From the Guidelines
Plantar fasciitis is diagnosed primarily through clinical evaluation based on patient history and physical examination, with a focus on assessing symptoms such as sharp heel pain and tenderness at the medial calcaneal tuberosity. The diagnosis typically begins with evaluating symptoms such as sharp heel pain that is worst with the first steps in the morning or after periods of rest, as noted in studies such as 1. During physical examination, a healthcare provider will check for tenderness at the medial calcaneal tuberosity (inner heel bone) where the plantar fascia attaches. Pain that worsens with dorsiflexion of the toes or standing on tiptoes supports the diagnosis.
While imaging is not routinely necessary, X-rays may be ordered to rule out other conditions like heel spurs or stress fractures, and ultrasound or MRI might be used in cases where the diagnosis is unclear or to evaluate for plantar fascia tears, as suggested by 1. The use of weightbearing radiographs is supported by evidence for the initial imaging study in patients with a painful heel, with a combination of thickened plantar fascia and fat pad abnormalities on radiographs having a sensitivity of 85% and a specificity of 95% for plantar fasciitis.
Differential diagnoses that should be considered include:
- Tarsal tunnel syndrome
- Heel pad syndrome
- Stress fractures
- Nerve entrapment The diagnosis is confirmed when clinical findings align with the characteristic pattern of plantar fascia inflammation, and when symptoms improve with appropriate treatment such as rest, stretching, and anti-inflammatory measures, as outlined in 1 and 1. No laboratory tests are specifically diagnostic for plantar fasciitis, making the clinical evaluation the cornerstone of diagnosis. Ultrasound may be performed when there is a high clinical suspicion of pathologic conditions of the Achilles tendon, plantar fascia, and other conditions such as tarsal tunnel syndrome, Morton’s neuroma, plantar plate tears, and intermetatarsal bursitis, but it is not typically the first imaging study, as noted in 1.
From the Research
Diagnosis of Plantar Fasciitis
- Plantar fasciitis is a common cause of heel pain in adults, affecting more than 1 million persons per year 2.
- The diagnosis is primarily based on history and physical examination, with patients presenting with heel pain with their first steps in the morning or after prolonged sitting, and sharp pain with palpation of the medial plantar calcaneal region 2, 3.
- Diagnostic imaging is rarely needed for the initial diagnosis of plantar fasciitis, but ultrasonography and magnetic resonance imaging can be used to confirm the diagnosis in recalcitrant cases or to rule out other heel pathology 2, 3.
- Physical examination findings are often limited to tenderness to palpation of the proximal plantar fascial insertion at the anteromedial calcaneus 3.
Risk Factors
- Risk factors for developing plantar fasciitis include obesity, excessive foot pronation, excessive running, and prolonged standing 2.
- Limited ankle dorsiflexion and increased body mass index are also risk factors for plantar fasciitis 3.
- Plantar fasciitis is common in runners but can also affect sedentary people 2, 3.
Diagnostic Criteria
- Symptoms of plantar fasciitis include stabbing, nonradiating pain first thing in the morning in the proximal medioplantar surface of the foot, which becomes worse at the end of the day 3.
- Ultrasonography is a reasonable and inexpensive diagnostic tool for patients with pain that persists beyond three months despite treatment 3.
- A comprehensive history and physical examination guide accurate diagnosis, and considering a complete differential diagnosis of plantar heel pain is important 4.