Hallmark Symptoms of Plantar Fasciitis
The classic presentation of plantar fasciitis is sharp, stabbing heel pain on the medial plantar surface that is most severe with the first few steps in the morning or after prolonged sitting, with tenderness to palpation at the medial plantar calcaneal region. 1
Primary Clinical Features
Pain Characteristics
- Sharp, stabbing, non-radiating pain localized to the proximal medioplantar surface of the foot, specifically at the plantar fascial insertion on the anteromedial calcaneus 1
- Morning pain is pathognomonic: Pain is particularly severe with the first few steps taken in the morning, which is the classic distinguishing feature 2, 3
- Post-static dyskinesia: Pain occurs after prolonged sitting or standing, then improves with activity but worsens again at the end of the day 1, 4
Physical Examination Findings
- Point tenderness on palpation of the medial plantar calcaneal region where the plantar fascia inserts on the calcaneus 2, 1
- Provocation with dorsiflexion: Discomfort in the proximal plantar fascia can be elicited by passive ankle and first toe dorsiflexion 2
- Physical examination findings are often limited to focal tenderness, making the history particularly important 1
Important Clinical Context
Diagnosis is Predominantly Clinical
- Plantar fasciitis is primarily a clinical diagnosis based on characteristic history and physical examination findings, with imaging reserved for cases persisting beyond 3 months or when diagnosis is uncertain 5, 1
- The combination of morning heel pain and medial calcaneal tenderness is sufficient for diagnosis in most cases 2
Common Pitfalls to Avoid
- Do not confuse plantar fasciitis with calcaneal stress fracture, which presents with pain on compression of the lateral calcaneal wall and may require bone scan for diagnosis 6, 5
- Rule out tarsal tunnel syndrome (neurologic heel pain from nerve entrapment) if symptoms are atypical, which may require electromyography or nerve conduction studies 6, 5
- Consider plantar fascia rupture if there is acute onset of severe pain, particularly in patients with prior corticosteroid injections 5
- In adolescents, calcaneal apophysitis is the most common cause of heel pain, not plantar fasciitis 6, 5
When to Image
- If diagnosis is unclear or symptoms persist beyond 3 months despite treatment, obtain weightbearing radiographs (85% sensitivity, 95% specificity) to exclude other pathologies 7, 5
- MRI is the most sensitive imaging study for definitive diagnosis when uncertainty remains, though findings must be correlated with clinical symptoms to avoid overcalling the diagnosis in asymptomatic patients 6, 5, 8
- Ultrasound can support diagnosis with 80% sensitivity and 88% specificity, looking for plantar fascia thickness >4mm, abnormal focal echogenicity, and perifascial edema 6, 7