment of foot pain. Cochrane Database Syst Rev. 2008;(3):CD006801.
20. Fong DT, Pang KY, Chung MM, et al. Evaluation of combined prescription of rocker sole shoes and custom-made foot orthoses for the treatment of plantar fasciitis. Clin Biomech. 2012;27: 1072-1077.
21. Berlet GC, Anderson RB, Davis H. A prospective trial of night splinting in the treatment of recalcitrant plantar fasciitis: the Ankle Dorsiflexion Dynasplint. Orthopedics. 2002;25: 1273-1275.
22. Roos E, Engstrom M, Soderberg B. Foot orthoses for the treatment of plantar fasciitis. Foot Ankle Int. 2006;27:606-611.
23. Goff JD, Crawford R. Diagnosis and treatment of plantar fasciitis. Am Fam Physician. 2011;84:676-682.
24. Wang CJ. Extracorporeal shockwave therapy in musculoskeletal disorders. J Orthop Surg Res. 2012;7:11.
25. Landorf KB, Menz HB. Plantar heel pain and fasciitis. Clin Evid (Online). 2008;2008:1111.
26. Ball EM, McKeeman HM, Patterson C, et al. Steroid injection for inferior heel pain: a randomized controlled trial. Ann Rheum Dis. 2013;72:996-1002.
27. Uden H, Boesch E, Kumar S. Plantar fasciitis – to jab or support? A systematic review of the current best evidence. J Multidiscip Healthc. 2011;4:155-164.
28. Shetty VD. Platelet-rich plasma: a ‘feeling’ and ‘hope’ ailing athletes. Br J Sports Med. 2010;44(suppl 1):i1-i82.
29. Aksahin E, Dogruyol D, Yüksel HY, et al. The comparison of the effect of corticosteroids and platelet-rich plasma (PRP) for the treatment of plantar fasciitis. Arch Orthop Trauma Surg. 2012;132:781-785.
30. Ragab EM, Othman AM. Platelets rich plasma for treatment of chronic plantar fasciitis. Arch Orthop Trauma Surg. 2012;132:1065-1070.
31. Saxena A. Uniportal endoscopic plantar fasciotomy: a prospective study on athletic patients. Foot Ankle Int. 2004;25:882-889.
› Use plantar fascia specific stretching to decrease pain in patients with plantar fasciitis. A
› Consider recommending prefabricated orthoses, including night splints, to decrease pain. A
› Consider using extracorporeal shock wave therapy for plantar fascial pain. A
Strength of recommendation (SOR)
A. Good-quality patient-oriented evidence
B. Inconsistent or limited-quality patient-oriented evidence
C. Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE A 43-year-old obese woman seeks advice for left heel pain she has had for 2 months. Before the onset of pain, her activity level had increased as part of a weight loss program. Her pain is at its worst in the morning, with her first few steps; it decreases with continued walking and intensifies again after being on her feet all day. There is no history of trauma, and she reports no paresthesias or radiation of the pain. Her medical history is otherwise unremarkable. She has used ibuprofen sparingly, with limited relief.
If you were this patient’s physician, how would you proceed with her care?
Plantar fasciitis (PF) is a common cause of heel pain that affects up to 10% of the US population and accounts for approximately 600,000 outpatient visits annually.1 The plantar fascia is a dense, fibrous membrane spanning the length of the foot. It originates at the medial calcaneal tubercle, attaches to the phalanges, and provides stability and arch support to the foot. The etiology of PF is unknown, but predisposing factors include overtraining, obesity, pes planus, decreased ankle dorsiflexion, and inappropriate footwear.2 Limited dorsiflexion due to tightness of the Achilles tendon strains the plantar fascia and can lead to PF. Histology shows minimal inflammatory changes, and some experts advocate the term plantar fasciosis to counter the misperception that it is primarily an inflammatory condition.3
A patient’s history and physical exam findings are the basis for confirming or dismissing a diagnosis of PF. Radiologic studies, used judiciously, can rule out important alternative diagnoses that should not be overlooked. Multiple treatment options range from conservative to surgical interventions, although studies of the effectiveness of each modality have had conflicting results. Clinical practice guidelines generally advocate a stepwise approach to treatment.
Diagnosis
The differential diagnosis of PF (TABLE) includes significant disorders such as calcaneal stress fracture, entrapment neuropathies (eg, tarsal tunnel syndrome), calcaneal tumor, Paget’s disease, and systemic arthritidies.4,5
What to look for in the history and physical exam
Severe heel pain upon initial weight bearing in the morning or after prolonged periods of inactivity is pathognomonic for PF.2 Initially the pain presents diffusely, but over time it localizes to the area of the medial calcaneal tubercle. Pain typically subsides with activity but may return with prolonged weight bearing, as it did with the patient in the opening case.
Test range of motion of the foot and ankle. Although this is not needed for diagnosing PF, some patients will exhibit limited ankle dorsiflexion, a predisposing factor for PF.4,6 Look for heel pad swelling, inflammation, or atrophy, and palpate the heel, plantar fascia, and calcaneal tubercle. Lastly, evaluate for gait abnormalities and the presence of sensory deficits or hypesthesias.4
The most common exam finding in PF is pain at the medial calcaneal tubercle, which may be exacerbated with passive ankle dorsiflexion or first digit extension.2,4 If paresthesias occur with percussion inferior to the medial malleolus, suspect possible nerve entrapment or tarsal tunnel syndrome. Tenderness with heel compression (squeeze test) may indicate a calcaneal fracture or apophysitis.
Imaging is useful to rule out alternative disorders
Radiologic studies generally do not contribute to the diagnosis or management of PF, but they can assist in ruling out alternative causes of heel pain or in reevaluation if symptoms of PF persist after 3 to 6 months of treatment.
Plain films lack the sensitivity to detect plantar fasciitis. While a plantar calcaneal spur is often seen on radiography, it does not confirm the diagnosis, correlate with severity of symptoms, or predict prognosis.4 Despite this deficiency, plain radiography remains the initial choice of imaging modalities, particularly to rule out other conditions.
Ultrasound accurately diagnoses plantar fasciitis. Plantar fascia thickness of more than 4.0 mm is diagnostic of PF.7 Additionally, a decrease in plantar fascia thickness correlates with a decrease in pain levels, and thus ultrasound can aid in monitoring treatment progress.8 If results of plain films and ultrasound are inconclusive and clinical concern for an alternative diagnosis warrants additional expense, consider arranging for magnetic resonance imaging.9
Noninvasive treatments
Conservative therapies remain the preferred approach to treating PF, successfully managing 85% to 90% of cases.10,11 A 2010 clinical practice guideline from the American College of Foot and Ankle Surgeons recommends conservative treatments such as nonsteroidal inflammatory drugs (NSAIDs), stretching, and prefabricated orthotics for the initial management of plantar heel pain.4 Emphasize to patients that it may take 6 to 12 months for symptoms to resolve.4
Stretching and trigger-point manual therapy are effective
The traditional primary treatment modality for PF has been early initiation of an Achilles-soleus (heel-cord) muscle–stretching program. However, studies have shown that plantar fascia–specific stretching (PFSS) (FIGURE) significantly diminishes or eliminates heel pain when compared with traditional stretching movements, and is useful in treating chronic recalcitrant heel pain.12,13 PFSS has also yielded results superior to low-dose shock wave therapy.14
In a 2011 study, adding myofascial trigger-point manual therapy to a PFSS routine improved self-reported physical function and pain vs stretching alone.15 This manual therapy technique is specialized and should be administered only by trained physical therapists. Data are limited and mixed regarding the effectiveness of deep tissue massage, iontophoresis, or eccentric stretching of the plantar fascia to alleviate plantar fascial pain. Support for therapies such as rest, ice, heat, and massage has largely been anecdotal.
NSAIDs for PF lack good evidence
Nonsteroidal anti-inflammatory drugs (NSAIDs) are often prescribed to treat PF, despite a lack of evidence supporting their use. A small randomized, placebo-controlled double-blind study established a trend toward improvement in pain and disability scores with the use of NSAIDs. However, no statistically significant difference was noted in the measures between the NSAID and placebo groups at 1, 2, and 6 months.16 We found no studies that demonstrate a significant reduction in pain or improvement in function with the use of NSAIDs alone.
Although NSAIDs carry their own risks, they may work for some patients. And studies showing a lack of significant pain reduction may have been underpowered. If patients are willing to accept the risks of NSAID use, it would be reasonable to prescribe a therapeutic trial.
Orthotics and night splints can help, depending on comfort and compliance
Foot orthotics help prevent overpronation and attenuate tensile forces on the plantar fascia. A 2009 meta-analysis confirmed that both prefabricated and custom-made foot orthotics can decrease pain.17 One prospective study showed that 95% of patients had improvement in PF symptoms after 8 weeks of treatment with prefabricated orthotics.18 A Cochrane review found no difference in pain reduction between custom and prefabricated foot orthotics.19 A recent study demonstrated that rocker sole shoes—a type of therapeutic footwear with a more rounded outsole contour—combined with custom orthotics significantly reduced pain during walking compared with either modality alone.20 More research needs to be conducted into the use of rocker sole shoes before recommending them to PF patients.
Night splints help keep the foot and ankle in a neutral position, or slightly dorsiflexed, while patients sleep. Several studies have shown a reduction in pain with the use of night splints alone.17,21,22 Patient comfort and compliance tend to be the limiting factors in their use. Anterior splints are better tolerated than posterior splints.23
Shock wave therapy has better long-term results than steroid injections
Shock waves used to treat PF are thought to invoke extracellular responses that cause neovascularization and induce tissue repair and regeneration. A 2012 review article concluded that most research confirms that extracorporeal shock wave therapy (ESWT) reduces PF pain and improves function in 34% to 88% of cases.24 ESWT is comparable to surgical plantar fasciotomy without the operative risks, and yields better long-term effects in recalcitrant PF compared with corticosteroid injections (CSI).24 Many studies are underway to validate the effectiveness of ESWT. Currently, expense or lack of availability limits its use in some communities.
