Laboratory Studies

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

Radiography

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 weightbearing 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.^{[23, 24]} (See the image below.)

Lateral radiograph of the hindfoot showing a cyst in the anterior aspect of the calcaneus in a 19-year-old patient who presented with heel pain.

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However, a report by Johal and Milner suggests a significant association between plantar fasciitis and calcaneal spur formation. In their study, the lateral heel radiographs of 19 patients with a diagnosis of plantar fasciitis and 19 comparison subjects with a lateral ankle ligament sprain matched for age and sex, were reviewed independently by two observers. Objective measurements of calcaneal spur length and a subjective grading of spur size were recorded. There was a significantly higher prevalence of calcaneal spurs in the plantar fasciitis group than in the comparison group (89% vs 32%). There was good interobserver and intraobserver agreement.^[25]

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.

Ultrasonography

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.^{[6, 26]}

Magnetic resonance imaging

Magnetic resonance imaging (MRI) can be used to confirm a diagnosis, such as a stress fracture, especially in the early stages before it is detectable with plain radiography. 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 that could cause a tarsal tunnel syndrome are also revealed.^[27]

Treatment & Management

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Media Gallery

Soft heel cushion to absorb shock.
Soft heel cushion and a cup.
Custom-molded orthotic.
Stretching exercise. Lean against the wall with the knee kept straight and the heel touching the floor.
Stretching the back of the leg at the edge of a stair.
Massaging and stretching the plantar fascia using a can.
A night splint applied on back of the leg and foot.
A night splint applied on the front of the leg.
Lateral radiograph of the hindfoot showing a cyst in the anterior aspect of the calcaneus in a 19-year-old patient who presented with heel pain.
Plantar fascia tissue-specific stretching exercise
Edema localized to plantar heel on the left foot in a patient with calcaneal stress fracture compared to the normal right heel

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Author

Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS Professor, Department of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedic Surgery, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Thomas M DeBerardino, MD, FAAOS, FAOA Professor of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, Joe R and Teresa Lozano Long School of Medicine; Professor of Orthopaedic Surgery and Faculty of Sports Medicine Fellowship, Baylor College of Medicine; Sports Medicine Orthopaedic Surgeon, Department of Orthopaedics, UT Health San Antonio; Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder

Thomas M DeBerardino, MD, FAAOS, FAOA is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Clinical Orthopaedic Society, Herodicus Society, International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Arthrex, Inc.; MTF; Aesculap; Conmed; JRF<br/>Received research grant from: Arthrex, Inc.; MTF.

Additional Contributors

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, Florida Medical Association

Disclosure: Nothing to disclose.