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Plantar fasciitis - Management
What else might it be?

  • If characteristic symptoms and signs are not consistent with plantar fasciitis, consider:
    • Calcaneal stress fracture, which typically presents with diffuse, warm swelling, and can be diagnosed by squeezing the calcaneum, inducing pain. It is confirmed by radiography, although changes may be subtle or even absent.
    • Achilles tendonitis may present with tenderness on palpation, and pain radiating up the calf with extension of the foot or standing on tiptoes (complete rupture causes severe pain and loss of foot stability). Flexor hallucis or posterior tibial tendonitis may also mimic plantar fasciitis.
    • Fat pad atrophy causes centralized heel pain, and a flattened atrophied surface may be felt on palpation.
    • Sub-calcaneal bursitis typically affects obese people or athletes, and presents as posterior heel pain under the fat pad of the calcaneum.
  • Other causes less likely to be misdiagnosed as plantar fasciitis include:
    • Neurological causes:
      • Tarsal tunnel syndrome, which is detected by a positive 'Tinel's sign' on a dorsiflexed, everted foot (often missed in primary care).
      • S1 radiculopathy causes pain that radiates throughout the leg. It can be ruled out by a comprehensive neurological examination.
      • Nerve entrapment (such as lateral plantar and medial nerves) can mimic plantar fasciitis, but tends not to specifically affect the medial tuberosity. In particular, the first branch of the lateral plantar nerve may present with tenderness on the medial side of the edge of the heel, with pain radiating to the lateral side of the heel.
      • Peripheral neuropathy lacks a specific focal area of pain and sensations may still be felt at rest.
    • Other musculoskeletal causes:
      • Plantar fascia rupture, which presents as a sudden onset of pain. There may be a palpable gap and evidence of collapse in the medial and longitudinal arches.
      • Plantar fibromatosis causes pain in the mid-section of the plantar fascia and palpable nodules.
      • Bone contusion typically affects obese people or athletes, and presents as posterior heel pain under the fat pad of the calcaneum.
      • Infection (osteomyelitis or subtalar pyoarthrosis) is rare in the absence of an open wound. It presents with a red, hot, swelling and systemic illness.
      • Subtalar arthritis usually presents with pain felt in the subtalar joint (i.e. deep within the heel) upon weight bearing.
      • Inflammatory arthropathies and gout can be ruled out by appropriate investigations.
    • Neoplasm and vascular insufficiency are very rare causes of heel pain (but should be considered in recalcitrant cases).

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