Invasive treatments
Corticosteroid injections may be used for more than just refractory pain
CSI have historically been reserved for recalcitrant heel pain. However, one systematic review cites evidence in support of CSI for the short-term management of plantar fascia pain.25 Compared with placebo, CSI reduces pain at both 6 and 12 weeks and decreases plantar fascia thickness.26 Additionally, the American College of Foot and Ankle Surgeons lists CSI as an acceptable first-line treatment for PF.4
The most common complication of CSI is postinjection pain. Other complications, such as fat pad atrophy, rarely occur.27 While the evidence is limited, CSI may be part of an initial approach to treating PF in addition to heel-cord or plantar fascia-specific stretching, particularly for patients who desire an expedited return to normal activity.
Platelet-rich plasma therapy holds promise
Platelet-rich plasma (PRP) has been gaining popularity as a treatment for PF pain. PRP is a component of whole blood that is centrifuged to a concentrated state, treated with an activating agent, and injected into the affected area. Theoretically, injected PRP increases the release of reparative growth factors, enhancing the healing process.28 PRP has been shown to be as effective in reducing pain scores as CSI at 3 weeks and 6 months.29 PRP also decreases plantar fascia thickness and improves pain scores and functional ability.30
To date, no trials have compared PRP with placebo injections. Postprocedural pain is the most common risk with PRP. While limited evidence exists, PRP seems to be a relatively safe and effective therapeutic alternative for treating chronic PF.
Surgery only when conservative measures fail
Reserve surgery for those who have not responded adequately after 6 to 12 months of conservative therapy.5 Endoscopic plantar fascia release is superior to traditional open surgery.31 Heel spur resection is no longer routinely practiced. Patients undergoing surgery should expect a return to normal activity in approximately 2 to 3 months, and up to 35% of patients may continue to have symptoms after surgical intervention.2,31
Treatment options in perspective
Treat conservatively at first. Stretching the plantar fascia and heel cord, using prefabricated orthotics, and wearing night splints are backed by firm clinical evidence of benefit. Acute treatment of PF may also include CSI, especially for patients who are athletic or otherwise active and wish to return to full function as soon as possible, and are willing to accept the risks associated with CSI.
ESWT improves pain and function scores and may also relieve pain in patients with recalcitrant PF pain. PRP has limited but promising evidence for patients with chronic PF pain. Surgical intervention remains the last line of therapy and is not always effective at reducing pain.
CASE You prescribe a conservative treatment program of plantar fascia–specific stretches and prefabricated orthoses for the patient in the opening scenario. At one month, her pain drops by 30%. At 6 months, her pain disappears, and she resumes a daily aerobic exercise program to assist in weight loss.
CORRESPONDENCE
Carlton J. Covey, MD, Nellis Family Medicine Residency, 99MDOS/SGOF, 4700 Las Vegas Boulevard N, Las Vegas, NV 89191;
carlton.covey@nellis.af.mil
› Use plantar fascia specific stretching to decrease pain in patients with plantar fasciitis. A
› Consider recommending prefabricated orthoses, including night splints, to decrease pain. A
› Consider using extracorporeal shock wave therapy for plantar fascial pain. A
Strength of recommendation (SOR)
A. Good-quality patient-oriented evidence
B. Inconsistent or limited-quality patient-oriented evidence
C. Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE A 43-year-old obese woman seeks advice for left heel pain she has had for 2 months. Before the onset of pain, her activity level had increased as part of a weight loss program. Her pain is at its worst in the morning, with her first few steps; it decreases with continued walking and intensifies again after being on her feet all day. There is no history of trauma, and she reports no paresthesias or radiation of the pain. Her medical history is otherwise unremarkable. She has used ibuprofen sparingly, with limited relief.
If you were this patient’s physician, how would you proceed with her care?
Plantar fasciitis (PF) is a common cause of heel pain that affects up to 10% of the US population and accounts for approximately 600,000 outpatient visits annually.1 The plantar fascia is a dense, fibrous membrane spanning the length of the foot. It originates at the medial calcaneal tubercle, attaches to the phalanges, and provides stability and arch support to the foot. The etiology of PF is unknown, but predisposing factors include overtraining, obesity, pes planus, decreased ankle dorsiflexion, and inappropriate footwear.2 Limited dorsiflexion due to tightness of the Achilles tendon strains the plantar fascia and can lead to PF. Histology shows minimal inflammatory changes, and some experts advocate the term plantar fasciosis to counter the misperception that it is primarily an inflammatory condition.3
A patient’s history and physical exam findings are the basis for confirming or dismissing a diagnosis of PF. Radiologic studies, used judiciously, can rule out important alternative diagnoses that should not be overlooked. Multiple treatment options range from conservative to surgical interventions, although studies of the effectiveness of each modality have had conflicting results. Clinical practice guidelines generally advocate a stepwise approach to treatment.
Diagnosis
The differential diagnosis of PF (TABLE) includes significant disorders such as calcaneal stress fracture, entrapment neuropathies (eg, tarsal tunnel syndrome), calcaneal tumor, Paget’s disease, and systemic arthritidies.4,5
What to look for in the history and physical exam
Severe heel pain upon initial weight bearing in the morning or after prolonged periods of inactivity is pathognomonic for PF.2 Initially the pain presents diffusely, but over time it localizes to the area of the medial calcaneal tubercle. Pain typically subsides with activity but may return with prolonged weight bearing, as it did with the patient in the opening case.
Test range of motion of the foot and ankle. Although this is not needed for diagnosing PF, some patients will exhibit limited ankle dorsiflexion, a predisposing factor for PF.4,6 Look for heel pad swelling, inflammation, or atrophy, and palpate the heel, plantar fascia, and calcaneal tubercle. Lastly, evaluate for gait abnormalities and the presence of sensory deficits or hypesthesias.4
The most common exam finding in PF is pain at the medial calcaneal tubercle, which may be exacerbated with passive ankle dorsiflexion or first digit extension.2,4 If paresthesias occur with percussion inferior to the medial malleolus, suspect possible nerve entrapment or tarsal tunnel syndrome. Tenderness with heel compression (squeeze test) may indicate a calcaneal fracture or apophysitis.
Imaging is useful to rule out alternative disorders
Radiologic studies generally do not contribute to the diagnosis or management of PF, but they can assist in ruling out alternative causes of heel pain or in reevaluation if symptoms of PF persist after 3 to 6 months of treatment.
Plain films lack the sensitivity to detect plantar fasciitis. While a plantar calcaneal spur is often seen on radiography, it does not confirm the diagnosis, correlate with severity of symptoms, or predict prognosis.4 Despite this deficiency, plain radiography remains the initial choice of imaging modalities, particularly to rule out other conditions.
Ultrasound accurately diagnoses plantar fasciitis. Plantar fascia thickness of more than 4.0 mm is diagnostic of PF.7 Additionally, a decrease in plantar fascia thickness correlates with a decrease in pain levels, and thus ultrasound can aid in monitoring treatment progress.8 If results of plain films and ultrasound are inconclusive and clinical concern for an alternative diagnosis warrants additional expense, consider arranging for magnetic resonance imaging.9
Noninvasive treatments
Conservative therapies remain the preferred approach to treating PF, successfully managing 85% to 90% of cases.10,11 A 2010 clinical practice guideline from the American College of Foot and Ankle Surgeons recommends conservative treatments such as nonsteroidal inflammatory drugs (NSAIDs), stretching, and prefabricated orthotics for the initial management of plantar heel pain.4 Emphasize to patients that it may take 6 to 12 months for symptoms to resolve.4
Stretching and trigger-point manual therapy are effective
The traditional primary treatment modality for PF has been early initiation of an Achilles-soleus (heel-cord) muscle–stretching program. However, studies have shown that plantar fascia–specific stretching (PFSS) (FIGURE) significantly diminishes or eliminates heel pain when compared with traditional stretching movements, and is useful in treating chronic recalcitrant heel pain.12,13 PFSS has also yielded results superior to low-dose shock wave therapy.14
In a 2011 study, adding myofascial trigger-point manual therapy to a PFSS routine improved self-reported physical function and pain vs stretching alone.15 This manual therapy technique is specialized and should be administered only by trained physical therapists. Data are limited and mixed regarding the effectiveness of deep tissue massage, iontophoresis, or eccentric stretching of the plantar fascia to alleviate plantar fascial pain. Support for therapies such as rest, ice, heat, and massage has largely been anecdotal.
NSAIDs for PF lack good evidence
Nonsteroidal anti-inflammatory drugs (NSAIDs) are often prescribed to treat PF, despite a lack of evidence supporting their use. A small randomized, placebo-controlled double-blind study established a trend toward improvement in pain and disability scores with the use of NSAIDs. However, no statistically significant difference was noted in the measures between the NSAID and placebo groups at 1, 2, and 6 months.16 We found no studies that demonstrate a significant reduction in pain or improvement in function with the use of NSAIDs alone.
Although NSAIDs carry their own risks, they may work for some patients. And studies showing a lack of significant pain reduction may have been underpowered. If patients are willing to accept the risks of NSAID use, it would be reasonable to prescribe a therapeutic trial.
Orthotics and night splints can help, depending on comfort and compliance
Foot orthotics help prevent overpronation and attenuate tensile forces on the plantar fascia. A 2009 meta-analysis confirmed that both prefabricated and custom-made foot orthotics can decrease pain.17 One prospective study showed that 95% of patients had improvement in PF symptoms after 8 weeks of treatment with prefabricated orthotics.18 A Cochrane review found no difference in pain reduction between custom and prefabricated foot orthotics.19 A recent study demonstrated that rocker sole shoes—a type of therapeutic footwear with a more rounded outsole contour—combined with custom orthotics significantly reduced pain during walking compared with either modality alone.20 More research needs to be conducted into the use of rocker sole shoes before recommending them to PF patients.
