eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Plantar Heel Pain

Author: Vinod K Panchbhavi, MD, Assistant Professor of Orthopedics, Department of Orthopedics and Rehabilitation, University of Texas Medical Branch
Contributor Information and Disclosures

Updated: Jun 17, 2008

Introduction

Background

Plantar heel pain is a commonly encountered orthopedic problem that can cause significant discomfort and a limp because of the difficulty in bearing weight. The etiologies of this condition are multiple; therefore, a careful clinical evaluation is necessary for its appropriate management. Nonsurgical or conservative care is successful in most cases.^{1,2,3,4,5,6,7,8,9,10}

For excellent patient education resources, visit eMedicine's Sports Injury Center and Foot, Ankle, Knee, and Hip Center. Also, see eMedicine's patient education articles Running and Arch Pain.

Related eMedicine topics:
Overuse Injury
Plantar Fasciitis [in the Emergency Medicine section]
Plantar Fasciitis [in the Sports Medicine section]

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Pathophysiology

The specialized soft tissue at the heel functions as a shock absorber. The subcutaneous structure consists of fibrous lamellae arranged in a complex whorl containing adipose tissues that attach with vertical fibers to the dermis and the plantar aponeurosis.

The heel can absorb 110% of the body's weight during walking and 200% of the body's weight during running. The plantar fascia is a multilayered fibroaponeurotic structure that arises predominantly from the medial calcaneal tuberosity and inserts distally through several slips into the plantar plates of the metatarsophalangeal joints, the flexor tendon sheaths, and the bases of the proximal phalanges of the toes.

Dorsiflexion of the toes applies traction stress at the origin of the plantar fascia. A contracture in the triceps surae, a pes cavus, or a pes planus can increase the traction load at the origin of the plantar fascia during weight-bearing activities.

Other anatomic factors that can have similar effects are overpronation, discrepancy in leg length, excessive lateral tibial torsion, and excessive femoral anteversion. However, overuse, not anatomy, is the most common cause of plantar fasciitis in athletes. The pain of plantar fasciitis is caused by collagen degeneration associated with repetitive microtears of the plantar fascia.

An inflammatory response and reparative process can double the thickness of the plantar fascia, which is normally approximately 3 mm. Biopsy specimens reveal collagen necrosis, angiofibroblastic hyperplasia, chondroid metaplasia, and calcification.

The heel pain can also have a neurologic basis. The tibial nerve, with nerve roots from L4-5 and S2-4, courses in the medial aspect of the hindfoot, through the tarsal tunnel, under the flexor retinaculum, and over the medial surface of the calcaneus. The calcaneal branch, arising directly from the tibial nerve, carries sensation from the medial and plantar heel dermis.

The tibial nerve divides into lateral and medial plantar nerves, which proceed into the plantar aspect of the foot through a foramen within the origin of the abductor hallucis muscles, which forms the distal tarsal tunnel. The first branch of the lateral plantar nerve changes course from a vertical to a horizontal direction around the medial plantar heel. It passes deep to the abductor hallucis muscle fascia and the plantar fascia and is the nerve supply to the abductor digiti minimi muscle. The tibial nerve and its branches in the hindfoot can be involved with compressive neuropathies. A valgus heel can stretch in the tibial nerve.

Related eMedicine topics:
Acute Nerve Injury
Nerve Entrapment Syndromes of the Lower Extremity
Tibial Bowing

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Frequency

United States

More than 2 million Americans seek treatment for plantar heel pain each year.

International

In both athletic and nonathletic populations, the incidence of plantar fasciitis is reported to be approximately 10%.

Sex

Proximal plantar fasciitis is twice as common in women as in men.

Age

The average age of a patient with proximal plantar fasciitis is approximately 45 years.

Clinical

History

A careful history and physical examination is valuable in identifying the etiology of heel pain. Taking a comprehensive medical and general history is important in order to distinguish between various causes. Seek the history on all the characteristics of the pain, such as onset, location, radiation, modifying factors, relation to time of the day, and relation to activities.

