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.
Question | Clue | Consider 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 heel | Diffuse, 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 areas | Unlikely 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 levels | High 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 health | Currently 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.
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.
Further assessment is indicated if there is a history of trauma or acute pain
Further strength testing may be applicable in the athletic individual.
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 studentDecember 2019