Occupational Plantar Fasciitis Claims Deconstructed

INTRODUCTION

Scientific journal articles claim that 1 in 10 people will suffer from plantar fasciitis in their lifetime and approximately 2 million people worldwide receive treatment every year for the condition.[1]

In this feature article, we present a detailed summary of the symptoms and causes of the lower limb condition, which has been the subject of personal injury claim pleadings. We also evaluate claimant prospects of success on issues of breach and causation in a hypothetical plantar fasciitis claim.

WHAT IS PLANTAR FASCIITIS?

Plantar fascia, the band of fibrous connective tissue which runs along the plantar surface (bottom) of the foot, linking the heel and the ball of the foot, acts as a passive limitation to the over-flattening of the arch of the foot.[2]

Plantar fasciitis, a sub-type of the chronic plantar heel pain (CPHP) umbrella,[3] occurs when the plantar fascia becomes inflamed, hence the suffix, ‘-itis’.

15.png

Source: Wikimedia Commons (Edited by BC Legal)

Inflammation is onset by the process of stretching plantar fascia beyond the normal range of extension, which causes fibrous tissue to tear, or over-stretch. This may be painful (sharp, aching sensation[4]), feeling worse when walking (especially on the first steps of the day) and improved when resting. It may be difficult to raise toes off the floor while the foot is planted.[5]

What is more, plantar fasciitis may potentially result in the growth of a bone spur, at the point where fascia attaches to the heel bone (the largest of the 26 bones in the human foot).[6] 

16.png

Source: Wikimedia Commons (Edited by BC Legal)

Since plantar fasciitis is often diagnosed by findings of thickening and degenerative tissue, rather than by evidence of inflammatory changes, some clinicians argue that the term, ‘plantar fasciopathy’, better describes the disorder.[7]

HOW IS THE CONDITION DIAGNOSED AND TREATED?

A doctor or physiotherapist will likely refer a patient, based on their symptoms, history and clinical examination, for ultrasound scans and MRI’s, which are used to identify plantar fasciitis tears, inflammation and calcification. Further, pathology tests may seek to rule out spondyloarthritis, a constitutional condition (often found in those that test positive for the HLA-B27 gene) which can cause symptoms that may be mistaken for plantar fasciitis.[8]

Once plantar fasciitis has been diagnosed, it is reversible and very successfully treated. The NHS claims that around 90% of patients improve significantly within 2 months of initial treatment. Preliminary treatment methods may include:

  • Stretching (of the plantar fascia and calf), including ‘ice bottle rolling’;[9]
  • Wrapping non-stretch tape around the affected area to offload plantar fascia strain;
  • Wearing more supportive footwear with increased cushioning in the sole, especially designed to support the heel;[10]
  • Wearing an orthotic foot support; and
  • Wearing night splints. Alternatively, wearing splints on multiple occasions during the course of the day for periods of 15-30 minutes at a time.

If initial treatment methods are unsuccessful, physiotherapy sessions and anti-inflammatory (corticosteroid) medications are commonly prescribed. Some studies suggest that cortisone injections should not be administered because their short-term benefits are outweighed by retarded progress in the medium-to-long term. Cortisone therapy therefore carries a possible risk of recurrent plantar fasciitis.

The only scenario where the NHS will recommend surgery is if plantar fasciitis does not improve within at least a year or 2 of initial development. This is rare.

WHAT ARE THE CAUSES?

Although it is generally understood that plantar fasciitis is caused by traction injury (severe movement stretching injury) and repetitive overstretching over time, the aetiology of plantar fasciitis is unknown. There is a range of opinion among clinicians.

