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Plantar Fasciitis : Diagnosis and Differentials

Author Information and Disclosures

Contents

Clinical

History:

  • The patient reports inferior heel pain with the first few steps taken in the morning or after other long periods of nonweightbearing.
  • A limp may be present, and patients may prefer to walk on their toes.
  • Initially, the pain decreases with ambulation but then increases throughout the day as activity increases. Pain is worsened by walking barefoot on hard surfaces or by walking up stairs.
  • Associated paresthesias, nocturnal pain, or systemic symptoms should raise suspicion of other causes of heel pain (ie, neoplastic, infectious, neurologic causes).
  • Patients may report that before the onset of pain, they had increased the amount or intensity of activity including, but not limited to, running or walking. They may have also started exercising on a different type of surface, or they may have recently changed footwear.

Physical:

  • The patient may have tenderness upon palpation of the anteromedial aspect of the heel.
  • Ankle dorsiflexion may be limited due to tightness of the Achilles tendon.
  • Pain may be exacerbated by passive dorsiflexion of the toes or by having the patient stand on his or her toes.

Causes:

  • The cause of plantar fasciitis is unclear and may be multifactorial. Because of the high incidence in runners, it is best postulated to be caused by repetitive microtrauma. Possible risk factors include obesity, occupations requiring prolonged standing, heel spurs, pes planus (excessive pronation of the foot), and reduced dorsiflexion of the ankle.

Differentials

Bursitis
Fractures, Foot
Osteomyelitis
Reiter Syndrome


Other Problems to be Considered:

Paget disease
Rupture of plantar fascia
S1 radiculopathy
Sickle cell disease
Spondyloarthropathy (ie, Reiter syndrome, ankylosing spondylitis, psoriatic arthritis)
Tarsal tunnel syndrome
Abductor digiti quinti nerve entrapment
Bone bruise
Calcaneal epiphysitis (Sever disease)
Calcaneal stress fracture
Fat-pad atrophy
Heel contusion
Inflammatory arthropathies
Neuropathic pain

Workup

Lab Studies:

  • Lab studies are not needed if plantar fasciitis is suspected. However, laboratory tests may be used to investigate other causes of heel pain if suspected.

Imaging Studies:

  • Diagnostic imaging is rarely indicated in the initial workup for plantar fasciitis. However, imaging studies may be helpful in defining the extent of the condition or if other etiology are suspected as the cause of the patient's of heel pain.
  • Plain radiographs can be used to detect calcaneal stress fractures and other bony lesions.
  • Ultrasonography, although rarely used, can aid in the diagnosis of plantar fasciitis. A marked increase in the thickness of the fascia (5-7 mm; normally 2-4 mm thick) may be noted. Other signs seen on sonogram include hypoechogenicity and edema of the fascia where it inserts into the calcaneus as well as loss of definition between the fascia and the surrounding soft tissue.
  • Plantar fascia thickening and surrounding edema can also be detected on magnetic resonance imaging (MRI).
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Bibliography

  1. Atkins D, Crawford F, Edwards J, Lambert M: A systematic review of treatments for the painful heel. Rheumatology (Oxford) 1999 Oct; 38(10): 968-73[Medline].
  2. Buchbinder R: Clinical practice. Plantar fasciitis. N Engl J Med 2004 May 20; 350(21): 2159-66[Medline].
  3. Cole C, Seto C, Gazewood J: Plantar fasciitis: evidence-based review of diagnosis and therapy. Am Fam Physician 2005 Dec 1; 72(11): 2237-42[Medline].
  4. Crawford F, Thomson C: Interventions for treating plantar heel pain. Cochrane Database Syst Rev 2003; CD000416[Medline].
  5. DiGiovanni BF, Nawoczenski DA, Lintal ME, et al: Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am 2003 Jul; 85-A(7): 1270-7[Medline].
  6. Hogan KA, Webb D, Shereff M: Endoscopic plantar fascia release. Foot Ankle Int 2004 Dec; 25(12): 875-81[Medline].
  7. Roxas M: Plantar fasciitis: diagnosis and therapeutic considerations. Altern Med Rev 2005 Jun; 10(2): 83-93[Medline].
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Synonyms And Related Keywords

plantar fasciitis, heel pain, jogger's heel, tennis heel, Policman's heel, bone spur, heel pain, pain on bottom of heel, exostosis, flat foot, highly-arched foot, excessively pronated foot, gait alteration, obesity, tight Achilles tendon, policeman's heel, pes planus, pes cavus

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Author Information and Disclosures

Author: Deepika Singh, MD, Staff Physician, Department of Emergency Medicine, Kings County Hospital Center

Coauthor(s): Mark A Silverberg, MD, FACEP, MMB, Assistant Professor of Emergency Medicine, State University of New York Downstate College of Medicine, Assistant Residency Director, Department of Emergency Medicine, Kings County Hospital; Leslie Milne, MD, Assistant Clinical Instructor, Department of Emergency Medicine, Harvard University School of Medicine

Deepika Singh, MD, is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Nurses Association, Emergency Medicine Residents' Association, and Sigma Theta Tau International

Editor Information

Editor(s): Miguel C Fernandez, MD, FACEP, FAAEM, FACMT, Associate Clinical Professor; Medical and Managing Director, South Texas Poison Center, Department of Surgery/Emergency Medicine and Toxicology, University of Texas Health Science Center at San Antonio; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Eric Legome, MD, Residency Director, Assistant Professor of Emergency Medicine, Department of Emergency Medicine New York University, New York University Hospital, Bellevue Hospital Center, Manhattan VA; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital

 
 
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