Epidemiology & Risk Factors

Clinical Features

History: c
- Sharp, localized plantar heel pain.
- Worst with the first few steps in the morning or after prolonged periods of inactivity/rest.
- Pain typically lessens with moderate activity/walking, but worsens toward the end of the day or after prolonged weight-bearing.
Physical Examination (PE):
- Point tenderness to palpation over the anteromedial calcaneus at the plantar fascia insertion.
- Pain exacerbated by passive dorsiflexion of the toes / great toe (Windlass test).
- Plantar fascia may feel indurated or tense.

Initial / Screening:
- Clinical diagnosis based on classic Hx and PE (no routine imaging required).
Imaging:
- Foot X-ray (Weight-bearing):
  - Indicated if red flags present, atypical features, or persistent pain despite conservative therapy to r/o bone pathology (e.g., stress fx).
  - May show a calcaneal spur (heel spur); incidental finding and not the cause of pain.
- Ultrasound / MRI Foot:
  - Reserved for refractory cases (> 3-6 mo) or suspected fascia rupture.
  - Shows thickening of the plantar fascia (> 4 mm) and perifascial fluid/edema.
Key Labs:
- Routine labs are normal (negative inflammatory markers).

Calcaneal Stress Fracture:
- Diff by pain elicited with the calcaneal squeeze test (mediolateral compression of the heel), pain worsening throughout the entire duration of weight-bearing (not just first steps), and focal bony tenderness.
Tarsal Tunnel Syndrome (Posterior Tibial Nerve Entrapment):
- Diff by burning pain, numbness, and paresthesias radiating to the plantar sole; (+) Tinel sign posterior to the medial malleolus; pain often worse at night.
Achilles Tendinopathy / Enthesitis:
- Diff by pain and tenderness localized to the posterior heel (Achilles insertion) rather than the inferior/plantar aspect; associated with seronegative spondyloarthropathies (e.g., Ankylosing Spondylitis, Reactive Arthritis).
Heel Fat Pad Atrophy:
- Diff by deep, diffuse aching directly under the central heel (not medial tubercle); worse when walking barefoot on hard surfaces; pain increases progressively with standing without a morning peak.
Plantar Fascia Rupture:
- Diff by sudden “pop” or acute onset of severe pain, often following a corticosteroid injection, accompanied by localized hematoma and palpable fascia defect.

First-line (Conservative Therapy):
- Plantar fascia-specific stretching and calf/Achilles tendon stretching exercises.
- Activity modification (low-impact exercise, avoiding barefoot walking).
- Orthotics: Over-the-counter arch supports, silicone heel cups, cushioned shoes.
- Short course of oral NSAIDs (for symptom relief; underlying process is degenerative rather than purely inflammatory).
- Ice massage/rolling sole over a cold water bottle.
Second-line (Persistent symptoms > 6–12 weeks):
- Night splints (holds foot in dorsiflexion to prevent fascia contracture overnight).
- Custom-molded shoe orthotics.
- Physical therapy (PT) supervised biomechanical rehabilitation.
Third-line / Refractory (> 3–6 months):
- Local corticosteroid injection: Provides short-term pain relief (must be used cautiously due to risk of complications).
- Extracorporeal shock wave therapy (ESWT).
Surgical (Refractory > 6–12 months):
- Partial plantar fasciotomy (rarely indicated).

Plantar fascia rupture (elevated risk post-corticosteroid injection).
Heel fat pad atrophy (iatrogenic secondary to repeated steroid injections).
Altered gait mechanics leading to secondary musculoskeletal pain (knee, hip, lower back).

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