Assessment

Key messages

Subjective

The following table provides examples of typical questions asked in a subjective interview alongside responses which may indicate a clinical diagnosis of plantar heel pain and factors associated with the condition.

All patients with plantar heel pain should be viewed through a biopsychosocial model of health.

QuestionClueConsider differential diagnosis
Where is the pain?In my heel(s)Pain that starts in the low back and radiates down the lower limb
Can you point to where the pain is?Commonly at the origin of the plantar fascia, though can be in the medial arch or whole heelDiffuse, radiating pain which is more laterally located on the plantar surface of the foot, or posteriorly located on the Achille's tendon
Nature of the pain "Like walking on glass, needles or knives"
"I feel like I have a rock in my shoe"

At other times, it may be more of an ache
Altered sensation in the foot or heel
24-hour pattern- Worse first thing in the morning when getting out of bed (first step pain)
- Worse after periods of non-weight bearing
- Pain improves initially with movement
- Gradually worsens throughout the day
- Often worse at end of the day or following increased activity
- Constant pain
- Night pain
Aggravating factors- Walking barefoot or in poorly supported footwear
- Driving
- Stairs
- Prolonged periods of standing
Easing factors- Initially improves with movement
- Non-weight bearing positions
How long have you had heel pain?Average time of presentation to seek help is approximately 13 months Prolonged history of plantar heel pain despite adhering to a standard program for plantar heel pain
Onset of symptoms- Insidious onset indicative of heel pain
- Following an increase in load
Be suspicious if there is a sudden onset of symptoms, especially following an acute injury or traumatic history
Other areasUnlikely to present with other related symptoms if purely plantar heel pain
- Clear lumbar spine, hip and knee
- Consider possibility of heel pain existing alongside other conditions such as Achille's tendinopathy, nerve entrapment, fat pad contusion
What do you do for a living?Occupations which involve a lot of standing such as a hairdresser or hospitality or factory worker
Activity levelsHigh versus low
- Sedentary with corresponding high BMI
- High activity levels which load the foot, such as running
Recent changes to activity - "zero to hero" sudden increase in load such as couch to 5k or a holiday involving more walking
General healthCurrently experiencing a lot of stress, anxiety and/or depression Chronic diseases such as diabetes, rheumatoid arthritis, gout

 

Other key questions to ask are:

Responses will often highlight current physical limitations and mental health status. For example, not being able to run, walk or participate in social activities due to pain and associated feelings such as frustration, sadness and anger.

Responses can indicate unhelpful beliefs about the cause of heel pain, pathology, prognosis, expectations and treatments. This also provides a useful starting point for education.

 

Objective

The objective examination should be guided by subjective exam findings and follow a clinical reasoning approach. Factors associated with plantar heel pain provide guidance for assessment. In addition, assessment should be tailored to patient goals and functional limitations.

Information below provides a basic objective assessment structure clinician’s may find helpful, where no red flags are suspected.

Observe

 

Palpation

Further assessment is indicated if there is a history of trauma or acute pain

Range of movement

Active  
Passive 

Muscle tests

Length 
Strength

Further strength testing may be applicable in the athletic individual.

Functional movements

Special tests

Outcome measures

Commonly used outcome measures include the Numerical Pain Rating Scale, Visual Analogue Scale and Global Rating of Change.

Examples of other appropriate outcome measures for plantar heel pain are provided below. Clinician’s should be selective and use their clinical reasoning to determine which are applicable for each patient.

 

Sky Daly-Holt

Bachelor of Applied Science and Master of Physiotherapy Practice 4th year student

December 2019