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Review Question - QID 148

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QID 148 (Type "148" in App Search)
A 44-year-old recreational runner began training for a half marathon 6 weeks ago. Over the last week he has developed heel pain that is worse in the morning upon awakening and when he arises from his desk at the end of the workday. Physical exam is notable for tenderness with direct palpation of the anteromedial heel. Which of the following is the best initial management?

Stretching of the achilles tendon and plantar fascia along with a prefabricated shoe insert

93%

1993/2143

Immobilization in a short leg cast

4%

81/2143

Steroid injection of the plantar fascia

1%

20/2143

Custom made orthotic with arch support

2%

37/2143

Surgical release of the medial third of the plantar fascia origin

0%

6/2143

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The clinical presentation is consistent with plantar fasciitis. Initial treatment includes stretching of the plantar fascia and achilles tendon. Shoe inserts and heel cups may be beneficial in relieving symptoms as well. Symptoms often take up to 6 months or a year to resolve and surgical release of the plantar fascia should be reserved for the exceptionally recalcitrant cases.

Pfeffer et al conducted a level 1 study of 236 patients with plantar fasciitis. All patients were treated with achilles tendon and plantar fascia stretching. The patients were then randomized to a custom orthotic or prefabricated insert. The patients who received a prefabricated insert demonstrated significantly greater improvement in clinical symptoms at 8 weeks.

Harty et al conducted a biomechanical study of foot loading on live subjects. Lack of knee extension was associated with prolonged loading of the forefoot. The authors concluded that through the windlass mechanism of the plantar fascia, hamstring tightness may predispose the foot to development of plantar fasciitis.

Illustration A demonstrates the proper technique of plantar fascia stretching through stabilization of the hindfoot and hyperextension of the toes. Illustration B demonstrates an achilles tendon stretch that also incorporates eccentric loading of the gastroc-soleus.

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