How can I differentiate between plantar fasciitis and other causes of heel pain in a primary care setting?

Differentiating plantar fasciitis from other causes of heel pain in primary care involves a focused clinical assessment emphasising characteristic history and examination findings. Plantar fasciitis typically presents with pain localized to the medial plantar aspect of the heel, often worst with the first steps in the morning or after periods of rest, and improves with activity but may worsen after prolonged weight-bearing. Tenderness is usually maximal at the anterior medial calcaneal tubercle on palpation ¹.

Other causes of heel pain to consider include:

• Sever's disease in children, presenting with heel pain related to growth plate inflammation, often bilateral and associated with recent increased activity or sports participation ².
• Diabetic foot problems, which may present with heel pain but are often accompanied by signs of infection, neuropathy, or ischaemia; these require careful assessment for redness, swelling, ulceration, or systemic signs and urgent referral if limb-threatening features are present ³.
• Calcaneal stress fractures, which may present with more diffuse heel pain, often worsening with weight-bearing and not improving with rest, and may require imaging for diagnosis ¹.
• Achilles tendinopathy, where pain is located posteriorly at the Achilles tendon insertion rather than the plantar fascia ¹.
• Other less common causes such as tarsal tunnel syndrome, fat pad atrophy, or nerve entrapment, which may have distinct clinical features like burning pain, numbness, or pain on nerve percussion ¹.

Clinical examination should include: palpation of the plantar fascia insertion, assessment of foot biomechanics, and exclusion of neurological signs. If diagnosis is uncertain or symptoms persist beyond 3–6 months despite initial management, consider imaging such as weight-bearing foot X-rays or ultrasound to exclude alternative diagnoses ¹.

In summary, the key to differentiation lies in the typical history of plantar fasciitis (morning heel pain, localized tenderness at the medial calcaneal tubercle), exclusion of systemic or neurological signs, and consideration of patient age and comorbidities such as diabetes ¹,²,³. Recent literature supports these clinical features as diagnostic hallmarks and highlights the importance of tailored assessment to exclude mimics (Johnson et al., 2014; May et al., 2002; Quaschnick, 1996).