Differentials
Plantar fascia rupture
Heel fat pad syndrome (fat pad atrophy)
SIGNS / SYMPTOMS
Pain felt in the center of the heel, whereas with plantar fasciitis pain is typically located on the medial calcaneal tuberosity.[11] Patients more likely to have pain aggravated by prolonged standing, night pain, and bilateral pain, without first-step pain in the morning.[11]
INVESTIGATIONS
Ultrasound shows thinning heel fat pad.[31]
Proximal plantar fibromatosis (Ledderhose disease)
SIGNS / SYMPTOMS
Slow-growing lump(s) along the medial longitudinal arch. Initially painless, but becomes painful as it enlarges. Often appears concomitantly with hyperproliferative fibromatosis of other appendages, such as Dupuytren disease in the hands, Peyronie disease in the penis, or keloid formation more generally.[32]
Inferior calcaneal bursitis
SIGNS / SYMPTOMS
Pain with palpation to the inferior central heel.
Tenderness found more proximally than with plantar fasciitis.
Negative Windlass test.
Fluctuant well-defined mass at the inferior central heel.[4]
No pain with ankle, metatarsophalangeal joint extension dorsiflexion.
INVESTIGATIONS
No differentiating tests.
Calcaneal contusion
SIGNS / SYMPTOMS
Minimal pain with palpation of the plantar heel and nonspecific findings on physical examination.
May be no differentiating signs or symptoms apart from a history of preceding trauma.
INVESTIGATIONS
MRI will show high signal on short TI inversion recovery (STIR) and T2-weighted images, and an ill-defined focus of low signal on T1-weighted images.[34] These appearances represent bone marrow edema.
Abductor hallucis tendonitis
SIGNS / SYMPTOMS
Targeted pain with palpation and percussion of the abductor hallucis muscle belly.
Pain with abduction and adduction of the hallux.
INVESTIGATIONS
Edema within the muscle belly or tendon or adjacent to the muscle fibers is found on MRI or ultrasound images.
Baxter neuritis
Calcaneal stress fracture
SIGNS / SYMPTOMS
Positive squeeze tests: pain with lateral compression of the heel is greater than inferior heel pain.[4][22]
INVESTIGATIONS
Radiolucent line transecting the calcaneal tuber from the rest of the calcaneal body on plain x-ray films, although radiographs can be negative initially with occult fracture.
MRI shows low signal intensity on T1 and T2 images with surrounding edema.[34]
Medial calcaneal nerve entrapment
Rheumatoid arthritis
SIGNS / SYMPTOMS
Typically bilaterally symmetric presentation with erythema and edema about the heels.[6]
Pain and inflammation in other joints, especially smaller joints, with a symmetric presentation.
INVESTIGATIONS
Rheumatoid factor 1:60 or more.
Calcaneal erosive changes in the absence of infection on x-ray.[6]
Axial spondyloarthritis
SIGNS / SYMPTOMS
Erythema and edema about the heel.
May have associated back pain.[4][6]
Pain more commonly bilateral, although unilateral pain may occur.[6]
INVESTIGATIONS
Often, but not always, HLA-B27 positive.
Oligoarthritis involving larger asymmetric joints on x-ray; radiographic presentation of enthesopathy.[6]
Rheumatoid arthritis
Sacroiliac nerve entrapment
SIGNS / SYMPTOMS
Pain of the plantar proximal heel.
Extending the knee and lifting the leg, with the patient supine, will incite low back pain.
INVESTIGATIONS
MRI may demonstrate intervertebral disk disease.
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