Question
A 46 year old nurse has plantar heel pain worst with the first steps in the morning.
- Describe the radiograph and its relevance.
- What is the differential diagnosis?
- Outline management.
Answer
Radiograph
- Plantar calcaneal spur
- Spurs are common in asymptomatic people and do not cause the pain
- Lie in flexor digitorum brevis origin more than the fascia
Differential diagnosis
- Baxter nerve (first branch of the lateral plantar nerve) entrapment
- Calcaneal stress fracture, positive squeeze test
- Fat pad atrophy
- Tarsal tunnel syndrome
- Seronegative spondyloarthropathy if bilateral in a young man
- Plantar fascia rupture
Management
- Most resolve within 12 months
- Plantar fascia specific stretching and calf stretching
- Heel cups, night splints
- Corticosteroid injection, risk of fat pad atrophy and rupture
- Extracorporeal shockwave therapy
- Gastrocnemius recession for isolated contracture (positive Silfverskiöld test)
- Partial plantar fasciotomy, release under 50% to avoid lateral column pain
Related pages
Author Contributions
Orthofracs team
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.