Nevertheless, Beeson (2005)[11] was able to identify multiple risk factors of plantar fasciitis, both intrinsic (within the body) and extrinsic (environmental):

  • Age – From ‘middle-age’ (40) onwards, the arch of the foot begins to sag and this explains why plantar fasciitis incidence increases with age (peak incidence occurs in patients aged between 45 and 64 years-old).
  • Gender – There does not appear to be a difference in prevalence between men and women.
  • Body weight – It has been found that overweight or obese patients have a 1.4-fold increase in risk of suffering chronic plantar fasciitis.[12] On this premise, pregnancy has been linked to plantar fasciitis, during which additional swelling can relax foot ligaments and alter biomechanics.
  • Heel spurs – Just because plantar fasciitis and calcaneal spurs co-exist does not mean that there is an association between the two. A 2016 study concluded that the shape and size of spurs are not correlated with heel function or pain in plantar fasciitis patients.[13]
  • Nerve entrapment – Baxter’s nerve is an example of neuritis, or nerve entrapment, which can stimulate plantar fasciitis. It is observed in those who complain of sensory disturbance and radiation of pain, despite undergoing a course of therapy.
  • Systemic disease – To reiterate, spondyloarthritis can be prevalent in younger patients with bilateral heel pain.[14] Generally speaking, arthritic conditions, such as gout, can cause inflammation in the tendons in the bottom of the feet.[15] What is more, increased thickness of plantar fascia in diabetic patients has been associated with an increased risk of plantar fasciitis.[16]
  • Genetics – We discussed above, that screening for HLA-B27 commonly takes place, but other genetic predispositions may also play a role in the progressive contracture of connective tissue.
  • Biomechanical dysfunction – Poor lower limb biomechanics, e.g. ‘flat feet’ (over-pronation of the foot) and weak foot arch control muscles, may reduce shock absorption, affecting the strain on plantar fascia. Some have also linked plantar fasciitis with the co-existence of a tight gastrocnemius muscle (calf muscle).[17]
  • Unsuitable footwear – Wearing shoes with poor arch support (e.g. flip flops and pumps), is thought to be associated with the disorder.
  • Lifestyle/occupation – Sports,[18] military activities[19] and Irish dancing[20] have all been connected with plantar fasciitis. Effectively, activities (e.g. running, long periods of walking or standing on hard flooring, etc.) which place excessive strain on the heel bone and attached tissue, may pose a risk.

ARE ANY OF THESE CAUSES LIKELY TO BE WORK RELATED?

Certain jobs, such as long shift work, may involve extensive periods of standing or walking, which is a risk factor of plantar fasciitis (see the causation section above). If a worker is wearing unsuitable footwear, this could serve to exacerbate the issue.

Accident Advice Helpline, which refers to plantar fasciitis as ‘plantar fascia rupture’, cites dinner ladies and shop workers as specific employees at risk. [21]

What does the academic literature say?

Certain studies, e.g. Lapidus et al (1965)[22] and Wells et al (1990),[23] which concluded that workers who spent prolonged periods on their feet were at higher risk of plantar fasciitis, can be dismissed, as they did not compare participant results against a control group, rendering their findings inconclusive.

Waclawski et al (2015), investigated the link between ‘weight-bearing tasks such as walking and standing on hard surfaces’ and incidence of plantar fasciitis. The research paper concluded that there was low-quality evidence of an association and the only occupation specifically identified as having a higher risk was engine assembly plant workers. Thus, further research was demanded to fully determine whether there is an association.

The connection between standing and plantar fasciitis in engine assembly workers was first observed in the study of Werner et al (2010),[24] in which ‘increasing time spent standing on hard surfaces, increased time spent walking, medium tenure at the plant, and an increased number of times getting in and out of the vehicle (for the truck/forklift drivers) increased the risk of presenting with plantar fasciitis’. The researchers went on to advise that allowing workers to alternate between sitting and standing may lower the risk for plantar fasciitis. However there was no evidence in support of this intimation.

Elsewhere, Riddle et al (2003)[25] noted that, although work-related weight bearing appeared to be an independent risk factor for plantar fasciitis, reduced ankle dorsiflexion was the ‘most important’ (or most significant) risk factor, followed by individuals who had a body-mass index of >30 kg/m2. Basically, work-related weight bearing was the least significant risk factor of all risk factors measured.