Night splints help keep the foot and ankle in a neutral position, or slightly dorsiflexed, while patients sleep. Several studies have shown a reduction in pain with the use of night splints alone.17,21,22 Patient comfort and compliance tend to be the limiting factors in their use. Anterior splints are better tolerated than posterior splints.23
Shock wave therapy has better long-term results than steroid injections
Shock waves used to treat PF are thought to invoke extracellular responses that cause neovascularization and induce tissue repair and regeneration. A 2012 review article concluded that most research confirms that extracorporeal shock wave therapy (ESWT) reduces PF pain and improves function in 34% to 88% of cases.24 ESWT is comparable to surgical plantar fasciotomy without the operative risks, and yields better long-term effects in recalcitrant PF compared with corticosteroid injections (CSI).24 Many studies are underway to validate the effectiveness of ESWT. Currently, expense or lack of availability limits its use in some communities.
Invasive treatments
Corticosteroid injections may be used for more than just refractory pain
CSI have historically been reserved for recalcitrant heel pain. However, one systematic review cites evidence in support of CSI for the short-term management of plantar fascia pain.25 Compared with placebo, CSI reduces pain at both 6 and 12 weeks and decreases plantar fascia thickness.26 Additionally, the American College of Foot and Ankle Surgeons lists CSI as an acceptable first-line treatment for PF.4
The most common complication of CSI is postinjection pain. Other complications, such as fat pad atrophy, rarely occur.27 While the evidence is limited, CSI may be part of an initial approach to treating PF in addition to heel-cord or plantar fascia-specific stretching, particularly for patients who desire an expedited return to normal activity.
Platelet-rich plasma therapy holds promise
Platelet-rich plasma (PRP) has been gaining popularity as a treatment for PF pain. PRP is a component of whole blood that is centrifuged to a concentrated state, treated with an activating agent, and injected into the affected area. Theoretically, injected PRP increases the release of reparative growth factors, enhancing the healing process.28 PRP has been shown to be as effective in reducing pain scores as CSI at 3 weeks and 6 months.29 PRP also decreases plantar fascia thickness and improves pain scores and functional ability.30
To date, no trials have compared PRP with placebo injections. Postprocedural pain is the most common risk with PRP. While limited evidence exists, PRP seems to be a relatively safe and effective therapeutic alternative for treating chronic PF.
Surgery only when conservative measures fail
Reserve surgery for those who have not responded adequately after 6 to 12 months of conservative therapy.5 Endoscopic plantar fascia release is superior to traditional open surgery.31 Heel spur resection is no longer routinely practiced. Patients undergoing surgery should expect a return to normal activity in approximately 2 to 3 months, and up to 35% of patients may continue to have symptoms after surgical intervention.2,31
Treatment options in perspective
Treat conservatively at first. Stretching the plantar fascia and heel cord, using prefabricated orthotics, and wearing night splints are backed by firm clinical evidence of benefit. Acute treatment of PF may also include CSI, especially for patients who are athletic or otherwise active and wish to return to full function as soon as possible, and are willing to accept the risks associated with CSI.
ESWT improves pain and function scores and may also relieve pain in patients with recalcitrant PF pain. PRP has limited but promising evidence for patients with chronic PF pain. Surgical intervention remains the last line of therapy and is not always effective at reducing pain.
CASE You prescribe a conservative treatment program of plantar fascia–specific stretches and prefabricated orthoses for the patient in the opening scenario. At one month, her pain drops by 30%. At 6 months, her pain disappears, and she resumes a daily aerobic exercise program to assist in weight loss.
CORRESPONDENCE
Carlton J. Covey, MD, Nellis Family Medicine Residency, 99MDOS/SGOF, 4700 Las Vegas Boulevard N, Las Vegas, NV 89191;
carlton.covey@nellis.af.mil
1. Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int. 2004;25: 303-310.
2. Glazer JL. An approach to the diagnosis and treatment of plantar fasciitis. Phys Sportsmed. 2009;37:74-79.
3. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003;93:234-237.
4. Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heal pain: a clinical practice guideline – revision 2010. J Foot Ankle Surg. 2010;49(suppl):S1-S19.
5. Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treatment. J Am Acad Orthop Surg. 2008;16:338-346.
6. Singh D, Angel J, Bentley G, et al. Fortnightly review: plantar fasciitis. BMJ. 1997;315:172-175.
7. McMillan AM, Landorf KB, Barrett JT, et al. Diagnostic imaging for chronic plantar heel pain: a systematic review and metaanalysis. J Foot Ankle Res. 2009;2:32.
8. Mahowald S, Legge BS, Grady JF. The correlation between plantar fascia thickness and symptoms of plantar fasciitis. J Am Podiatr Med Assoc. 2011;101:385-389.
9. American College of Radiology. ACR appropriateness criteria. Chronic foot pain. Available at: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/ChronicFootPain.pdf. Accessed November 11, 2012.
10. Gill LH. Plantar fasciitis: diagnosis and conservative treatment. J Am Acad Orthop Surg. 1997;5:109-117.
11. Martin RL, Irrgang JJ, Conti SF. Outcome study of subjects with insertional plantar fasciitis. Foot Ankle Int. 1998;19:803-811.
12. DiGiovanni BF, Nawoczenski DA, Malay DP, et al. Plantar fasciaspecific stretching exercise improves outcomes in patients with chronic plantar fasciitis: a prospective clinic trial with two-year follow up. J Bone Joint Surg Am. 2006;88:1775-1781.
13. Sweeting D, Parish B, Hooper L, et al. The effectiveness of manual stretching in the treatment of plantar heel pain: a systemic review. J Foot Ankle Res. 2011;4:1-13.
14. Rompe JD, Cacchio A, Lowell W, et al. Plantar fascia-specific stretching versus radial shock-wave therapy as initial treatment of plantar fasciopathy. J Bone Joint Surg Am. 2010;92:2514-2522.
15. Renan-Ordine R, Alburquerque-Sendin F, Rodriques De Souza DP, et al. Effectiveness of myofascial trigger point manual therapy combined with a self stretching protocol for the management of plantar heel pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2011;41:43-50.
16. Donley BG, Moore T, Sferra J, et al. The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: a randomized, prospective, placebo-controlled study. Foot Ankle Int. 2007;28:20-23.
17. Lee SY, McKeon P, Hertel J. Does the use of orthoses improve selfreported pain and function measures in patients with plantar fasciitis? A meta-analysis. Phys Ther Sport. 2009;10:12-18.
18. Pfeffer G, Bacchetti P, Deland J, et al. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int. 1999;20:214-221.
19. Hawke F, Burns J, Radford JA, et al. Custom-made foot orthoses for the treatment of foot pain. Cochrane Database Syst Rev. 2008;(3):CD006801.
20. Fong DT, Pang KY, Chung MM, et al. Evaluation of combined prescription of rocker sole shoes and custom-made foot orthoses for the treatment of plantar fasciitis. Clin Biomech. 2012;27: 1072-1077.
21. Berlet GC, Anderson RB, Davis H. A prospective trial of night splinting in the treatment of recalcitrant plantar fasciitis: the Ankle Dorsiflexion Dynasplint. Orthopedics. 2002;25: 1273-1275.
22. Roos E, Engstrom M, Soderberg B. Foot orthoses for the treatment of plantar fasciitis. Foot Ankle Int. 2006;27:606-611.
23. Goff JD, Crawford R. Diagnosis and treatment of plantar fasciitis. Am Fam Physician. 2011;84:676-682.
24. Wang CJ. Extracorporeal shockwave therapy in musculoskeletal disorders. J Orthop Surg Res. 2012;7:11.
25. Landorf KB, Menz HB. Plantar heel pain and fasciitis. Clin Evid (Online). 2008;2008:1111.
26. Ball EM, McKeeman HM, Patterson C, et al. Steroid injection for inferior heel pain: a randomized controlled trial. Ann Rheum Dis. 2013;72:996-1002.
27. Uden H, Boesch E, Kumar S. Plantar fasciitis – to jab or support? A systematic review of the current best evidence. J Multidiscip Healthc. 2011;4:155-164.
28. Shetty VD. Platelet-rich plasma: a ‘feeling’ and ‘hope’ ailing athletes. Br J Sports Med. 2010;44(suppl 1):i1-i82.
29. Aksahin E, Dogruyol D, Yüksel HY, et al. The comparison of the effect of corticosteroids and platelet-rich plasma (PRP) for the treatment of plantar fasciitis. Arch Orthop Trauma Surg. 2012;132:781-785.
30. Ragab EM, Othman AM. Platelets rich plasma for treatment of chronic plantar fasciitis. Arch Orthop Trauma Surg. 2012;132:1065-1070.
31. Saxena A. Uniportal endoscopic plantar fasciotomy: a prospective study on athletic patients. Foot Ankle Int. 2004;25:882-889.
1. Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int. 2004;25: 303-310.
2. Glazer JL. An approach to the diagnosis and treatment of plantar fasciitis. Phys Sportsmed. 2009;37:74-79.
3. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003;93:234-237.
4. Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heal pain: a clinical practice guideline – revision 2010. J Foot Ankle Surg. 2010;49(suppl):S1-S19.
5. Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treatment. J Am Acad Orthop Surg. 2008;16:338-346.
6. Singh D, Angel J, Bentley G, et al. Fortnightly review: plantar fasciitis. BMJ. 1997;315:172-175.
7. McMillan AM, Landorf KB, Barrett JT, et al. Diagnostic imaging for chronic plantar heel pain: a systematic review and metaanalysis. J Foot Ankle Res. 2009;2:32.
8. Mahowald S, Legge BS, Grady JF. The correlation between plantar fascia thickness and symptoms of plantar fasciitis. J Am Podiatr Med Assoc. 2011;101:385-389.
9. American College of Radiology. ACR appropriateness criteria. Chronic foot pain. Available at: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/ChronicFootPain.pdf. Accessed November 11, 2012.
10. Gill LH. Plantar fasciitis: diagnosis and conservative treatment. J Am Acad Orthop Surg. 1997;5:109-117.
11. Martin RL, Irrgang JJ, Conti SF. Outcome study of subjects with insertional plantar fasciitis. Foot Ankle Int. 1998;19:803-811.
12. DiGiovanni BF, Nawoczenski DA, Malay DP, et al. Plantar fasciaspecific stretching exercise improves outcomes in patients with chronic plantar fasciitis: a prospective clinic trial with two-year follow up. J Bone Joint Surg Am. 2006;88:1775-1781.
