Differential diagnosis Plantar fasciitis often presents with heel pain, especially in the morning. Commonly, the pain subsides somewhat after stretching the foot and calf musculature. This condition can then be aggravated either by walking or immobility for long periods of time. Pain is most frequently on the plantar surface of the heel but may extend throughout the plantar fascia. Occasionally, a patient will present with a diagnosis of plantar fasciitis, but this may not be the true source of the pain. Many conditions may present with similar symptoms, so it is important to understand the differences in each. The following are common causes of heel pain that may be misconstrued as plantar fasciitis: ● Fat pad atrophy : May mimic many of the symptoms of plantar fasciitis; however, patients will often have increased pain with standing, but not significant pain when first standing in the morning. ● Heel spurs : Can also cause heel pain, but the pain is more likely to be constant throughout the day. If the patient stands on their toes, the heel spur pain should diminish; however, if the pain is caused by plantar fasciitis, the pain will increase. ● Tibial nerve injury (S1,2) : Can also cause heel pain. A nerve injury will often present with numbness and tingling, de- creased motor function, and/or decreased tendon reflexes. The medial plantar nerve (L4,5) innervates the arch of the foot, but not the heel, so if pain from the heel extends into the arch, the source of the injury is unlikely to be this nerve. Physical therapy examination With so many possibilities as to the underlying cause of heel pain, every patient should receive a thorough exam when they present to physical therapy. The subjective exam should include questions related to unexplained weight loss or gain (cancer), pain in other joints (rheumatoid arthritis), if the pain is constant (cancer) vs. intermittent (musculoskeletal cause), and if numbness and tingling are present (nerve injury). Therapists should also question patients on their knowledge of the source of the pain. For instance, did they jump up and hear a popping sound (possibly an Achilles tendon injury)? Therapists should also question patients about their level of activity, as a sudden increase in activity can lead to Achilles tendinitis, plantar fasciitis, or stress fractures. Is the pain worse in the morning (potentially arthritis or plantar fasciitis)? The objective portion should include observation of the foot posture in standing, such as using the Foot Posture Index (FPI) to determine the level of pronation or supination of the foot. The exam should also include palpation of the foot, ankle, heel, and calf. Pain specifically at the proximal insertion of the plantar fascia may strongly suggest that plantar fasciitis is the cause of the pain. Clinicians can screen for lumps or unusually shaped bony prominences (on the heel for Haglund’s deformity, near the joint for rheumatoid arthritis nodules, other places may be tumors or scar tissue). Range-of-motion (ROM) measurements are key, as decreased ankle dorsiflexion is a primary factor leading to plantar fasciitis. Decreased ROM may also be present with many other Special tests Links to some of these tests can be found in the Resource Section . The windlass test This test is completed in two positions: sitting and in standing. In sitting, the examiner stabilizes the ankle in neutral with one hand just proximal to the first metatarsal head. Next, the examiner extends the first phalange while allowing the IP joint to flex. A test is considered positive if passive extension is continued to end range or until the patient’s pain is reproduced. This is repeated in standing with the patient standing on a stool and the metatarsal heads extending just off the stool. A positive Windlass test indicates the presence of plantar fasciitis (De Garceau et al., 2003). See Resources for more information on this test.
● Achilles tendon injury : Will present not only with heel pain, but with a decrease in function of the gastrocnemius and/or soleus musculature. ● Rheumatoid arthritis : Can also cause heel pain that is worse in the morning, worse after inactivity, and is more common in women and obese patients. Rheumatoid arthritis, however, will often present with warm, swollen joints and most com- monly will have other areas of pain, so a thorough subjective exam is very important. ● Haglund’s deformity : A bony bump on the back of the heel, can mimic the heel pain caused by plantar fasciitis, but the pain will often be present over the back of the heel where the Achilles tendon attaches instead of on the bottom of the foot. ● A patient with a stress fracture on the bottom of the foot will often have a history of a sudden increase of activity. This pain will often diminish somewhat with rest and decreased weight bearing. If the clinician suspects this as a possibility, the pa- tient will need an x-ray, bone scan, or MRI to diagnose this. ● Lastly, tumors can also cause heel pain. Therapists can screen for these by asking questions about unexplained weight loss or gain and whether or not the pain is constant. Cancer is char- acterized by a constant pain unaffected by rest, and palpating may reveal unexplained lumps. If therapists suspect cancer as a possibility, the patient should immediately return to their physician for further assessment. diagnoses, including Achilles tendon injuries and rheumatoid arthritis. Physical therapists should assess strength of the muscles surrounding the ankle, knee, and foot. Plantar fasciitis does not necessarily diminish strength, though strength measurements may be limited by pain. Strength will likely be diminished if the source of the problem is neurological. If the heel pain decreases when the patient stands on their toes, the pain is more likely caused by heel spurs than by plantar fasciitis. If, however, the pain increases in this position, the pain may likely be caused by plantar fasciitis. Assessment of the Achilles tendon deep tendon reflex can also rule out neurological causes of dysfunction. Special tests should include the windlass test and tarsal tunnel tests. These are described below. If, after screening for all of the aforementioned conditions, the patient’s pain is found to be primarily in the heel and extending into the arch of the foot, specifically with palpation of the proximal insertion of the plantar fascia, without painful lumps or numbness and tingling or swollen joints, it may point to plantar fasciitis. In addition, if the patient’s pain is worst first thing in the morning and gradually subsides somewhat after initial stretching, then increases gradually with continued time on the feet throughout the day, and the patient has decreased ankle dorsiflexion and normal strength, the patient likely has plantar fasciitis. Please refer to Figure 2 for a flow chart which summarizes the diagnosis process. The tarsal tunnel test This test is performed by the examiner maximally dorsiflexing the ankle, everting the foot, and extending all of the toes. Next, the examiner maintains this position for five to ten seconds while tapping over the tarsal tunnel (just posterior to the medial malleolus). A positive test is complaints of localized nerve tenderness and/or a positive Tinel’s sign. If this test is positive, it indicates compression of the posterior tibial nerve, and therefore, could rule out the presence of plantar fasciitis (Kinoshita et al.,2003). See Resources for more information.
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Book Code: PTCA2624
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