Conducting an assessment of plantar fasciitis risk within the US military, no employment categories studied by Owens et al (2013)[26] displayed a more than 2-fold increase in risk, compared to the general population:

  • Electronic equipment repair 1.56-fold increase;
  • Healthcare: 1.55-fold increase;
  • Admin or functional support: – 1.30-fold increase;
  • Equipment repair: 1.26-fold increase;
  • Craft work: 1.48-fold increase; and
  • Service and Supply: 1.36-fold increase.

In addition, Irving et al. (2007) found no association with time spent standing, sitting, walking on uneven ground, squatting, climbing or lifting at work,[27] while Gill and Kiebzak (2012)[28] reported a 1.45-fold increase in risk of plantar fasciitis among 411 participants who walked on hard floor ‘most of time’.

It is evident from the literature, therefore, that an association between possible employment risk factors and plantar fasciitis is weak, at best. Where associations have been isolated, they have seldom demonstrated a ‘doubling of risk’.

The only plantar fasciitis studies to report a more than ‘doubling of risk’ were Ryan (1989) and Buckle (1986), which were both analysed in a Canadian paper. However, these studies in supermarket staff made specific reference to associations with ‘foot pain’ and not plantar fasciitis.[29]

In any event, in a critical review of foot and ankle disorder aetiology, quoted by HSE, Guyton et al. (2000) did not support the view that ‘heel pain’ is caused by ‘cumulative trauma such as may occur in industrial workplaces’.[30]

WHAT ARE THE PROSPECTS OF SUCCESS FOR CLAIMANTS BRINGING OCCUPATIONAL PLANTAR FASCIITIS CLAIMS?

As stated earlier in this article, an estimated 10% of people suffer from plantar fasciitis within their lifetime. It is a common condition with multiple comorbidities. Adding insult to injury, excessive walking or standing, or wearing inappropriate footwear, are not exposure sources exclusive to work.

Somewhat frustratingly, while some argue that (long) periods of activity may be a risk factor of plantar fasciitis, it is also argued that long periods of inactivity may increase the risk of the condition.[31] Much like the debate between sitting and standing, it begs the question whether conditions like plantar fasciitis can ever be prevented?

From a medical causation aspect, it would be a challenge for an expert to be able to differentiate between the proportionate contributions of occupational and non-occupational exposures, especially if it is ascertained that occupational risk factors do not surpass the legal threshold of at least ‘doubling the risk’ of plantar fasciitis.

In terms of submissions on breach of duty, occupational plantar fasciitis claimants may argue, in a hypothetical claim, that their defendant employers have breached Article 3 of the Management of Health and Safety at Work Regulations 1999:

17.png

What is more, if a claimant alleges that their employer(s) failed to provide them with the appropriate footwear, which was the direct cause of their alleged condition, it is possible that Articles 4, 5, 6, 7, 9, 10 and 12 of the Personal Protective Equipment at Work Regulations 1992 will apply:

18.png

19.png

20.png

21.png

22.png

23.png

24.png

Although the HSE has published Guidance on the 1992 Regulations (now in its 3rd edition), within the section on ‘hazards which could require foot protection’, there is no reference to hard floors, or prolonged periods of standing, or walking.

25.png

It may be that this is because ‘PPE is not necessary when the risk is insignificant’ (see paragraph 29). Can an employer be in breach of their duty to provide adequate footwear if the risk of occupational standing or walking, as a risk factor of plantar fasciitis, is low?

26.png

Nevertheless, there are references to an employers’ duty to ensure that footwear is ‘cushioned’ and ‘comfortable’:

27.png

WHAT WOULD BE AN APPROPRIATE LEVEL OF DAMAGES IN A SUCCESSFUL CLAIM?

Tylers Solicitors asserts that a typical award of general damages for pain, suffering and loss of amenity in a plantar fasciitis claim varies between £10,000 and £30,000, depending on the severity of the injury.

By this reckoning, Tylers’ assessment of damages implies that plantar fasciitis injuries fall within the ‘moderate’-to-‘serious’ brackets of foot injuries in the 14th edition of the JC Guidelines.

