Plantar Fasciitis Clinical Presentation

Updated: Nov 28, 2016
  • Author: Craig C Young, MD; Chief Editor: Craig C Young, MD  more...
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Presentation

History

The sine qua non of plantar fasciitis is a history of intense sharp heel pain with the first couple of steps in the morning or after other long periods without weight-bearing. [7] Pain is experienced primarily on the plantar surface of the foot at the anterior aspect of the calcaneus, but it may radiate proximally in more severe cases. A limp may be present, and patients may prefer to walk on their toes. Associated paresthesias, nocturnal pain, or systemic symptoms should raise suspicion of other causes of heel pain (ie, neoplastic, infectious, neurologic causes).

Initially, the pain decreases with ambulation or athletic warmup, but then increases throughout the day as activity increases. In more severe cases, patients complain of heel pain after periods of prolonged sitting. A dull ache may be felt in the heel at the end of the day, especially after extensive walking or standing. In addition to pain, patients may complain of stiffness in the foot and localized swelling in the heel.

An important element in the history is the period preceding the start of plantar fasciitis. 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 may have recently changed footwear (eg, started a barefoot style running program). They may have sustained previous trauma to the foot (eg, falls, motor vehicle accidents, work-related injuries).

Any precipitating factors should be identified if possible. Ask the patient what makes the pain worse and what makes it better.

  • Most patients report that the pain usually is most severe during the first few steps after prolonged inactivity, such as sleeping or sitting
  • Patients may report that symptoms typically are relieved by unloading the affected foot (via sitting, elevation, or other means)
  • Pain may be worsened by walking barefoot on hard surfaces or by walking up stairs
  • In athletes, the pain may be particularly aggravated by sprinting
  • Patients who are generally on their feet all day report that the symptoms may actually worsen by the end of the day

If this condition occurred in the course of the patient’s employment, then it may be considered a worker’s compensation issue. The physician should obtain a thorough history of the onset of the pain, any previous diagnostic assessment and/or treatments, and current functional capacities. This history is important for potential medicolegal purposes, such as impairment ratings.

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Physical Examination

The pain of plantar fasciitis can usually be reproduced by palpating the plantar-medial calcaneal tubercle at the site of plantar fascial insertion to the heel bone. [8] Less frequently, the pain will localize directly below the heel bone or even in the midsubstance of the plantar arch. In more severe cases, pain may be reproduced by palpation over the proximal portion of the plantar fascia.

A tight Achilles tendon (as in talipes equinus) is commonly a secondary finding and usually contributes to the pathology [8, 25] ; ankle dorsiflexion may be limited as a result. [26] Other findings may include various deformities, skin changes, and flat-foot or pes planus foot type, overpronation, pes cavus or high-arched foot type, leg-length discrepancy, excessive lateral tibial torsion, and excessive femoral anteversion.

Other maneuvers that may reproduce the pain of plantar fasciitis include passive dorsiflexion of the toes, which is sometimes called the windlass test, and having the patient stand on the tiptoes and toe-walk. In a study by De Garceau et al, having the patient bear weight during the windlass test (see the image below) increased the sensitivity of the test from 13.6% to 31.8%. [27]

Weight-bearing windlass test. Weight-bearing windlass test.

To ensure that the patient is not presenting with retrocalcaneal bursitis or Achilles tendonitis, the clinician also should palpate the posterior aspect of the heel and ankle to look for tenderness.

Reproduction of pain in the forefoot by compressing together the metatarsal heads of the second and third or the third and fourth toes suggests the presence of a Morton neuroma and is not a typical finding in plantar fasciitis. Morton neuroma is due to the entrapment of the common digital nerve between the metatarsal heads.

A full musculoskeletal examination, including range of motion of hind-foot joints and medial-to-lateral squeeze of the calcaneus, aids further in diagnosis. Pain with compression is more frequently seen in stress fracture.

Tarsal tunnel syndrome can be ruled out by percussing over the tarsal tunnel behind the medial malleolus. This test produces no pain in patients with plantar fasciitis. To rule out an S1 radiculopathy, perform the straight leg raise test, the Achilles tendon reflex, and calf strength assessment with toe-walking, or 1-legged heel raises. In patients with plantar fasciitis, the results of all of these tests are within the reference range.

The vascular examination includes palpation of the foot and ankle pulses. The Perthes test can be used to determine whether tortuous varicosities are contributing to the medial heel pain. In this test, a blood pressure cuff is inflated just proximal to the ankle at a pressure just below the patient’s systolic pressure, causing engorgement of symptomatic varicosities that may be entrapping the tibial nerve or causing claudication-type symptoms.

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Complications

In rare cases, the plantar fascia may rupture spontaneously. The risk of such a rupture is greatly increased by a history of treatment with a corticosteroid injection. [28] Long-term sequelae of rupture occur in approximately 50% of the patients who have a plantar fascia rupture. [28, 29] Moreover, longitudinal arch strain accounts for over 50% of the chronic complications of plantar fascia rupture. [28, 29]

Corticosteroid injection into the superficial fat pad may cause fat pad necrosis, due to loss of the shock absorption normally provided by the superficial fat pad, with subsequent pain during the early part of stance phase with ambulation. This development could create a significant disability in the event of a worker’s compensation case.

Potential complications include flattening of the longitudinal arch and heel hypoesthesia, as well as the potential complications that are associated with plantar fascia rupture. Longitudinal arch strain appears to account for over 50% of the chronic complications. [28, 29]

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