Plantar Heel Pain Workup

Updated: Mar 28, 2022
  • Author: Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS; Chief Editor: Thomas M DeBerardino, MD, FAAOS, FAOA  more...
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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).


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 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 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.

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.


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]