28.png

However, since 90% of plantar fasciitis cases resolve within a couple of months, it would be more accurate to describe cases as being ‘modest’ (up to the value of £10,960), as Chapter 7(P)(g) covers ‘minor foot injuries resolving within a short space of time’. In fact:

‘... minor foot injuries resolving within a few months, with little impact on lifestyle or day to day activities, are unlikely to exceed £1,950 (£2,150 accounting for 10% uplift)’.

 

[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 Int2004;25:303–310 <https://www.ncbi.nlm.nih.gov/pubmed/15134610/> accessed 6 June 2019.

[2] J. Miller and Z. Russell, ‘Plantar Fasciitis’ (Physio Works) <https://physioworks.com.au/injuries-conditions-1/plantar-fasciitis> accessed 6 June 2019.

[3] Irving et al., Obesity and pronated foot type may increase the risk of chronic plantar heel pain: a matched case-control study. BMC Musculoskelet Disord. 2007 May 17;8:41. <https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-8-41> accessed 7 June 2019.

[4] Nicola Blower, ‘Managing plantar heel pain in the pharmacy’ (4 December 2018 Pharmaceutical Journal) <https://www.pharmaceutical-journal.com/learning/learning-article/managing-plantar-heel-pain-in-the-pharmacy/20205661.article?firstPass=false> accessed 7 June 2019.

[5] ‘Heel pain’ (1 April 2019 NHS) <https://www.nhs.uk/conditions/foot-pain/heel-pain/> accessed 6 June 2019.

[6] ‘Heel Pain’ (APMA) <https://www.apma.org/Patients/FootHealth.cfm?ItemNumber=985> accessed 6 June 2019

[7] Monteagudo M. et al., Plantar fasciopathy – A current concepts review. EFORT Open Rev. 2018 Aug; 3(8): 485–493 <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6134886/> accessed 6 June 2019.

[8] Information for Patients: Plantar Fasciopathy (aka plantar fasciitis) (NHS Borders) <https://www.nhsborders.scot.nhs.uk/media/450853/Plantar-Fasciopathy-Patient-Information-leaflet-December-2016.pdf> accessed 6 June 2019.

[9] Thompson JV et al., Diagnosis and management of plantar fasciitis. J Am Osteopath Assoc. 2014 Dec;114(12):900-6. <https://www.ncbi.nlm.nih.gov/pubmed/25429080> accessed 7 June 2019.

[10] <http://www.healthy-footwear-guide.com/> accessed 7 June 2019.

[11] Beeson P. Plantar fasciopathy: revisiting the risk factors. Foot Ankle Surg 2014;20:160–165. <https://www.ncbi.nlm.nih.gov/pubmed/25103701> accessed 6 June 2019.

[12] Frey C, Zamora J. The effects of obesity on orthopaedic foot and ankle pathology. Foot Ankle Int 2007;28:996–999. <https://www.ncbi.nlm.nih.gov/pubmed/17880874> accessed 6 June 2019.

Van Leeuwen KD, Rogers J, Winzenberg T, van Middelkoop M. Higher body mass index is associated with plantar fasciopathy/‘plantar fasciitis’: systematic review and meta-analysis of various clinical and imaging risk factors. Br J Sports Med 2016;50:972–981. <https://www.ncbi.nlm.nih.gov/pubmed/26644427> accessed 6 June 2019.

[13] Ahmad J, Karim A, Daniel JN. Relationship and classification of plantar heel spurs in patients with plantar fasciitis. Foot Ankle Int 2016;37:994–1000. <https://www.ncbi.nlm.nih.gov/pubmed/27177888> accessed 6 June 2019.

[14] Barouk LS, Baudet B, Bonnel F, et al. Gastrocnemius tightness: from anatomy to treatment. Montpellier: Sauramps Médical, 2012. 

[15] Cutts S. et al., Plantar fasciitis. Ann R Coll Surg Engl. 2012 Nov; 94(8): 539–542. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3954277/> accessed 6 June 2019.