13. Sweeting D, Parish B, Hooper L, et al. The effectiveness of manual stretching in the treatment of plantar heel pain: a systemic review. J Foot Ankle Res. 2011;4:1-13.
14. Rompe JD, Cacchio A, Lowell W, et al. Plantar fascia-specific stretching versus radial shock-wave therapy as initial treatment of plantar fasciopathy. J Bone Joint Surg Am. 2010;92:2514-2522.
15. Renan-Ordine R, Alburquerque-Sendin F, Rodriques De Souza DP, et al. Effectiveness of myofascial trigger point manual therapy combined with a self stretching protocol for the management of plantar heel pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2011;41:43-50.
16. Donley BG, Moore T, Sferra J, et al. The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: a randomized, prospective, placebo-controlled study. Foot Ankle Int. 2007;28:20-23.
17. Lee SY, McKeon P, Hertel J. Does the use of orthoses improve selfreported pain and function measures in patients with plantar fasciitis? A meta-analysis. Phys Ther Sport. 2009;10:12-18.
18. Pfeffer G, Bacchetti P, Deland J, et al. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int. 1999;20:214-221.
19. Hawke F, Burns J, Radford JA, et al. Custom-made foot orthoses for the treatment of foot pain. Cochrane Database Syst Rev. 2008;(3):CD006801.
20. Fong DT, Pang KY, Chung MM, et al. Evaluation of combined prescription of rocker sole shoes and custom-made foot orthoses for the treatment of plantar fasciitis. Clin Biomech. 2012;27: 1072-1077.
21. Berlet GC, Anderson RB, Davis H. A prospective trial of night splinting in the treatment of recalcitrant plantar fasciitis: the Ankle Dorsiflexion Dynasplint. Orthopedics. 2002;25: 1273-1275.
22. Roos E, Engstrom M, Soderberg B. Foot orthoses for the treatment of plantar fasciitis. Foot Ankle Int. 2006;27:606-611.
23. Goff JD, Crawford R. Diagnosis and treatment of plantar fasciitis. Am Fam Physician. 2011;84:676-682.
24. Wang CJ. Extracorporeal shockwave therapy in musculoskeletal disorders. J Orthop Surg Res. 2012;7:11.
25. Landorf KB, Menz HB. Plantar heel pain and fasciitis. Clin Evid (Online). 2008;2008:1111.
26. Ball EM, McKeeman HM, Patterson C, et al. Steroid injection for inferior heel pain: a randomized controlled trial. Ann Rheum Dis. 2013;72:996-1002.
27. Uden H, Boesch E, Kumar S. Plantar fasciitis – to jab or support? A systematic review of the current best evidence. J Multidiscip Healthc. 2011;4:155-164.
28. Shetty VD. Platelet-rich plasma: a ‘feeling’ and ‘hope’ ailing athletes. Br J Sports Med. 2010;44(suppl 1):i1-i82.
29. Aksahin E, Dogruyol D, Yüksel HY, et al. The comparison of the effect of corticosteroids and platelet-rich plasma (PRP) for the treatment of plantar fasciitis. Arch Orthop Trauma Surg. 2012;132:781-785.
30. Ragab EM, Othman AM. Platelets rich plasma for treatment of chronic plantar fasciitis. Arch Orthop Trauma Surg. 2012;132:1065-1070.
31. Saxena A. Uniportal endoscopic plantar fasciotomy: a prospective study on athletic patients. Foot Ankle Int. 2004;25:882-889.
Plantar fasciitis: How best to treat?
› Use plantar fascia specific stretching to decrease pain in patients with plantar fasciitis. A
› Consider recommending prefabricated orthoses, including night splints, to decrease pain. A
› Consider using extracorporeal shock wave therapy for plantar fascial pain. A
Strength of recommendation (SOR)
A. Good-quality patient-oriented evidence
B. Inconsistent or limited-quality patient-oriented evidence
C. Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE A 43-year-old obese woman seeks advice for left heel pain she has had for 2 months. Before the onset of pain, her activity level had increased as part of a weight loss program. Her pain is at its worst in the morning, with her first few steps; it decreases with continued walking and intensifies again after being on her feet all day. There is no history of trauma, and she reports no paresthesias or radiation of the pain. Her medical history is otherwise unremarkable. She has used ibuprofen sparingly, with limited relief.
If you were this patient’s physician, how would you proceed with her care?
Plantar fasciitis (PF) is a common cause of heel pain that affects up to 10% of the US population and accounts for approximately 600,000 outpatient visits annually.1 The plantar fascia is a dense, fibrous membrane spanning the length of the foot. It originates at the medial calcaneal tubercle, attaches to the phalanges, and provides stability and arch support to the foot. The etiology of PF is unknown, but predisposing factors include overtraining, obesity, pes planus, decreased ankle dorsiflexion, and inappropriate footwear.2 Limited dorsiflexion due to tightness of the Achilles tendon strains the plantar fascia and can lead to PF. Histology shows minimal inflammatory changes, and some experts advocate the term plantar fasciosis to counter the misperception that it is primarily an inflammatory condition.3
A patient’s history and physical exam findings are the basis for confirming or dismissing a diagnosis of PF. Radiologic studies, used judiciously, can rule out important alternative diagnoses that should not be overlooked. Multiple treatment options range from conservative to surgical interventions, although studies of the effectiveness of each modality have had conflicting results. Clinical practice guidelines generally advocate a stepwise approach to treatment.
Diagnosis
The differential diagnosis of PF (TABLE) includes significant disorders such as calcaneal stress fracture, entrapment neuropathies (eg, tarsal tunnel syndrome), calcaneal tumor, Paget’s disease, and systemic arthritidies.4,5
What to look for in the history and physical exam
Severe heel pain upon initial weight bearing in the morning or after prolonged periods of inactivity is pathognomonic for PF.2 Initially the pain presents diffusely, but over time it localizes to the area of the medial calcaneal tubercle. Pain typically subsides with activity but may return with prolonged weight bearing, as it did with the patient in the opening case.
Test range of motion of the foot and ankle. Although this is not needed for diagnosing PF, some patients will exhibit limited ankle dorsiflexion, a predisposing factor for PF.4,6 Look for heel pad swelling, inflammation, or atrophy, and palpate the heel, plantar fascia, and calcaneal tubercle. Lastly, evaluate for gait abnormalities and the presence of sensory deficits or hypesthesias.4
The most common exam finding in PF is pain at the medial calcaneal tubercle, which may be exacerbated with passive ankle dorsiflexion or first digit extension.2,4 If paresthesias occur with percussion inferior to the medial malleolus, suspect possible nerve entrapment or tarsal tunnel syndrome. Tenderness with heel compression (squeeze test) may indicate a calcaneal fracture or apophysitis.
Imaging is useful to rule out alternative disorders
Radiologic studies generally do not contribute to the diagnosis or management of PF, but they can assist in ruling out alternative causes of heel pain or in reevaluation if symptoms of PF persist after 3 to 6 months of treatment.
Plain films lack the sensitivity to detect plantar fasciitis. While a plantar calcaneal spur is often seen on radiography, it does not confirm the diagnosis, correlate with severity of symptoms, or predict prognosis.4 Despite this deficiency, plain radiography remains the initial choice of imaging modalities, particularly to rule out other conditions.
Ultrasound accurately diagnoses plantar fasciitis. Plantar fascia thickness of more than 4.0 mm is diagnostic of PF.7 Additionally, a decrease in plantar fascia thickness correlates with a decrease in pain levels, and thus ultrasound can aid in monitoring treatment progress.8 If results of plain films and ultrasound are inconclusive and clinical concern for an alternative diagnosis warrants additional expense, consider arranging for magnetic resonance imaging.9
Noninvasive treatments
Conservative therapies remain the preferred approach to treating PF, successfully managing 85% to 90% of cases.10,11 A 2010 clinical practice guideline from the American College of Foot and Ankle Surgeons recommends conservative treatments such as nonsteroidal inflammatory drugs (NSAIDs), stretching, and prefabricated orthotics for the initial management of plantar heel pain.4 Emphasize to patients that it may take 6 to 12 months for symptoms to resolve.4
Stretching and trigger-point manual therapy are effective
The traditional primary treatment modality for PF has been early initiation of an Achilles-soleus (heel-cord) muscle–stretching program. However, studies have shown that plantar fascia–specific stretching (PFSS) (FIGURE) significantly diminishes or eliminates heel pain when compared with traditional stretching movements, and is useful in treating chronic recalcitrant heel pain.12,13 PFSS has also yielded results superior to low-dose shock wave therapy.14
In a 2011 study, adding myofascial trigger-point manual therapy to a PFSS routine improved self-reported physical function and pain vs stretching alone.15 This manual therapy technique is specialized and should be administered only by trained physical therapists. Data are limited and mixed regarding the effectiveness of deep tissue massage, iontophoresis, or eccentric stretching of the plantar fascia to alleviate plantar fascial pain. Support for therapies such as rest, ice, heat, and massage has largely been anecdotal.
NSAIDs for PF lack good evidence
Nonsteroidal anti-inflammatory drugs (NSAIDs) are often prescribed to treat PF, despite a lack of evidence supporting their use. A small randomized, placebo-controlled double-blind study established a trend toward improvement in pain and disability scores with the use of NSAIDs. However, no statistically significant difference was noted in the measures between the NSAID and placebo groups at 1, 2, and 6 months.16 We found no studies that demonstrate a significant reduction in pain or improvement in function with the use of NSAIDs alone.
Although NSAIDs carry their own risks, they may work for some patients. And studies showing a lack of significant pain reduction may have been underpowered. If patients are willing to accept the risks of NSAID use, it would be reasonable to prescribe a therapeutic trial.
Orthotics and night splints can help, depending on comfort and compliance
Foot orthotics help prevent overpronation and attenuate tensile forces on the plantar fascia. A 2009 meta-analysis confirmed that both prefabricated and custom-made foot orthotics can decrease pain.17 One prospective study showed that 95% of patients had improvement in PF symptoms after 8 weeks of treatment with prefabricated orthotics.18 A Cochrane review found no difference in pain reduction between custom and prefabricated foot orthotics.19 A recent study demonstrated that rocker sole shoes—a type of therapeutic footwear with a more rounded outsole contour—combined with custom orthotics significantly reduced pain during walking compared with either modality alone.20 More research needs to be conducted into the use of rocker sole shoes before recommending them to PF patients.
