Plantar Fasciitis: Clinical Presentation
Plantar fasciitis presents with sharp, stabbing heel pain that is most severe with the first few steps in the morning or after prolonged sitting, localized to the medial plantar heel at the calcaneal insertion of the plantar fascia. 1, 2
Cardinal Symptoms
Morning pain pattern: Patients experience intense, stabbing pain with their first steps upon waking or after prolonged periods of rest, which is the hallmark symptom 1, 2, 3
Pain location: Discomfort is concentrated on the proximal medioplantar surface of the foot, specifically at the anteromedial calcaneus where the plantar fascia inserts 2, 3
Pain progression: The pain typically improves with initial activity but worsens again at the end of the day with prolonged standing or walking 2
Non-radiating quality: The pain remains localized to the heel and does not radiate distally along the foot 2
Physical Examination Findings
Point tenderness: The most consistent finding is sharp tenderness to palpation at the medial plantar calcaneal region, specifically at the proximal plantar fascial insertion on the medial tubercle of the calcaneus 1, 3
Dorsiflexion test: Discomfort in the proximal plantar fascia can be elicited by passive dorsiflexion of the ankle and first toe, which stretches the plantar fascia 1
Limited findings: Physical examination findings are often limited beyond the localized tenderness, which helps distinguish plantar fasciitis from other heel pathologies 2
Clinical Diagnosis Approach
Primarily clinical: Plantar fasciitis is predominantly a clinical diagnosis based on characteristic history and physical examination findings, without requiring imaging for initial diagnosis 4, 1, 2
Imaging reserved for persistent cases: Diagnostic imaging should only be obtained if symptoms persist beyond 3 months despite treatment or when the diagnosis is uncertain 4
Risk factor assessment: Evaluate for obesity, excessive foot pronation, excessive running, prolonged standing, limited ankle dorsiflexion, and increased body mass index 1, 2
Key Differential Diagnoses to Exclude
Calcaneal stress fracture: Can present with similar heel pain and should be considered if pain is more diffuse or associated with recent increase in activity 5, 4
Tarsal tunnel syndrome: Causes neurologic heel pain from nerve entrapment, typically with radiating symptoms or paresthesias 5, 4
Plantar fascia rupture: May occur as a complication, presenting with sudden sharp pain and possible palpable defect 5, 4
Calcaneal apophysitis: The most common cause of heel pain in adolescents, not adults 4
Common Pitfalls
Avoid over-reliance on heel spurs: Heel spurs on radiographs are often incidental findings and do not correlate with plantar fasciitis symptoms 1
Don't delay treatment: Symptoms resolve more quickly when treatment begins earlier after symptom onset 6
Recognize self-limiting nature: This is a self-limiting condition with 80-90% of patients improving within 12 months with conservative treatment 1, 2