History and exam

Key diagnostic factors

common

presence of risk factors

Associated risk factors include running, increased BMI, presence of equinus, patient age between 40 and 60 years, presence of pes planus or pes cavus, and history of prolonged standing.

heel pain (stabbing or knife-like)

The most common location of pain is at the plantar medial tubercle of the calcaneus at the plantar fascial insertion (the anteromedial aspect of the heel). Symptoms can extend along the course of the plantar fascia into the central arch. Pain may also radiate to the lateral heel.[3]

pain relieved with rest

To make a diagnosis of plantar fasciitis, the pain must be relieved with rest.

Pain may be aggravated by activity.

post-static dyskinesia

Pain with the first few steps after rising from a seated or lying position.[5]

pain exacerbated by standing and other activities of daily living

A progressive worsening of symptoms often occurs, with increased complaints of pain at the end of the day. The severity of symptoms is often related to the hours of standing during daily activities.[3]

Other diagnostic factors

common

pain exacerbated by walking barefoot or in non-supportive footwear

Reported relief of heel pain with supportive footwear.

pain improved with non-steroidal anti-inflammatory drug (NSAID) use

Most would report improvement.

no history of acute injury to the heel

Although history of acute trauma may be present, it is more likely not to be so.

Plantar fasciitis is most often an overuse injury.

self-limiting pain

Usually resolves between 6 to 18 months without treatment.[2]

unilateral heel pain

It is a bilateral complaint in about one third of patients.[4]

However, people with bilateral pain are more likely to have a systemic cause for their pain.[5][6]

positive dorsiflexion-eversion test

Positive test if there is pain with dorsiflexion of the ankle joint and eversion of the subtalar joint.

May be positive in patients with plantar fasciitis or tarsal tunnel syndrome.[24]

positive Windlass test

Pain with metatarsophalangeal joint extension.

Usually positive, but it may still be negative in cases of plantar fasciitis.[23]

uncommon

negative Tinel's sign

Paraesthesia with percussion of the tibial nerve or its branches.

Performed on every patient to rule out nerve entrapment, tarsal tunnel, and neuritis.[25]

May be positive if these conditions occur concomitantly with plantar fasciitis.

Risk factors

strong

Increased body mass index (BMI)

Multiple studies have found that increased BMI is a significant risk factor for plantar fasciitis.[3]​​[8][9]​​​​

BMI >25 kg/m² has been shown to be associated with a 2-fold increased risk; BMI >30 kg/m² has an odds ratio of 5.6 for the condition.[16] A high BMI appears to confer the greatest risk in non-athletic individuals. It is uncertain whether BMI exhibits a threshold effect for plantar fasciitis or if the risk continues to increase at higher BMI categories.[3]​​

BMI is not only a risk factor for plantar fasciitis but also a predictor of the extent of functional loss as reported by patients.[16][17]

Weight has not been a factor in the success of surgical outcomes. Overweight individuals may experience the same success as others if surgical intervention is elected.

equinus

Gastrocnemius or gastrocsoleus equinus is an inability to reach 10 degrees of dorsiflexion at the ankle joint. This puts excessive strain on the plantar fascia during gait and predisposes to plantar fasciitis.[2][9]​​​​

weak

pes planus

A condition due to excessive pronation, resulting in flattening of the medial longitudinal arch of the foot. It is postulated that the presence of pes planus increases the strain at the plantar fascial attachment into the calcaneus.

In addition, it may be associated with posterior tibia tendonitis or posterior tibial tendon dysfunction.[14]

pes cavus

An abnormally high foot arch, often seen as a sign of neuromuscular dysfunction or a rigidly plantar-flexed first ray.

Shock absorption from ground forces are reduced due to the abnormal supinated foot position, resulting in widespread foot fatigue and pain.[14]

age >40 years old

Plantar fasciitis most commonly occurs in the 40- to 60-year-old age range.

Increasing age has also been suggested as a risk factor.[4][18]

history of prolonged standing or walking

Commonly seen in people who work in a standing position, especially those who are standing on a hard, unforgiving surface such as concrete (e.g., factory or postal workers), as well as in those who spend much of the workday on their feet.[3][5][7]​​​​

athletes, particularly runners

Occurs in 8% to 21% of runners and athletes.[3] One study found that street running, spiked shoes, cavus foot, and hind-foot varus were related to the onset of plantar fasciitis in a group of runners.[19] Running on unyielding surfaces and other training errors have been proposed as pre-disposing factors.[3]​​

sedentary lifestyle

One study found that undertaking no regular exercise conferred a three to four times greater risk of plantar fasciitis.[20] Another found that physical activity three times a week for >20 minutes was associated with a decreased risk.[21]​​

wearing improper or excessively worn shoes

Proposed as a cause of plantar fasciitis.[3]

increases or changes in activity

Proposed as a cause of plantar fasciitis.[3]

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