Night splints help keep the foot and ankle in a neutral position, or slightly dorsiflexed, while patients sleep. Several studies have shown a reduction in pain with the use of night splints alone.17,21,22 Patient comfort and compliance tend to be the limiting factors in their use. Anterior splints are better tolerated than posterior splints.23
Shock wave therapy has better long-term results than steroid injections
Shock waves used to treat PF are thought to invoke extracellular responses that cause neovascularization and induce tissue repair and regeneration. A 2012 review article concluded that most research confirms that extracorporeal shock wave therapy (ESWT) reduces PF pain and improves function in 34% to 88% of cases.24 ESWT is comparable to surgical plantar fasciotomy without the operative risks, and yields better long-term effects in recalcitrant PF compared with corticosteroid injections (CSI).24 Many studies are underway to validate the effectiveness of ESWT. Currently, expense or lack of availability limits its use in some communities.
Invasive treatments
Corticosteroid injections may be used for more than just refractory pain
CSI have historically been reserved for recalcitrant heel pain. However, one systematic review cites evidence in support of CSI for the short-term management of plantar fascia pain.25 Compared with placebo, CSI reduces pain at both 6 and 12 weeks and decreases plantar fascia thickness.26 Additionally, the American College of Foot and Ankle Surgeons lists CSI as an acceptable first-line treatment for PF.4
The most common complication of CSI is postinjection pain. Other complications, such as fat pad atrophy, rarely occur.27 While the evidence is limited, CSI may be part of an initial approach to treating PF in addition to heel-cord or plantar fascia-specific stretching, particularly for patients who desire an expedited return to normal activity.
Platelet-rich plasma therapy holds promise
Platelet-rich plasma (PRP) has been gaining popularity as a treatment for PF pain. PRP is a component of whole blood that is centrifuged to a concentrated state, treated with an activating agent, and injected into the affected area. Theoretically, injected PRP increases the release of reparative growth factors, enhancing the healing process.28 PRP has been shown to be as effective in reducing pain scores as CSI at 3 weeks and 6 months.29 PRP also decreases plantar fascia thickness and improves pain scores and functional ability.30
To date, no trials have compared PRP with placebo injections. Postprocedural pain is the most common risk with PRP. While limited evidence exists, PRP seems to be a relatively safe and effective therapeutic alternative for treating chronic PF.
Surgery only when conservative measures fail
Reserve surgery for those who have not responded adequately after 6 to 12 months of conservative therapy.5 Endoscopic plantar fascia release is superior to traditional open surgery.31 Heel spur resection is no longer routinely practiced. Patients undergoing surgery should expect a return to normal activity in approximately 2 to 3 months, and up to 35% of patients may continue to have symptoms after surgical intervention.2,31
Treatment options in perspective
Treat conservatively at first. Stretching the plantar fascia and heel cord, using prefabricated orthotics, and wearing night splints are backed by firm clinical evidence of benefit. Acute treatment of PF may also include CSI, especially for patients who are athletic or otherwise active and wish to return to full function as soon as possible, and are willing to accept the risks associated with CSI.
ESWT improves pain and function scores and may also relieve pain in patients with recalcitrant PF pain. PRP has limited but promising evidence for patients with chronic PF pain. Surgical intervention remains the last line of therapy and is not always effective at reducing pain.
CASE You prescribe a conservative treatment program of plantar fascia–specific stretches and prefabricated orthoses for the patient in the opening scenario. At one month, her pain drops by 30%. At 6 months, her pain disappears, and she resumes a daily aerobic exercise program to assist in weight loss.
CORRESPONDENCE
Carlton J. Covey, MD, Nellis Family Medicine Residency, 99MDOS/SGOF, 4700 Las Vegas Boulevard N, Las Vegas, NV 89191;
carlton.covey@nellis.af.mil
1. Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int. 2004;25: 303-310.
2. Glazer JL. An approach to the diagnosis and treatment of plantar fasciitis. Phys Sportsmed. 2009;37:74-79.
3. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003;93:234-237.
4. Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heal pain: a clinical practice guideline – revision 2010. J Foot Ankle Surg. 2010;49(suppl):S1-S19.
5. Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treatment. J Am Acad Orthop Surg. 2008;16:338-346.
6. Singh D, Angel J, Bentley G, et al. Fortnightly review: plantar fasciitis. BMJ. 1997;315:172-175.
7. McMillan AM, Landorf KB, Barrett JT, et al. Diagnostic imaging for chronic plantar heel pain: a systematic review and metaanalysis. J Foot Ankle Res. 2009;2:32.
8. Mahowald S, Legge BS, Grady JF. The correlation between plantar fascia thickness and symptoms of plantar fasciitis. J Am Podiatr Med Assoc. 2011;101:385-389.
9. American College of Radiology. ACR appropriateness criteria. Chronic foot pain. Available at: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/ChronicFootPain.pdf. Accessed November 11, 2012.
10. Gill LH. Plantar fasciitis: diagnosis and conservative treatment. J Am Acad Orthop Surg. 1997;5:109-117.
11. Martin RL, Irrgang JJ, Conti SF. Outcome study of subjects with insertional plantar fasciitis. Foot Ankle Int. 1998;19:803-811.
12. DiGiovanni BF, Nawoczenski DA, Malay DP, et al. Plantar fasciaspecific stretching exercise improves outcomes in patients with chronic plantar fasciitis: a prospective clinic trial with two-year follow up. J Bone Joint Surg Am. 2006;88:1775-1781.
13. Sweeting D, Parish B, Hooper L, et al. The effectiveness of manual stretching in the treatment of plantar heel pain: a systemic review. J Foot Ankle Res. 2011;4:1-13.
14. Rompe JD, Cacchio A, Lowell W, et al. Plantar fascia-specific stretching versus radial shock-wave therapy as initial treatment of plantar fasciopathy. J Bone Joint Surg Am. 2010;92:2514-2522.
15. Renan-Ordine R, Alburquerque-Sendin F, Rodriques De Souza DP, et al. Effectiveness of myofascial trigger point manual therapy combined with a self stretching protocol for the management of plantar heel pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2011;41:43-50.
16. Donley BG, Moore T, Sferra J, et al. The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: a randomized, prospective, placebo-controlled study. Foot Ankle Int. 2007;28:20-23.
17. Lee SY, McKeon P, Hertel J. Does the use of orthoses improve selfreported pain and function measures in patients with plantar fasciitis? A meta-analysis. Phys Ther Sport. 2009;10:12-18.
18. Pfeffer G, Bacchetti P, Deland J, et al. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int. 1999;20:214-221.
19. Hawke F, Burns J, Radford JA, et al. Custom-made foot orthoses for the treatment of foot pain. Cochrane Database Syst Rev. 2008;(3):CD006801.
20. Fong DT, Pang KY, Chung MM, et al. Evaluation of combined prescription of rocker sole shoes and custom-made foot orthoses for the treatment of plantar fasciitis. Clin Biomech. 2012;27: 1072-1077.
21. Berlet GC, Anderson RB, Davis H. A prospective trial of night splinting in the treatment of recalcitrant plantar fasciitis: the Ankle Dorsiflexion Dynasplint. Orthopedics. 2002;25: 1273-1275.
22. Roos E, Engstrom M, Soderberg B. Foot orthoses for the treatment of plantar fasciitis. Foot Ankle Int. 2006;27:606-611.
23. Goff JD, Crawford R. Diagnosis and treatment of plantar fasciitis. Am Fam Physician. 2011;84:676-682.
24. Wang CJ. Extracorporeal shockwave therapy in musculoskeletal disorders. J Orthop Surg Res. 2012;7:11.
25. Landorf KB, Menz HB. Plantar heel pain and fasciitis. Clin Evid (Online). 2008;2008:1111.
26. Ball EM, McKeeman HM, Patterson C, et al. Steroid injection for inferior heel pain: a randomized controlled trial. Ann Rheum Dis. 2013;72:996-1002.
27. Uden H, Boesch E, Kumar S. Plantar fasciitis – to jab or support? A systematic review of the current best evidence. J Multidiscip Healthc. 2011;4:155-164.
28. Shetty VD. Platelet-rich plasma: a ‘feeling’ and ‘hope’ ailing athletes. Br J Sports Med. 2010;44(suppl 1):i1-i82.
29. Aksahin E, Dogruyol D, Yüksel HY, et al. The comparison of the effect of corticosteroids and platelet-rich plasma (PRP) for the treatment of plantar fasciitis. Arch Orthop Trauma Surg. 2012;132:781-785.
30. Ragab EM, Othman AM. Platelets rich plasma for treatment of chronic plantar fasciitis. Arch Orthop Trauma Surg. 2012;132:1065-1070.
31. Saxena A. Uniportal endoscopic plantar fasciotomy: a prospective study on athletic patients. Foot Ankle Int. 2004;25:882-889.
› Use plantar fascia specific stretching to decrease pain in patients with plantar fasciitis. A
› Consider recommending prefabricated orthoses, including night splints, to decrease pain. A
› Consider using extracorporeal shock wave therapy for plantar fascial pain. A
Strength of recommendation (SOR)
A. Good-quality patient-oriented evidence
B. Inconsistent or limited-quality patient-oriented evidence
C. Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE A 43-year-old obese woman seeks advice for left heel pain she has had for 2 months. Before the onset of pain, her activity level had increased as part of a weight loss program. Her pain is at its worst in the morning, with her first few steps; it decreases with continued walking and intensifies again after being on her feet all day. There is no history of trauma, and she reports no paresthesias or radiation of the pain. Her medical history is otherwise unremarkable. She has used ibuprofen sparingly, with limited relief.
If you were this patient’s physician, how would you proceed with her care?
