Which physical 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

The association between plantar fasciitis and isolated contracture of the gastrocnemius was studied by Patel et al in a prospective evaluation of patients with either acute or chronic plantar fasciitis (N = 254). Of the 254 patients, 211 (83%) had limited ankle dorsiflexion, 145 (57%) had an isolated contracture of the gastrocnemius, 66 (26%) had a contracture of the gastrocnemius-soleus complex, and only 43 (17%) did not have a dorsiflexion limitation. Equinus contracture was noted in 83% (129/155) of acute cases and 82% (82/99) of chronic cases. An isolated contracture of the gastrocnemius was found in 60% (93/155) of acute cases and 52% (52/99) of chronic cases. [19]

In persons with proximal plantar fasciitis, the tenderness is typically localized over the medial calcaneal tuberosity at the origin of the plantar fascia. Associated features may include a triceps surae contracture, decreased subtalar mobility, pes cavus, or pes planus. These conditions can create increased tension on the plantar fascia. However, when a clinical test is performed to stretch the plantar fascia by dorsiflexion of the toes, patients do not experience any aggravation of pain. On the other hand, pain may be aggravated by this maneuver in persons with an acute plantar fascia rupture, which may be accompanied by localized bruising or even a palpable defect.

Tenderness upon squeezing both the medial and lateral sides of the posterior calcaneal tuberosity is highly indicative of a stress fracture in the calcaneus, and this may be associated with local edema (see the image below). [20]

Edema localized to plantar heel on the left foot i Edema localized to plantar heel on the left foot in a patient with calcaneal stress fracture compared to the normal right heel

In persons with compressive neuropathy, either of the tibial nerve in the tarsal tunnel or of the first branch of the lateral plantar nerve, the point of maximal tenderness in the heel is located more medially in the posterior heel.

Percussion over the tibial nerve branches elicits tingling, burning, or numbness. A valgus heel associated with pes planus or acquired flatfoot can put increased stretch on the tibial nerve and can cause tarsal tunnel syndrome.

In elderly patients or persons who have had multiple steroid injections in the heel, the pain and tenderness is maximal over the central weightbearing area of the heel. Dorsiflexion of the toes does not aggravate the pain. The heel does not have the usual firmness; it feels soft, and the underlying calcaneus is more readily palpable.


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