[16] D’Ambrogi E. et al., Contribution of Plantar Fascia to the Increased Forefoot Pressures in Diabetic Patients. Diabetes Care 2003 May; 26(5): 1525-1529. <http://care.diabetesjournals.org/content/26/5/1525> accessed 6 June 2019.

[17] Amis J. The gastrocnemius: a new paradigm for the human foot and ankle. Foot Ankle Clin N Am 2014;19:637–647. <https://www.ncbi.nlm.nih.gov/pubmed/25456713> accessed 6 June 2019.

[18] Sobhani S, Dekker R, Postema K, Dijkstra PU. Epidemiology of ankle and foot overuse injuries in sports: a systematic review. Scand J Med Sci Sports 2013;23:669–686. <https://www.ncbi.nlm.nih.gov/pubmed/22846101> accessed 7 June 2019. 

[19] Scher DL, Belmont PJ, Jr, Bear R, et al. The incidence of plantar fasciitis in the United States military. J Bone Joint Surg Am 2009;91:2867–2872. <https://www.ncbi.nlm.nih.gov/pubmed/19952249> accessed 7 June 2019.

[20] Noon M, Hoch AZ, McNamara L, Schimke J. Injury patterns in female Irish dancers. PM R 2010;2:1030–1034. <https://www.ncbi.nlm.nih.gov/pubmed/20800567> accessed 7 June 2019.

[21] ‘Claiming for a foot injury plantar fascia rupture’ (Accident Advice Helpline) <https://www.accidentadvicehelpline.co.uk/blog/claiming-foot-injury-plantar-fascia-rupture/> accessed 6 June 2019.

[22] Lapidus et al., PAINFUL HEEL: REPORT OF 323 PATIENTS WITH 364 PAINFUL HEELS. Clin Orthop Relat Res. 1965 Mar-Apr;39:178-86. <https://www.ncbi.nlm.nih.gov/pubmed/14289759/> accessed 7 June 2019.

[23] Wells R, Ranney D, Norman R, Brawley L, Orr S. 1990. Ergonomics of the supermarket cashiers' environment. University of Waterloo, Ontario, Canada.

[24] Werner et al., Risk factors for plantar fasciitis among assembly plant workers. PM R. 2010 Feb;2(2):110-6; <https://www.ncbi.nlm.nih.gov/pubmed/20193937> accessed 7 June 2019.

[25] Riddle DL et al., Risk factors for Plantar fasciitis: a matched case-control study. J Bone Joint Surg Am. 2003 May;85(5):872-7. <https://pdfs.semanticscholar.org/d30a/6a6e5c88841801931137b54ed9870af8c9b6.pdf> accessed 7 June 2019.

[26] Owens et al., Risk Factors for Lower Extremity Tendinopathies in Military Personnel. Orthop J Sports Med. 2013 Jan-Jun; 1(1): 2325967113492707. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4555504/pdf/10.1177_2325967113492707.pdf> accessed 7 June 2019.

[27] Irving et al., Obesity and pronated foot type may increase the risk of chronic plantar heel pain: a matched case-control study. BMC Musculoskelet Disord. 2007 May 17;8:41. <https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-8-41> accessed 7 June 2019.

[28] Gill and Kiebzak et al., Outcome of nonsurgical treatment for plantar fasciitis. Foot Ankle Int. 1996 Sep;17(9):527-32. <https://www.ncbi.nlm.nih.gov/pubmed/8886778> accessed 7 June 2019.

[29] Wong R, IS WORK EXPOSURE A RISK FACTOR FOR PLANTAR FASCIITIS?

<https://pdfs.semanticscholar.org/a7f2/cdbe068b218857bcb04ca3b1e064e7d3e5bc.pdf> accessed 7 June 2019.

[30] ‘Lower limb MSD’ (2009 HSE) <http://www.hse.gov.uk/research/rrpdf/rr706.pdf> accessed 7 June 2019.

[31] Cole C Seto C Gazewood J . Plantar fasciitis: evidence-based review of diagnosis and therapy. Am Fam Physician  2005;72:2237–2242. <https://www.aafp.org/afp/2005/1201/p2237.html> accessed 7 June 2019.