Plantar fasciitis (PF) is a common cause of heel pain that affects up to 10% of the US population and accounts for approximately 600,000 outpatient visits annually.1 The plantar fascia is a dense, fibrous membrane spanning the length of the foot. It originates at the medial calcaneal tubercle, attaches to the phalanges, and provides stability and arch support to the foot. The etiology of PF is unknown, but predisposing factors include overtraining, obesity, pes planus, decreased ankle dorsiflexion, and inappropriate footwear.2 Limited dorsiflexion due to tightness of the Achilles tendon strains the plantar fascia and can lead to PF. Histology shows minimal inflammatory changes, and some experts advocate the term plantar fasciosis to counter the misperception that it is primarily an inflammatory condition.3
A patient’s history and physical exam findings are the basis for confirming or dismissing a diagnosis of PF. Radiologic studies, used judiciously, can rule out important alternative diagnoses that should not be overlooked. Multiple treatment options range from conservative to surgical interventions, although studies of the effectiveness of each modality have had conflicting results. Clinical practice guidelines generally advocate a stepwise approach to treatment.
Diagnosis
The differential diagnosis of PF (TABLE) includes significant disorders such as calcaneal stress fracture, entrapment neuropathies (eg, tarsal tunnel syndrome), calcaneal tumor, Paget’s disease, and systemic arthritidies.4,5
What to look for in the history and physical exam
Severe heel pain upon initial weight bearing in the morning or after prolonged periods of inactivity is pathognomonic for PF.2 Initially the pain presents diffusely, but over time it localizes to the area of the medial calcaneal tubercle. Pain typically subsides with activity but may return with prolonged weight bearing, as it did with the patient in the opening case.
Test range of motion of the foot and ankle. Although this is not needed for diagnosing PF, some patients will exhibit limited ankle dorsiflexion, a predisposing factor for PF.4,6 Look for heel pad swelling, inflammation, or atrophy, and palpate the heel, plantar fascia, and calcaneal tubercle. Lastly, evaluate for gait abnormalities and the presence of sensory deficits or hypesthesias.4
The most common exam finding in PF is pain at the medial calcaneal tubercle, which may be exacerbated with passive ankle dorsiflexion or first digit extension.2,4 If paresthesias occur with percussion inferior to the medial malleolus, suspect possible nerve entrapment or tarsal tunnel syndrome. Tenderness with heel compression (squeeze test) may indicate a calcaneal fracture or apophysitis.
Imaging is useful to rule out alternative disorders
Radiologic studies generally do not contribute to the diagnosis or management of PF, but they can assist in ruling out alternative causes of heel pain or in reevaluation if symptoms of PF persist after 3 to 6 months of treatment.
Plain films lack the sensitivity to detect plantar fasciitis. While a plantar calcaneal spur is often seen on radiography, it does not confirm the diagnosis, correlate with severity of symptoms, or predict prognosis.4 Despite this deficiency, plain radiography remains the initial choice of imaging modalities, particularly to rule out other conditions.
Ultrasound accurately diagnoses plantar fasciitis. Plantar fascia thickness of more than 4.0 mm is diagnostic of PF.7 Additionally, a decrease in plantar fascia thickness correlates with a decrease in pain levels, and thus ultrasound can aid in monitoring treatment progress.8 If results of plain films and ultrasound are inconclusive and clinical concern for an alternative diagnosis warrants additional expense, consider arranging for magnetic resonance imaging.9
Noninvasive treatments
Conservative therapies remain the preferred approach to treating PF, successfully managing 85% to 90% of cases.10,11 A 2010 clinical practice guideline from the American College of Foot and Ankle Surgeons recommends conservative treatments such as nonsteroidal inflammatory drugs (NSAIDs), stretching, and prefabricated orthotics for the initial management of plantar heel pain.4 Emphasize to patients that it may take 6 to 12 months for symptoms to resolve.4
Stretching and trigger-point manual therapy are effective
The traditional primary treatment modality for PF has been early initiation of an Achilles-soleus (heel-cord) muscle–stretching program. However, studies have shown that plantar fascia–specific stretching (PFSS) (FIGURE) significantly diminishes or eliminates heel pain when compared with traditional stretching movements, and is useful in treating chronic recalcitrant heel pain.12,13 PFSS has also yielded results superior to low-dose shock wave therapy.14
In a 2011 study, adding myofascial trigger-point manual therapy to a PFSS routine improved self-reported physical function and pain vs stretching alone.15 This manual therapy technique is specialized and should be administered only by trained physical therapists. Data are limited and mixed regarding the effectiveness of deep tissue massage, iontophoresis, or eccentric stretching of the plantar fascia to alleviate plantar fascial pain. Support for therapies such as rest, ice, heat, and massage has largely been anecdotal.
NSAIDs for PF lack good evidence
Nonsteroidal anti-inflammatory drugs (NSAIDs) are often prescribed to treat PF, despite a lack of evidence supporting their use. A small randomized, placebo-controlled double-blind study established a trend toward improvement in pain and disability scores with the use of NSAIDs. However, no statistically significant difference was noted in the measures between the NSAID and placebo groups at 1, 2, and 6 months.16 We found no studies that demonstrate a significant reduction in pain or improvement in function with the use of NSAIDs alone.
Although NSAIDs carry their own risks, they may work for some patients. And studies showing a lack of significant pain reduction may have been underpowered. If patients are willing to accept the risks of NSAID use, it would be reasonable to prescribe a therapeutic trial.
Orthotics and night splints can help, depending on comfort and compliance
Foot orthotics help prevent overpronation and attenuate tensile forces on the plantar fascia. A 2009 meta-analysis confirmed that both prefabricated and custom-made foot orthotics can decrease pain.17 One prospective study showed that 95% of patients had improvement in PF symptoms after 8 weeks of treatment with prefabricated orthotics.18 A Cochrane review found no difference in pain reduction between custom and prefabricated foot orthotics.19 A recent study demonstrated that rocker sole shoes—a type of therapeutic footwear with a more rounded outsole contour—combined with custom orthotics significantly reduced pain during walking compared with either modality alone.20 More research needs to be conducted into the use of rocker sole shoes before recommending them to PF patients.
Night splints help keep the foot and ankle in a neutral position, or slightly dorsiflexed, while patients sleep. Several studies have shown a reduction in pain with the use of night splints alone.17,21,22 Patient comfort and compliance tend to be the limiting factors in their use. Anterior splints are better tolerated than posterior splints.23
Shock wave therapy has better long-term results than steroid injections
Shock waves used to treat PF are thought to invoke extracellular responses that cause neovascularization and induce tissue repair and regeneration. A 2012 review article concluded that most research confirms that extracorporeal shock wave therapy (ESWT) reduces PF pain and improves function in 34% to 88% of cases.24 ESWT is comparable to surgical plantar fasciotomy without the operative risks, and yields better long-term effects in recalcitrant PF compared with corticosteroid injections (CSI).24 Many studies are underway to validate the effectiveness of ESWT. Currently, expense or lack of availability limits its use in some communities.
Invasive treatments
Corticosteroid injections may be used for more than just refractory pain
CSI have historically been reserved for recalcitrant heel pain. However, one systematic review cites evidence in support of CSI for the short-term management of plantar fascia pain.25 Compared with placebo, CSI reduces pain at both 6 and 12 weeks and decreases plantar fascia thickness.26 Additionally, the American College of Foot and Ankle Surgeons lists CSI as an acceptable first-line treatment for PF.4
The most common complication of CSI is postinjection pain. Other complications, such as fat pad atrophy, rarely occur.27 While the evidence is limited, CSI may be part of an initial approach to treating PF in addition to heel-cord or plantar fascia-specific stretching, particularly for patients who desire an expedited return to normal activity.
Platelet-rich plasma therapy holds promise
Platelet-rich plasma (PRP) has been gaining popularity as a treatment for PF pain. PRP is a component of whole blood that is centrifuged to a concentrated state, treated with an activating agent, and injected into the affected area. Theoretically, injected PRP increases the release of reparative growth factors, enhancing the healing process.28 PRP has been shown to be as effective in reducing pain scores as CSI at 3 weeks and 6 months.29 PRP also decreases plantar fascia thickness and improves pain scores and functional ability.30
To date, no trials have compared PRP with placebo injections. Postprocedural pain is the most common risk with PRP. While limited evidence exists, PRP seems to be a relatively safe and effective therapeutic alternative for treating chronic PF.
Surgery only when conservative measures fail
Reserve surgery for those who have not responded adequately after 6 to 12 months of conservative therapy.5 Endoscopic plantar fascia release is superior to traditional open surgery.31 Heel spur resection is no longer routinely practiced. Patients undergoing surgery should expect a return to normal activity in approximately 2 to 3 months, and up to 35% of patients may continue to have symptoms after surgical intervention.2,31
Treatment options in perspective
Treat conservatively at first. Stretching the plantar fascia and heel cord, using prefabricated orthotics, and wearing night splints are backed by firm clinical evidence of benefit. Acute treatment of PF may also include CSI, especially for patients who are athletic or otherwise active and wish to return to full function as soon as possible, and are willing to accept the risks associated with CSI.
ESWT improves pain and function scores and may also relieve pain in patients with recalcitrant PF pain. PRP has limited but promising evidence for patients with chronic PF pain. Surgical intervention remains the last line of therapy and is not always effective at reducing pain.
CASE You prescribe a conservative treatment program of plantar fascia–specific stretches and prefabricated orthoses for the patient in the opening scenario. At one month, her pain drops by 30%. At 6 months, her pain disappears, and she resumes a daily aerobic exercise program to assist in weight loss.
CORRESPONDENCE
Carlton J. Covey, MD, Nellis Family Medicine Residency, 99MDOS/SGOF, 4700 Las Vegas Boulevard N, Las Vegas, NV 89191;
carlton.covey@nellis.af.mil
› Use plantar fascia specific stretching to decrease pain in patients with plantar fasciitis. A
› Consider recommending prefabricated orthoses, including night splints, to decrease pain. A
› Consider using extracorporeal shock wave therapy for plantar fascial pain. A
Strength of recommendation (SOR)
A. Good-quality patient-oriented evidence
B. Inconsistent or limited-quality patient-oriented evidence
C. Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE A 43-year-old obese woman seeks advice for left heel pain she has had for 2 months. Before the onset of pain, her activity level had increased as part of a weight loss program. Her pain is at its worst in the morning, with her first few steps; it decreases with continued walking and intensifies again after being on her feet all day. There is no history of trauma, and she reports no paresthesias or radiation of the pain. Her medical history is otherwise unremarkable. She has used ibuprofen sparingly, with limited relief.
