eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Plantar Heel Pain: Differential Diagnoses & Workup

Author: Vinod K Panchbhavi, MD, FRCS, FACS, Associate Professor, Chief, Division of Foot and Ankle Surgery, Department of Orthopedics, University of Texas Medical Branch School of Medicine
Contributor Information and Disclosures

Updated: Jun 17, 2008

Differential Diagnoses

Achilles Tendon Pathology
Tarsal Tunnel Syndrome

Other Problems to Be Considered

Pain under the arch

  • Distal plantar fasciitis: The tenderness is under the mid foot, and, as opposed to proximal plantar fasciitis, dorsiflexion of the toes aggravates pain.
  • Plantar fibromatosis: Painful nodules or lumps are palpable in the plantar fascia.

Pain on the posterior aspect of the hindfoot

  • Insertional Achilles tendinitis: Pain, tenderness, and a bony prominence are mainly located at the back of the heel. Plain radiographs may show calcification at the insertion of the Achilles tendon.
  • Haglund syndrome: This is a term given to the prominent posterosuperior corner of the calcaneus that is thought to impinge on the Achilles tendon and give rise to pain, swelling, and tenderness in the posterior aspect of the heel. The diagnosis is made based on plain radiographic findings.
  • Pump bump: This is a term used to describe a prominent posterolateral protuberance in the calcaneus near the attachment of the Achilles tendon. The pain is usually caused by friction from footwear.
  • Flexor hallucis longus tenosynovitis: The pain and tenderness are posteromedial at the level of the subtalar joint and can be aggravated by dorsiflexion of the great toe with the ankle held in full plantarflexion.
  • Posterior impingement of the os trigonal or Stieda process or fracture: Usually, activities that require acute plantar flexion, such as a pointe in ballet, can aggravate the pain, and the tenderness is posterolateral at the level of the subtalar joint.

Pain on the medial aspect of the ankle

  • Posterior tibial tendon dysfunction: This is associated with pain on the medial side of the ankle, which radiates proximally along the leg and distally into the mid foot. Swelling and pitting edema often occur over the region of the tendon. The patient has weakness in active inversion of the hindfoot and difficulty performing a single or double raise on the toes.
  • Medial ankle instability: The patient history includes an ankle sprain, followed later by the ankle giving way. The pain and tenderness are in the medial gutter of the ankle. The heel is in valgus; however, unlike posterior tibial tendon dysfunction, the heel valgus is corrected when the person raises up on the toes.

Pain on the lateral aspect of the ankle

  • Peroneal tendon dysfunction: The pain is on the lateral aspect of the heel over the peroneal tendons and behind the lateral malleolus. This may be associated with swelling, tenderness, and pes cavus.
  • Chronic lateral ankle sprain: Pain is on the lateral aspect of the ankle. The condition is associated with a history of repeated sprains of the ankle and symptoms of instability. The patient has swelling and tenderness at the points of attachment of the anterior talofibular and calcaneofibular ligaments. A positive drawer sign signifies ligament laxity. A pes cavus and heel varus may be contributory factors.
  • Sinus tarsi syndrome: This condition often follows a lateral ligament sprain of the ankle, and patients have pain and tenderness in the sinus tarsi region and lateral aspect of the hindfoot. The diagnosis is confirmed if symptoms improve with local injection of an anesthetic or a steroid. A magnetic resonance image (MRI) shows an obliteration of the fat plane, with or without interruption of the ligaments.

Workup

Laboratory Studies

  • Generally, plantar fasciitis is a clinical diagnosis; laboratory and imaging studies are rarely indicated. However, heel pain, especially bilaterally, can be a rare primary presenting sign of systemic inflammatory disorders. If a patient presents with bilateral heel pain in association with systemic symptoms, then screen the blood for inflammatory markers, such as the erythrocyte sedimentation rate (ESR), human leukocyte antigen (HLA)-B27, rheumatoid factor (RF), and antinuclear antibodies (ANA).

Imaging Studies

  • Heel spurs develops in the origin of the flexor digitorum brevis in approximately 50% of patients with proximal plantar fasciitis. The etiology is thought to be repetitive traction that leads to collagen degeneration, angiofibroblastic hyperplasia, and matrix calcification. Plain weight-bearing radiographs can show calcaneal spurs in approximately 50% of patients with plantar fasciitis, but, because spurs are frequently noted in patients without heel pain, the presence of calcaneal spurs is not considered contributory to the pain, and it does not affect the diagnosis or treatment.11 Plain radiographs showing the lateral view of the calcaneus can be useful in detecting a stress fracture, which appears as a double-dense sclerotic line. However, 3-4 weeks may pass from the onset of symptoms until the injury is detectable on plain radiographs. Bony infections or tumors can also be detected on plain radiographs.
  • Ultrasonographic examination of the plantar heel can identify a thickened plantar fascia, but this investigation and the interpretation of the results depend on the expertise of the person performing the procedure.7,12
  • MRI can be used to confirm a diagnosis, such as a stress fracture, especially in the early stages before it is detectable with plain radiographs. MRI is also used to investigate further for soft-tissue or bone lesions in the hindfoot. In persons with plantar fasciitis, this modality demonstrates edema and thickening of the plantar fascia, but MRI is not used to diagnose this condition. Any space-occupying lesions in the tarsal tunnel, which can cause a tarsal tunnel syndrome, is also revealed.13

More on Plantar Heel Pain

Overview: Plantar Heel Pain
Differential Diagnoses & Workup: Plantar Heel Pain
Treatment & Medication: Plantar Heel Pain
Follow-up: Plantar Heel Pain
Multimedia: Plantar Heel Pain
References
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References

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Further Reading

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Keywords

heel pain syndrome, plantar fasciitis, proximal plantar fasciitis, heel spur, plantar heel pain, tarsal tunnel syndrome, fat pad atrophy, heel pain, foot pain, plantar fascia rupture, lateral plantar nerve compression, calcaneal stress fracture, stress fracture of the calcaneus, bone tumor, bone cyst, osteomyelitis, spinal stenosis, prolapsed intervertebral disk, prolapsed intervertebral disc, arthritic inflammatory bowel disease, seronegative spondyloarthropathy, inflammatory arthritis, rheumatoid arthritis

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Contributor Information and Disclosures

Author

Vinod K Panchbhavi, MD, FRCS, FACS, Associate Professor, Chief, Division of Foot and Ankle Surgery, Department of Orthopedics, University of Texas Medical Branch School of Medicine
Vinod K Panchbhavi, MD, FRCS, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Foot and Ankle Society, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England, and Texas Orthopaedic Association
Disclosure: Nothing to disclose.

Medical Editor

Heidi M Stephens, MD, MBA, Associate Professor, Department of Surgery, Division of Orthopedic Surgery, University of South Florida College of Medicine; Courtesy Joint Associate Professor, Department of Environmental and Occupational Health, University of South Florida College of Public Health
Heidi M Stephens, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, and Florida Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Shepard R Hurwitz, MD, Executive Director, American Board of Orthopaedic Surgery
Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FACS, Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center
Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association
Disclosure: Nothing to disclose.

 
 
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