What are the differences between stress fracture and plantar fasciitis symptoms?

Differentiating Stress Fracture from Plantar Fasciitis Symptoms

Stress fractures and plantar fasciitis present with distinctly different symptom patterns, with stress fractures causing pain on direct compression of the bone and plantar fasciitis causing pain at the plantar fascia insertion that is worst with the first steps in the morning. 1, 2

Key Differences in Symptoms

Pain Location

• Stress Fracture:

  • Pain is typically localized to the specific bone affected (commonly calcaneus in foot)
  • Tenderness occurs at the lateral wall of the calcaneus, slightly posterior to the subtalar facet 1
  • Pain is directly over the bone rather than at a tendon insertion

• Plantar Fasciitis:

  • Pain is specifically at the origin of the plantar fascia on the medial tubercle of the calcaneus 2
  • Point tenderness at the plantar fascia insertion is the hallmark finding

Pain Characteristics

• Stress Fracture:

  • Pain on compression of the calcaneus is highly suspicious for stress fracture 1
  • Pain increases with weight-bearing activities and improves with rest
  • Pain is constant during activity and doesn't typically improve during a workout

• Plantar Fasciitis:

  • Characteristic "first-step pain" in the morning or after periods of rest 2
  • Pain typically improves after a few steps but worsens with prolonged activity
  • Aching plantar heel pain that may improve during activity but returns afterward

Associated Findings

• Stress Fracture:

  • Swelling and warmth may be present over the fracture site 1
  • Many patients report increased walking activity just before symptom onset
  • Pain on direct compression or percussion of the bone

• Plantar Fasciitis:

  • Often associated with gastrocnemius tightness 2
  • Pain with passive dorsiflexion of the toes (windlass test)
  • No warmth or swelling typically present

Diagnostic Considerations

When to Suspect Stress Fracture

• Pain fails to respond to typical plantar fasciitis treatments 3
• History of recent increase in activity or repetitive activity with limited rest 4
• Direct pain on compression of the calcaneus
• Risk factors present (osteoporosis, athletes, military personnel) 3

When to Suspect Plantar Fasciitis

• Classic morning pain that improves with initial steps
• Point tenderness at the medial calcaneal tubercle
• Pain with passive toe extension (windlass test)
• Pain that has gradually developed over time rather than suddenly 2

Imaging Differences

Stress Fracture Imaging

• Initial radiographs often negative (sensitivity only 12-56%) 1
• MRI shows linear T1 and T2 hypointense signal (fracture lines) with surrounding bone marrow edema 1
• Bone scan may show increased uptake at fracture site 1

Plantar Fasciitis Imaging

• Radiographs typically show thickened plantar fascia and fat pad abnormalities 1
• MRI or ultrasound shows thickening of the plantar fascia at its calcaneal insertion 5
• No fracture lines or bone marrow edema as seen in stress fractures

Clinical Pitfalls to Avoid

1. Misdiagnosis: Stress fractures are frequently misdiagnosed as plantar fasciitis, leading to inappropriate treatment and delayed healing 3

2. Relying on initial radiographs: Stress fractures often don't appear on initial X-rays; negative radiographs don't rule out stress fracture 1

3. Overlooking risk factors: Failure to consider stress fracture in high-risk individuals (athletes, military personnel, osteoporotic patients) 3

4. Corticosteroid injections: These may provide temporary relief for plantar fasciitis but can increase risk of plantar fascia rupture and could worsen a misdiagnosed stress fracture 6

5. Delayed diagnosis: Stress fractures require early diagnosis to prevent progression to complete fracture, especially in high-risk locations 1

By understanding these key differences in symptom presentation, clinicians can more accurately differentiate between these common causes of heel pain and implement appropriate treatment strategies.