If you were this patient’s physician, how would you proceed with her care?
Plantar fasciitis (PF) is a common cause of heel pain that affects up to 10% of the US population and accounts for approximately 600,000 outpatient visits annually.1 The plantar fascia is a dense, fibrous membrane spanning the length of the foot. It originates at the medial calcaneal tubercle, attaches to the phalanges, and provides stability and arch support to the foot. The etiology of PF is unknown, but predisposing factors include overtraining, obesity, pes planus, decreased ankle dorsiflexion, and inappropriate footwear.2 Limited dorsiflexion due to tightness of the Achilles tendon strains the plantar fascia and can lead to PF. Histology shows minimal inflammatory changes, and some experts advocate the term plantar fasciosis to counter the misperception that it is primarily an inflammatory condition.3
A patient’s history and physical exam findings are the basis for confirming or dismissing a diagnosis of PF. Radiologic studies, used judiciously, can rule out important alternative diagnoses that should not be overlooked. Multiple treatment options range from conservative to surgical interventions, although studies of the effectiveness of each modality have had conflicting results. Clinical practice guidelines generally advocate a stepwise approach to treatment.
Diagnosis
The differential diagnosis of PF (TABLE) includes significant disorders such as calcaneal stress fracture, entrapment neuropathies (eg, tarsal tunnel syndrome), calcaneal tumor, Paget’s disease, and systemic arthritidies.4,5
What to look for in the history and physical exam
Severe heel pain upon initial weight bearing in the morning or after prolonged periods of inactivity is pathognomonic for PF.2 Initially the pain presents diffusely, but over time it localizes to the area of the medial calcaneal tubercle. Pain typically subsides with activity but may return with prolonged weight bearing, as it did with the patient in the opening case.
Test range of motion of the foot and ankle. Although this is not needed for diagnosing PF, some patients will exhibit limited ankle dorsiflexion, a predisposing factor for PF.4,6 Look for heel pad swelling, inflammation, or atrophy, and palpate the heel, plantar fascia, and calcaneal tubercle. Lastly, evaluate for gait abnormalities and the presence of sensory deficits or hypesthesias.4
The most common exam finding in PF is pain at the medial calcaneal tubercle, which may be exacerbated with passive ankle dorsiflexion or first digit extension.2,4 If paresthesias occur with percussion inferior to the medial malleolus, suspect possible nerve entrapment or tarsal tunnel syndrome. Tenderness with heel compression (squeeze test) may indicate a calcaneal fracture or apophysitis.
Imaging is useful to rule out alternative disorders
Radiologic studies generally do not contribute to the diagnosis or management of PF, but they can assist in ruling out alternative causes of heel pain or in reevaluation if symptoms of PF persist after 3 to 6 months of treatment.
Plain films lack the sensitivity to detect plantar fasciitis. While a plantar calcaneal spur is often seen on radiography, it does not confirm the diagnosis, correlate with severity of symptoms, or predict prognosis.4 Despite this deficiency, plain radiography remains the initial choice of imaging modalities, particularly to rule out other conditions.
Ultrasound accurately diagnoses plantar fasciitis. Plantar fascia thickness of more than 4.0 mm is diagnostic of PF.7 Additionally, a decrease in plantar fascia thickness correlates with a decrease in pain levels, and thus ultrasound can aid in monitoring treatment progress.8 If results of plain films and ultrasound are inconclusive and clinical concern for an alternative diagnosis warrants additional expense, consider arranging for magnetic resonance imaging.9
Noninvasive treatments
Conservative therapies remain the preferred approach to treating PF, successfully managing 85% to 90% of cases.10,11 A 2010 clinical practice guideline from the American College of Foot and Ankle Surgeons recommends conservative treatments such as nonsteroidal inflammatory drugs (NSAIDs), stretching, and prefabricated orthotics for the initial management of plantar heel pain.4 Emphasize to patients that it may take 6 to 12 months for symptoms to resolve.4
Stretching and trigger-point manual therapy are effective
The traditional primary treatment modality for PF has been early initiation of an Achilles-soleus (heel-cord) muscle–stretching program. However, studies have shown that plantar fascia–specific stretching (PFSS) (FIGURE) significantly diminishes or eliminates heel pain when compared with traditional stretching movements, and is useful in treating chronic recalcitrant heel pain.12,13 PFSS has also yielded results superior to low-dose shock wave therapy.14
In a 2011 study, adding myofascial trigger-point manual therapy to a PFSS routine improved self-reported physical function and pain vs stretching alone.15 This manual therapy technique is specialized and should be administered only by trained physical therapists. Data are limited and mixed regarding the effectiveness of deep tissue massage, iontophoresis, or eccentric stretching of the plantar fascia to alleviate plantar fascial pain. Support for therapies such as rest, ice, heat, and massage has largely been anecdotal.
NSAIDs for PF lack good evidence
Nonsteroidal anti-inflammatory drugs (NSAIDs) are often prescribed to treat PF, despite a lack of evidence supporting their use. A small randomized, placebo-controlled double-blind study established a trend toward improvement in pain and disability scores with the use of NSAIDs. However, no statistically significant difference was noted in the measures between the NSAID and placebo groups at 1, 2, and 6 months.16 We found no studies that demonstrate a significant reduction in pain or improvement in function with the use of NSAIDs alone.
Although NSAIDs carry their own risks, they may work for some patients. And studies showing a lack of significant pain reduction may have been underpowered. If patients are willing to accept the risks of NSAID use, it would be reasonable to prescribe a therapeutic trial.
Orthotics and night splints can help, depending on comfort and compliance
Foot orthotics help prevent overpronation and attenuate tensile forces on the plantar fascia. A 2009 meta-analysis confirmed that both prefabricated and custom-made foot orthotics can decrease pain.17 One prospective study showed that 95% of patients had improvement in PF symptoms after 8 weeks of treatment with prefabricated orthotics.18 A Cochrane review found no difference in pain reduction between custom and prefabricated foot orthotics.19 A recent study demonstrated that rocker sole shoes—a type of therapeutic footwear with a more rounded outsole contour—combined with custom orthotics significantly reduced pain during walking compared with either modality alone.20 More research needs to be conducted into the use of rocker sole shoes before recommending them to PF patients.
Night splints help keep the foot and ankle in a neutral position, or slightly dorsiflexed, while patients sleep. Several studies have shown a reduction in pain with the use of night splints alone.17,21,22 Patient comfort and compliance tend to be the limiting factors in their use. Anterior splints are better tolerated than posterior splints.23
Shock wave therapy has better long-term results than steroid injections
Shock waves used to treat PF are thought to invoke extracellular responses that cause neovascularization and induce tissue repair and regeneration. A 2012 review article concluded that most research confirms that extracorporeal shock wave therapy (ESWT) reduces PF pain and improves function in 34% to 88% of cases.24 ESWT is comparable to surgical plantar fasciotomy without the operative risks, and yields better long-term effects in recalcitrant PF compared with corticosteroid injections (CSI).24 Many studies are underway to validate the effectiveness of ESWT. Currently, expense or lack of availability limits its use in some communities.
Invasive treatments
Corticosteroid injections may be used for more than just refractory pain
CSI have historically been reserved for recalcitrant heel pain. However, one systematic review cites evidence in support of CSI for the short-term management of plantar fascia pain.25 Compared with placebo, CSI reduces pain at both 6 and 12 weeks and decreases plantar fascia thickness.26 Additionally, the American College of Foot and Ankle Surgeons lists CSI as an acceptable first-line treatment for PF.4
The most common complication of CSI is postinjection pain. Other complications, such as fat pad atrophy, rarely occur.27 While the evidence is limited, CSI may be part of an initial approach to treating PF in addition to heel-cord or plantar fascia-specific stretching, particularly for patients who desire an expedited return to normal activity.
Platelet-rich plasma therapy holds promise
Platelet-rich plasma (PRP) has been gaining popularity as a treatment for PF pain. PRP is a component of whole blood that is centrifuged to a concentrated state, treated with an activating agent, and injected into the affected area. Theoretically, injected PRP increases the release of reparative growth factors, enhancing the healing process.28 PRP has been shown to be as effective in reducing pain scores as CSI at 3 weeks and 6 months.29 PRP also decreases plantar fascia thickness and improves pain scores and functional ability.30
To date, no trials have compared PRP with placebo injections. Postprocedural pain is the most common risk with PRP. While limited evidence exists, PRP seems to be a relatively safe and effective therapeutic alternative for treating chronic PF.
Surgery only when conservative measures fail
Reserve surgery for those who have not responded adequately after 6 to 12 months of conservative therapy.5 Endoscopic plantar fascia release is superior to traditional open surgery.31 Heel spur resection is no longer routinely practiced. Patients undergoing surgery should expect a return to normal activity in approximately 2 to 3 months, and up to 35% of patients may continue to have symptoms after surgical intervention.2,31
Treatment options in perspective
Treat conservatively at first. Stretching the plantar fascia and heel cord, using prefabricated orthotics, and wearing night splints are backed by firm clinical evidence of benefit. Acute treatment of PF may also include CSI, especially for patients who are athletic or otherwise active and wish to return to full function as soon as possible, and are willing to accept the risks associated with CSI.
ESWT improves pain and function scores and may also relieve pain in patients with recalcitrant PF pain. PRP has limited but promising evidence for patients with chronic PF pain. Surgical intervention remains the last line of therapy and is not always effective at reducing pain.
CASE You prescribe a conservative treatment program of plantar fascia–specific stretches and prefabricated orthoses for the patient in the opening scenario. At one month, her pain drops by 30%. At 6 months, her pain disappears, and she resumes a daily aerobic exercise program to assist in weight loss.
CORRESPONDENCE
Carlton J. Covey, MD, Nellis Family Medicine Residency, 99MDOS/SGOF, 4700 Las Vegas Boulevard N, Las Vegas, NV 89191;
carlton.covey@nellis.af.mil
1. Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int. 2004;25: 303-310.
