Which clinical history findings are characteristic of plantar heel pain?

Updated: Oct 01, 2018
  • Author: Vinod K Panchbhavi, MD, FACS; Chief Editor: Thomas C Dowd, MD  more...
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Answer

A careful history and a thorough physical examination are valuable in identifying the etiology of heel pain. Taking a comprehensive medical and general history is important for distinguishing between various causes. Seek the history on all the characteristics of the pain, such as onset, location, radiation, modifying factors, relation to time of the day, and relation to activities.

The most common cause of plantar heel pain in both athletic and nonathletic populations is proximal plantar fasciitis. [15] Patients usually have occupations that involve spending most of their time on their feet. The pain is often unilateral, but it can manifest bilaterally, with one side being more painful than the other.

The discomfort commonly manifests spontaneously and insidiously without an antecedent trauma or fever. Occasionally, some patients state they might have stepped on a small object such as a pebble or they may have recently started an exercise regimen involving walking or running. Some patients may have a history of recent weight gain.

The pain is localized to the plantar and medial aspects of the heel. It is worse typically with the first few steps in the morning. The pain causes patients to limp for approximately half an hour. It is also worse after a period of rest, such as after standing up from a chair or getting out of a car.

The pain then improves with walking and stretching, but it is aggravated by prolonged walking and standing. The pain can be present with every step, causing a limp, and patients tend to walk bearing weight on the forefoot and the outer aspect of the foot, which can exacerbate the problem.

An acute onset of pain, especially after a vigorous or sudden athletic activity, can be indicative of traumatic rupture of the plantar fascia.

Fat pad atrophy in elderly patients and in persons who have received multiple steroid injections manifests with pain under the heel that is more diffuse, involving most of the weightbearing surface. The pain worsens when the patients walk on hard surfaces and when they wear hard-soled footwear. The initial improvement in walking observed in patients with plantar fasciitis is not observed in patients with fat pad atrophy.

Pain radiating from the heel distally or proximally and associated with numbness, paresthesia, or a burning sensation after activity and continuing even after rest is likely to be neurologic in origin. This is usually due to a compressive neuropathy locally, as in tarsal tunnel syndrome, or proximally at the level of the nerve root, in which case low back pain may be associated.

Bilateral heel pain and pain at the tendon insertions (or enthesopathy), especially associated with general symptoms such as malaise, recurrent fever, multiple joint pains, or bowel dysfunction, may indicate an association with inflammatory disorders such as rheumatoid arthritis, spondyloarthropathies, Reiter syndrome, or Behcet syndrome. Significant loss of appetite and weight or pain at night can be indicative of a neoplasm. Heel pain in elderly patients or patients with atypical presentations should be investigated for deficiency fractures or for tumors.


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