Plantar Fasciitis: Evidence-Based Management

Robert D. Glatter, MD, FAAEM

Disclosures

October 10, 2007

Differential Diagnosis

Careful physical examination generally allows the clinician to make the diagnosis of plantar fasciitis. Patients with an atypical history and pain on palpation of areas other than the medial aspect of the calcaneus should be considered for alternative diagnoses.

In children and older patients, consider other bony abnormalities. Any history of trauma or sudden onset of pain should make the clinician search for other causes. Specifically, consider Paget's disease, osteoporosis, or metastatic disease in patients with fractures from minor trauma. Pain due to Achilles tendonitis or bursitis is typically distinguished from plantar fasciitis on careful physical examination.

Other considerations for heel pain include neuralgias, either due to injury or entrapment of the posterior tibial nerve or lateral calcaneal nerve. As opposed to plantar fasciitis, neuropathic pain is often worse at bedtime or can awaken a patient from sleep. In addition, patients with neuralgia often do not have pain with dorsiflexion of the great toe or pain with palpation at the insertion of the medial aspect of the plantar aponeurosis.

Finally, heel pain may occur due to systemic disease that is inflammatory in origin. Ankylosing spondylitis, systemic lupus erythematosus (SLE), and Reiter's syndrome (arthritis, uveitis, conjunctivitis) must be in the differential diagnosis of individuals presenting with other systemic complaints or in atypical cases. Clinicians should consider an underlying illness if warmth, erythema, or effusion is noted on examination of the heel. Plain radiography is of limited value in distinguishing plantar fasciitis from inflammatory causes; bone scans and MRI are more useful to investigate alternative diagnoses.

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