2. Glazer JL. An approach to the diagnosis and treatment of plantar fasciitis. Phys Sportsmed. 2009;37:74-79.
3. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003;93:234-237.
4. Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heal pain: a clinical practice guideline – revision 2010. J Foot Ankle Surg. 2010;49(suppl):S1-S19.
5. Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treatment. J Am Acad Orthop Surg. 2008;16:338-346.
6. Singh D, Angel J, Bentley G, et al. Fortnightly review: plantar fasciitis. BMJ. 1997;315:172-175.
7. McMillan AM, Landorf KB, Barrett JT, et al. Diagnostic imaging for chronic plantar heel pain: a systematic review and metaanalysis. J Foot Ankle Res. 2009;2:32.
8. Mahowald S, Legge BS, Grady JF. The correlation between plantar fascia thickness and symptoms of plantar fasciitis. J Am Podiatr Med Assoc. 2011;101:385-389.
9. American College of Radiology. ACR appropriateness criteria. Chronic foot pain. Available at: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/ChronicFootPain.pdf. Accessed November 11, 2012.
10. Gill LH. Plantar fasciitis: diagnosis and conservative treatment. J Am Acad Orthop Surg. 1997;5:109-117.
11. Martin RL, Irrgang JJ, Conti SF. Outcome study of subjects with insertional plantar fasciitis. Foot Ankle Int. 1998;19:803-811.
12. DiGiovanni BF, Nawoczenski DA, Malay DP, et al. Plantar fasciaspecific stretching exercise improves outcomes in patients with chronic plantar fasciitis: a prospective clinic trial with two-year follow up. J Bone Joint Surg Am. 2006;88:1775-1781.
13. Sweeting D, Parish B, Hooper L, et al. The effectiveness of manual stretching in the treatment of plantar heel pain: a systemic review. J Foot Ankle Res. 2011;4:1-13.
14. Rompe JD, Cacchio A, Lowell W, et al. Plantar fascia-specific stretching versus radial shock-wave therapy as initial treatment of plantar fasciopathy. J Bone Joint Surg Am. 2010;92:2514-2522.
15. Renan-Ordine R, Alburquerque-Sendin F, Rodriques De Souza DP, et al. Effectiveness of myofascial trigger point manual therapy combined with a self stretching protocol for the management of plantar heel pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2011;41:43-50.
16. Donley BG, Moore T, Sferra J, et al. The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: a randomized, prospective, placebo-controlled study. Foot Ankle Int. 2007;28:20-23.
17. Lee SY, McKeon P, Hertel J. Does the use of orthoses improve selfreported pain and function measures in patients with plantar fasciitis? A meta-analysis. Phys Ther Sport. 2009;10:12-18.
18. Pfeffer G, Bacchetti P, Deland J, et al. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int. 1999;20:214-221.
19. Hawke F, Burns J, Radford JA, et al. Custom-made foot orthoses for the treatment of foot pain. Cochrane Database Syst Rev. 2008;(3):CD006801.
20. Fong DT, Pang KY, Chung MM, et al. Evaluation of combined prescription of rocker sole shoes and custom-made foot orthoses for the treatment of plantar fasciitis. Clin Biomech. 2012;27: 1072-1077.
21. Berlet GC, Anderson RB, Davis H. A prospective trial of night splinting in the treatment of recalcitrant plantar fasciitis: the Ankle Dorsiflexion Dynasplint. Orthopedics. 2002;25: 1273-1275.
22. Roos E, Engstrom M, Soderberg B. Foot orthoses for the treatment of plantar fasciitis. Foot Ankle Int. 2006;27:606-611.
23. Goff JD, Crawford R. Diagnosis and treatment of plantar fasciitis. Am Fam Physician. 2011;84:676-682.
24. Wang CJ. Extracorporeal shockwave therapy in musculoskeletal disorders. J Orthop Surg Res. 2012;7:11.
25. Landorf KB, Menz HB. Plantar heel pain and fasciitis. Clin Evid (Online). 2008;2008:1111.
26. Ball EM, McKeeman HM, Patterson C, et al. Steroid injection for inferior heel pain: a randomized controlled trial. Ann Rheum Dis. 2013;72:996-1002.
27. Uden H, Boesch E, Kumar S. Plantar fasciitis – to jab or support? A systematic review of the current best evidence. J Multidiscip Healthc. 2011;4:155-164.
28. Shetty VD. Platelet-rich plasma: a ‘feeling’ and ‘hope’ ailing athletes. Br J Sports Med. 2010;44(suppl 1):i1-i82.
29. Aksahin E, Dogruyol D, Yüksel HY, et al. The comparison of the effect of corticosteroids and platelet-rich plasma (PRP) for the treatment of plantar fasciitis. Arch Orthop Trauma Surg. 2012;132:781-785.
30. Ragab EM, Othman AM. Platelets rich plasma for treatment of chronic plantar fasciitis. Arch Orthop Trauma Surg. 2012;132:1065-1070.
31. Saxena A. Uniportal endoscopic plantar fasciotomy: a prospective study on athletic patients. Foot Ankle Int. 2004;25:882-889.
1. Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int. 2004;25: 303-310.
2. Glazer JL. An approach to the diagnosis and treatment of plantar fasciitis. Phys Sportsmed. 2009;37:74-79.
3. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003;93:234-237.
4. Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heal pain: a clinical practice guideline – revision 2010. J Foot Ankle Surg. 2010;49(suppl):S1-S19.
5. Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treatment. J Am Acad Orthop Surg. 2008;16:338-346.
6. Singh D, Angel J, Bentley G, et al. Fortnightly review: plantar fasciitis. BMJ. 1997;315:172-175.
7. McMillan AM, Landorf KB, Barrett JT, et al. Diagnostic imaging for chronic plantar heel pain: a systematic review and metaanalysis. J Foot Ankle Res. 2009;2:32.
8. Mahowald S, Legge BS, Grady JF. The correlation between plantar fascia thickness and symptoms of plantar fasciitis. J Am Podiatr Med Assoc. 2011;101:385-389.
9. American College of Radiology. ACR appropriateness criteria. Chronic foot pain. Available at: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/ChronicFootPain.pdf. Accessed November 11, 2012.
10. Gill LH. Plantar fasciitis: diagnosis and conservative treatment. J Am Acad Orthop Surg. 1997;5:109-117.
11. Martin RL, Irrgang JJ, Conti SF. Outcome study of subjects with insertional plantar fasciitis. Foot Ankle Int. 1998;19:803-811.
12. DiGiovanni BF, Nawoczenski DA, Malay DP, et al. Plantar fasciaspecific stretching exercise improves outcomes in patients with chronic plantar fasciitis: a prospective clinic trial with two-year follow up. J Bone Joint Surg Am. 2006;88:1775-1781.
13. Sweeting D, Parish B, Hooper L, et al. The effectiveness of manual stretching in the treatment of plantar heel pain: a systemic review. J Foot Ankle Res. 2011;4:1-13.
14. Rompe JD, Cacchio A, Lowell W, et al. Plantar fascia-specific stretching versus radial shock-wave therapy as initial treatment of plantar fasciopathy. J Bone Joint Surg Am. 2010;92:2514-2522.
15. Renan-Ordine R, Alburquerque-Sendin F, Rodriques De Souza DP, et al. Effectiveness of myofascial trigger point manual therapy combined with a self stretching protocol for the management of plantar heel pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2011;41:43-50.
16. Donley BG, Moore T, Sferra J, et al. The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: a randomized, prospective, placebo-controlled study. Foot Ankle Int. 2007;28:20-23.
17. Lee SY, McKeon P, Hertel J. Does the use of orthoses improve selfreported pain and function measures in patients with plantar fasciitis? A meta-analysis. Phys Ther Sport. 2009;10:12-18.
18. Pfeffer G, Bacchetti P, Deland J, et al. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int. 1999;20:214-221.
19. Hawke F, Burns J, Radford JA, et al. Custom-made foot orthoses for the treatment of foot pain. Cochrane Database Syst Rev. 2008;(3):CD006801.
20. Fong DT, Pang KY, Chung MM, et al. Evaluation of combined prescription of rocker sole shoes and custom-made foot orthoses for the treatment of plantar fasciitis. Clin Biomech. 2012;27: 1072-1077.
21. Berlet GC, Anderson RB, Davis H. A prospective trial of night splinting in the treatment of recalcitrant plantar fasciitis: the Ankle Dorsiflexion Dynasplint. Orthopedics. 2002;25: 1273-1275.
22. Roos E, Engstrom M, Soderberg B. Foot orthoses for the treatment of plantar fasciitis. Foot Ankle Int. 2006;27:606-611.
23. Goff JD, Crawford R. Diagnosis and treatment of plantar fasciitis. Am Fam Physician. 2011;84:676-682.
24. Wang CJ. Extracorporeal shockwave therapy in musculoskeletal disorders. J Orthop Surg Res. 2012;7:11.
25. Landorf KB, Menz HB. Plantar heel pain and fasciitis. Clin Evid (Online). 2008;2008:1111.
26. Ball EM, McKeeman HM, Patterson C, et al. Steroid injection for inferior heel pain: a randomized controlled trial. Ann Rheum Dis. 2013;72:996-1002.
27. Uden H, Boesch E, Kumar S. Plantar fasciitis – to jab or support? A systematic review of the current best evidence. J Multidiscip Healthc. 2011;4:155-164.
28. Shetty VD. Platelet-rich plasma: a ‘feeling’ and ‘hope’ ailing athletes. Br J Sports Med. 2010;44(suppl 1):i1-i82.
29. Aksahin E, Dogruyol D, Yüksel HY, et al. The comparison of the effect of corticosteroids and platelet-rich plasma (PRP) for the treatment of plantar fasciitis. Arch Orthop Trauma Surg. 2012;132:781-785.
30. Ragab EM, Othman AM. Platelets rich plasma for treatment of chronic plantar fasciitis. Arch Orthop Trauma Surg. 2012;132:1065-1070.
31. Saxena A. Uniportal endoscopic plantar fasciotomy: a prospective study on athletic patients. Foot Ankle Int. 2004;25:882-889.
