Plantar Heel Pain Clinical Presentation

Updated: May 11, 2017
  • Author: Vinod K Panchbhavi, MD, FACS; Chief Editor: Anthony E Johnson, MD, FAOA, FACS  more...
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Presentation

History

A careful history and a thorough physical examination are valuable in identifying the etiology of heel pain. Taking a comprehensive medical and general history is important for distinguishing 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. [15] 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 it is aggravated by prolonged walking and standing. 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, which can exacerbate the problem.

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 weightbearing 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. Heel pain in elderly patients or patients with atypical presentations should be investigated for deficiency fractures or for tumors.

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Physical Examination

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

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. Practitioners should be cognizant of the "windlass mechanism" of the plantar fascia. [16, 17] 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. [18]

The association between plantar fasciitis and isolated contracture of the gastrocnemius was studied by Patel et al in a prospective evaluation of patients with either acute or chronic plantar fasciitis (N=254). Of the 254 patients, 83% (n=211) had limited ankle dorsiflexion, 57% (n=145) had an isolated contracture of the gastrocnemius, 26% (n=66) had a contracture of the gastrocnemius-soleus complex, and only 17% (n=43) did not have a dorsiflexion limitation. Equinus contracture was noted in 83% (129/155) of acute cases and 82% (82/99) of chronic cases. An isolated contracture of the gastrocnemius was found in 60% (93/155) of acute cases and 52% (52/99) of chronic cases. [19]

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 (see the image below). [20]

Edema localized to plantar heel on the left foot i Edema localized to plantar heel on the left foot in a patient with calcaneal stress fracture compared to the normal right heel

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 flatfoot 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 weightbearing 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.

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