• The most common cause of plantar heel pain in both athletic and nonathletic populations is proximal plantar fasciitis. Patients usually have occupations that involve spending most of their time on their feet. The pain is often unilateral, but it can manifest bilaterally, with one side being more painful than the other.
• The discomfort commonly manifests spontaneously and insidiously without an antecedent trauma or fever. Occasionally, some patients state they might have stepped on a small object such as a pebble or they may have recently started an exercise regimen involving walking or running. Some patients may have a history of recent weight gain.
• The pain is localized to the plantar and medial aspects of the heel. It is worse typically with the first few steps in the morning. The pain causes patients to limp for approximately half an hour. It is also worse after a period of rest, such as after standing up from a chair or getting out of a car.
• The pain then improves with walking and stretching, but prolonged walking and standing aggravate the pain. The pain can be present with every step, causing a limp, and patients tend to walk bearing weight on the forefoot and the outer aspect of the foot.
• An acute onset of pain, especially after a vigorous or sudden athletic activity, can be indicative of traumatic rupture of the plantar fascia.
• Fat pad atrophy in elderly patients and in persons who have received multiple steroid injections manifests with pain under the heel that is more diffuse, involving most of the weight-bearing surface. The pain worsens when the patients walk on hard surfaces and when they wear hard-soled footwear. The initial improvement in walking observed in patients with plantar fasciitis is not observed in patients with fat pad atrophy.
• Pain radiating from the heel distally or proximally and associated with numbness, paresthesia, or a burning sensation after activity and continuing even after rest is likely to be neurologic in origin. This is usually due to a compressive neuropathy locally, as in tarsal tunnel syndrome, or proximally at the level of the nerve root, in which case low back pain may be associated.
• Bilateral heel pain and pain at the tendon insertions (or enthesopathy), especially associated with general symptoms such as malaise, recurrent fever, multiple joint pains, or bowel dysfunction, may indicate an association with inflammatory disorders such as rheumatoid arthritis, spondyloarthropathies, Reiter syndrome, or Behcet syndrome.
• Significant loss of appetite and weight or pain at night can be indicative of a neoplasm.

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Physical

A general examination is necessary to rule out systemic causes of heel pain. A spine examination is required if the pain radiates.

• In the local examination, inspect the foot and the heel for any abnormalities such as swelling, lumps, scars, bruising, or foot deformities such as pes planus or pes cavus.
• Palpation is performed to elicit the site of maximum tenderness. Check the condition of the fad pad, feel for defects or lumps in the plantar fascia, and identify any bony deformity due to previous fractures.
• Percussion over the tibial nerve in the tarsal tunnel and its distal branches is performed to check for hypersensitivity or tingling. Percussion over any previous scars in the region can be performed to detect a neuroma in the scar.
• Examining the range of motion at the ankle joint and a performing a Silfverskiöld test reveals any stiffness in the gastrocnemius and/or the triceps surae complex.
• In persons with proximal plantar fasciitis, the tenderness is typically localized over the medial calcaneal tuberosity at the origin of the plantar fascia. Associated features may include a triceps surae contracture, decreased subtalar mobility, pes cavus, or pes planus. These conditions can create increased tension on the plantar fascia. However, when a clinical test is performed to stretch the plantar fascia by dorsiflexion of the toes, patients do not experience any aggravation of pain. On the other hand, pain may be aggravated by this maneuver in persons with an acute plantar fascia rupture, which may be accompanied by localized bruising or even a palpable defect.
• Tenderness upon squeezing both the medial and lateral sides of the posterior calcaneal tuberosity is highly indicative of a stress fracture in the calcaneus, and this may be associated with local edema.
• In persons with compressive neuropathy, either of the tibial nerve in the tarsal tunnel or of the first branch of the lateral plantar nerve, the point of maximal tenderness in the heel is located more medially in the posterior heel.
• Percussion over the tibial nerve branches elicits tingling, burning, or numbness. A valgus heel associated with pes planus or acquired flat foot can put increased stretch on the tibial nerve and can cause tarsal tunnel syndrome.
• In elderly patients or persons who have had multiple steroid injections in the heel, the pain and tenderness is maximal over the central weight-bearing area of the heel. Dorsiflexion of the toes does not aggravate the pain. The heel does not have the usual firmness; it feels soft and the underlying calcaneus is more readily palpable.

Related eMedicine topics:
Black Heel (Calcaneal Petechiae)
Calcaneal Bursitis
Fracture, Foot

Causes

• Local
  • Proximal plantar fasciitis
  • Fat pad atrophy
  • Plantar fascia rupture
  • Tarsal tunnel syndrome
  • Compression of the first branch of the lateral plantar nerve
  • Plantar fasciitis coexisting with compression of the first branch of lateral plantar nerve
  • Stress fracture of the calcaneus
  • Bone tumor or bone cyst
  • Osteomyelitis
• Regional
  • Spinal stenosis
  • Prolapsed intervertebral disc
• Systemic
  • Inflammatory bowel disease –associated arthritis
  • Seronegative spondyloarthropathies
  • Inflammatory arthritis (ie, rheumatoid arthritis)

• Search for CME/CE on This Topic »

• Plantar Fasciitis (Orthopedic Surgery)
• Pes Planus (Orthopedic Surgery)
• Plantar Fasciitis (Physical Medicine and Rehabilitation)

• AAOS 2009: Shock-Wave Therapy Effectively Eases Chronic Plantar Heel Pain