Is there a relationship between plantar fasciitis and hyperuricemia?

Relationship Between Plantar Fasciitis and Hyperuricemia

There is no clinically significant relationship between plantar fasciitis and hyperuricemia, and routine screening for elevated uric acid levels in patients presenting with heel pain from plantar fasciitis is not recommended.

Evidence Against a Clinical Association

The most direct evidence addressing this question comes from a 2023 cross-sectional study of 284 patients with plantar fasciitis compared to 150 hyperuricemic controls 1. This study found:

• No correlation between serum uric acid levels and plantar fasciitis severity as measured by visual analog scale (VAS) pain scores, foot function index (FFI), or duration of symptoms 1
• Mean uric acid levels were actually lower in plantar fasciitis patients (7.6 mg/dL in males, 7.3 mg/dL in females) compared to hyperuricemic controls (8.3 mg/dL in males, 8.1 mg/dL in females) 1
• The study explicitly concluded that routine screening for asymptomatic hyperuricemia is not recommended in plantar fasciitis 1

Why This Distinction Matters Clinically

Plantar Fasciitis is a Mechanical Condition

Plantar fasciitis is fundamentally a degenerative overuse condition affecting the plantar fascia, not an inflammatory arthropathy 2, 3. The established risk factors are entirely biomechanical and metabolic:

• Obesity and excessive weight-bearing 2, 4
• Excessive foot pronation 2
• Prolonged standing and running 2, 3
• Anatomical deformities like pes planus 5

Gout Presents Differently

If hyperuricemia were causing heel pain, you would expect to see:

• Monosodium urate (MSU) crystal deposition demonstrable on synovial fluid analysis or imaging 6
• Acute inflammatory arthritis with rapid onset of severe pain, swelling, and erythema 6, 7
• Response to urate-lowering therapy rather than mechanical interventions 7, 8

The European League Against Rheumatism emphasizes that gout diagnosis requires demonstration of MSU crystals, and hyperuricemia alone should never be used to diagnose gout 6. Only 20% of patients with serum urate >9 mg/dL develop gout within 5 years 9, confirming that hyperuricemia is insufficient to cause crystal-related pathology in most cases.

Clinical Approach to Heel Pain

When to Suspect Plantar Fasciitis (Not Gout)

Look for these specific features 2, 3, 4:

• Pain with first steps in the morning or after prolonged sitting
• Sharp pain on palpation of the medial plantar calcaneal region
• Pain worsened by passive ankle/first toe dorsiflexion
• Gradual onset over weeks to months
• Pain worse after prolonged weight-bearing activities

When to Suspect Gout Instead

Consider gout if the patient has 6, 7:

• Rapid onset of severe pain reaching maximum intensity within 24 hours
• Monoarticular involvement of foot or ankle (especially first metatarsophalangeal joint)
• Visible erythema and swelling
• Previous similar acute episodes
• Male gender with cardiovascular comorbidities

Red Flag: Do Not Miss Septic Arthritis

The European League Against Rheumatism recommends Gram stain and culture even when MSU crystals are identified, as gout and sepsis can coexist 7. If there is any concern for infection (fever, systemic symptoms, immunocompromise), joint aspiration is mandatory.

Treatment Implications

For Plantar Fasciitis

Treat with mechanical and supportive interventions 2, 3, 4:

• Plantar fascia-specific stretching and calf stretching
• Appropriate orthotics and arch supports
• Night dorsiflexion splinting
• Activity modification to reduce cyclical loading
• NSAIDs or corticosteroid injections for pain (short-term only)
• Physical therapy modalities
• Extracorporeal shock wave therapy for chronic cases (>6 months)

Asymptomatic Hyperuricemia Does Not Require Treatment

The American College of Rheumatology conditionally recommends against initiating urate-lowering therapy for asymptomatic hyperuricemia 9. Even among patients with serum urate >9 mg/dL, the number needed to treat is 24 patients for 3 years to prevent a single gout flare 9. The 2024 KDIGO guidelines similarly recommend against treating asymptomatic hyperuricemia in CKD patients 9.

Common Pitfalls to Avoid

• Do not order serum uric acid levels in patients with typical plantar fasciitis presentation—it adds no diagnostic or therapeutic value 1
• Do not confuse chronic tophaceous gout (which can involve the heel) with plantar fasciitis—tophi are palpable subcutaneous nodules, not fascial tenderness 6, 7
• Do not delay appropriate mechanical treatment of plantar fasciitis by pursuing unnecessary metabolic workup 2, 3
• Do not start urate-lowering therapy based solely on an incidentally discovered elevated uric acid level in a plantar fasciitis patient 9