Bilateral plantar fasciitis diagnosis, coding, and clinical documentation information for healthcare professionals. Learn about plantar fascial fibromatosis, heel spur syndrome, and ICD-10 codes related to bilateral heel pain. Find resources for accurate medical coding and effective treatment of bilateral plantar fasciitis.
Also known as
Plantar fasciitis
Inflammation of the plantar fascia, the thick tissue on the bottom of the foot.
Calcaneal spur
Bony growth on the heel bone, sometimes associated with plantar fasciitis.
Other enthesopathies of lower leg
Disorders affecting the attachment of tendons or ligaments in the lower leg.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the plantar fasciitis confirmed bilateral?
Yes
Is there plantar fascial fibromatosis?
No
Do not code as bilateral. Code unilateral plantar fasciitis (M72.2) for each affected side.
When to use each related code
| Description |
|---|
| Heel pain, usually worse in the morning or after rest. |
| Unilateral heel pain, often worse in the morning. |
| Heel pain associated with a bony growth. |
ICD-10 requires specifying laterality (right, left, bilateral) for plantar fasciitis (M72.2). Incorrect laterality impacts reimbursement.
Heel spurs (M77.3) are distinct from plantar fasciitis. Coding both when only fasciitis is present leads to overcoding and potential audits.
Using unspecified codes like M72.9 when documentation supports M72.2 for bilateral plantar fasciitis can lead to claim denials.
Q: How can I differentiate between bilateral plantar fasciitis and other causes of heel pain in my differential diagnosis, considering conditions like heel spurs, Achilles tendinopathy, and tarsal tunnel syndrome?
A: Differentiating bilateral plantar fasciitis from other heel pain etiologies requires a thorough clinical evaluation. While plantar fasciitis pain is typically localized to the medial heel and worse with first steps in the morning or after periods of rest, Achilles tendinopathy often presents with posterior heel pain exacerbated by activity. Tarsal tunnel syndrome presents with burning, numbness, and tingling radiating into the foot. Heel spurs, while often present in plantar fasciitis, are not the primary cause of pain and can be asymptomatic. Physical examination, including palpation of the plantar fascia, assessment of ankle dorsiflexion, and neurological testing, can help distinguish these conditions. Consider implementing diagnostic imaging like X-rays or ultrasound to rule out other pathologies and confirm the diagnosis. Explore how advanced imaging modalities can help identify subtle findings in complex cases.
Q: What are the best evidence-based conservative treatment options for managing bilateral plantar fasciitis refractory to initial interventions like rest, ice, and NSAIDs, specifically focusing on modalities like corticosteroid injections, extracorporeal shockwave therapy (ESWT), and custom orthotics?
A: When initial conservative measures fail to alleviate bilateral plantar fasciitis symptoms, clinicians should consider escalating treatment options. Corticosteroid injections can provide short-term pain relief but are not recommended for long-term management due to potential risks. Extracorporeal shockwave therapy (ESWT) has shown promising results in reducing pain and improving function in chronic plantar fasciitis. Custom orthotics, particularly those providing arch support and cushioning, can help redistribute pressure and reduce strain on the plantar fascia. Learn more about the current research supporting the efficacy of various treatment modalities and how to tailor treatment plans based on individual patient needs. Consider implementing a structured rehabilitation program that incorporates stretching, strengthening, and proprioceptive exercises.
Patient presents with complaints of bilateral heel pain, consistent with plantar fasciitis. The patient describes the pain as sharp or stabbing, particularly upon first weight-bearing in the morning or after periods of rest, gradually improving with activity but worsening throughout the day, especially with prolonged standing or walking. The pain is localized to the plantar aspect of the heel and may radiate into the arch of the foot. Physical examination reveals tenderness to palpation along the plantar fascia insertion at the calcaneus bilaterally. Pain is elicited with dorsiflexion of the toes and ankle. Negative Tinel's sign at the ankle suggests against tarsal tunnel syndrome. Assessment includes bilateral plantar fasciitis (plantar fascial fibromatosis, sometimes referred to as heel spur syndrome although radiographic evidence of heel spurs is not required for diagnosis). Differential diagnoses considered include Achilles tendinitis, stress fracture, nerve entrapment, and inflammatory arthritis. Plan includes conservative management with rest, ice, stretching exercises focusing on the plantar fascia and Achilles tendon, non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief, and orthotic support with arch supports or custom orthotics. Patient education provided on proper footwear and activity modification. Follow-up scheduled in 4-6 weeks to assess response to treatment. Referral to physical therapy or podiatry will be considered if symptoms do not improve. ICD-10 code M72.2 assigned.