When Heel Pain Is Not Plantar Fasciitis
Although plantar fasciitis is an exceedingly common pathology in podiatry offices, there are key findings that may point one toward an alternative diagnosis for heel pain. Accordingly, this author shares his personal treatment algorithm, insights from the literature and essential pearls in dealing with recalcitrant cases.
Heel pain on the plantar aspect of the foot is often plantar fasciitis. The classic symptom of pain upon rising from rest that resolves after a few steps often points us toward the proper diagnosis. If the pain is not occurring at the attachment of the plantar fascia, then one should consider other possible diagnoses.
My treatment plan on the initial visit for plantar heel pain almost always includes taping of the bottom of the foot with a kinesiology-type tape. If this yields relief, that often confirms a diagnosis of plantar fasciitis. My typical protocol for plantar fasciitis includes supporting the foot via taping and sometimes an over-the-counter (OTC) or custom orthotic device, icing with a frozen water bottle, extracorporeal shockwave therapy (ESWT) and calf stretching.
I advise the patient to perform the stretch against the wall and focus on feeling the stretch in the gastroc-soleus complex and not in the foot. Plantar fasciitis pain is associated with traction of the plantar aponeurosis insertion. For this reason, I discourage my patients from hanging off a step or putting their toes up against the wall to feel the stretch in the heel. The plantar fascia cannot stretch because it is a ligament with limited elasticity.
Another stretch I utilize in my protocol is a technique described by DiGiovanni and colleagues, who proved in high-level studies that this technique of stretching and massage of the arch works well to alleviate plantar fasciitis symptoms.1,2 Massage along the flexor hallucis longus (FHL) tendon and on both sides of that tendon. Patients may feel crepitus adjacent to the tendon and breaking up the bound down fascia overlying the FHL tendon can help improve the symptoms and the function of the foot (see first photo above).
For my initial treatment plan, I also seek to improve proprioception and engage the intrinsic muscles of the foot, also known as the foot core.3 For proprioception, patients start by balancing on one foot while brushing their teeth. Then they can add more of a challenge by closing their eyes.
I also have my patients perform a series of maneuvers to get the intrinsic muscles reengaged for the foot core (see second photo set above)
• Short foot exercise (see photo A in second photo set above). One performs this exercise, which involves shortening and raising the medial longitudinal arch by bringing the metatarsal heads toward the calcaneus without flexing the toes or contracting the extrinsic foot muscles.4
• Toes spread out exercise (photo B in second photo set above). The toes spread out exercise involves extending all five toes and then simultaneously abducting all five toes while flexing the first and fifth toes to the ground, keeping the second through fourth toes extended. The middle toe can then relax.5
• First and second through fifth toe extension exercise (see photos C and D in second photo set above). For the first toe extension, one would have the patient extend the great toe while the second through fifth toes remain on the floor in a neutral position. For the second through fifth toe extension exercise, the patient would attempt to extend the second to fifth toes while the great toe remains flat on the floor.6
What The Literature Reveals
Studies have demonstrated that new modalities and technologies used for plantar fasciitis including platelet-rich plasma (PRP), amniotic cells, prolotherapy, laser and others do not have significant evidence that they work any better than placebo.7-9 In their review of the literature, Pontin and coworkers found good evidence that orthotic devices can help heel pain, minimal evidence that stretching or manual therapy helps, and no evidence that laser or ultrasound helps at all.10
After a review of randomized controlled trials for soft tissue injuries, Schmitz and team concluded that ESWT is an effective and safe musculoskeletal treatment modality.11 I will often initiate ESWT on the first visit for plantar fasciitis, especially if the condition is more than a few months in duration. Many studies reveal good to excellent results with the use of ESWT for plantar fasciosis.12 ESWT is not covered by most insurance companies. We charge a separate cash fee for the treatment.
Case Study: When An Elite Runner Presents With Worsening Heel Pain
A 24-year-old male elite professional distance runner presented with low-level heel pain for several months that worsened a week before his last road race of the season. The race was very important to him. He wanted to compete there and then take time off to fully treat the heel. He performed some home treatments including non-steroidal anti-inflammatory drugs (NSAIDs), icing, stretching, inserts, massage and rest. His training group had an AlterG® treadmill, which allowed him to continue running with little to no pain.
With technology developed by the National Aeronautics and Space Administration (NASA), the AlterG treadmill reportedly can offload as much as 90 percent of a person’s body weight via a pressurized chamber.13 (The AlterG company website (https://www.alterg.com/ products/find-an-alterg) allows one to search for a unit by ZIP code. Hospitals and medical offices may have these treadmills, and will often rent them to injured patients.)
Initially, the pain was worse with his first steps in the morning and then went away. However, he says it slowly progressed, taking longer for the pain to resolve until he started to have the heel pain during an entire run.
The patient did not recall any specific injury and there was no change in shoe gear, training routine, running surface or topography. The athlete in question lives in another state and I consulted with him by phone. I advised him to find a local podiatrist and see if he or she would consider administering a corticosteroid injection. I discussed the possibility that an injection in that area could lead to a tear of the plantar fascia and the patient understood the risks. He obtained the injection five days before the race. However, he did not get much relief and was forced to drop out. The patient flew directly from the race for treatment at my office.
The physical exam revealed a rectus foot type and ankle dorsiflexion of five degrees with the knee extended. There was pain with side to side compression, which is sometimes a sign of a stress fracture of the calcaneus (see third photo above). The patient had significant pain at the attachment of the plantar fascia.
Radiographs did not reveal the presence of a spur or any signs of fracture. I decided to obtain magnetic resonance imaging (MRI). Although the patient exhibited many of the signs of typical plantar fasciitis, his pain seemed to be out of proportion to that diagnosis. The MRI revealed a thickening of the plantar fascia and a partial tear of the plantar fascia from the top down.
I would estimate that the tear did not occur after the injection but rather coincided with his increased pain in the last two weeks prior to contacting me, and was related more to the thickening of the tendon, which is a sign of degeneration associated with chronic plantar fasciitis.
In a study I coauthored about plantar fascia ruptures in athletes, we developed a treatment protocol and found that the average return to activity in athletes after such a rupture was nine weeks.14 This protocol consisted of two to three weeks of non-weightbearing in a high-top or short-leg removable cast boot. After experiencing no pain at rest or with passive extension of the digits, patients proceeded to protected weightbearing in the boot, as tolerated, for a one-week to three-week period. When there was no pain with ambulating for one week, the patient could discontinue the boot. I now add ESWT to that study protocol, initiating it at the first visit with two additional treatments spaced a week apart.
The patient began running again six weeks after his last run on the AlterG treadmill and at eight weeks on normal ground. He experienced some heel pain but this was more along the medial aspect. A physical exam revealed no pain plantarly but there was pain medially along the course of the medial calcaneal nerve. I gave an injection of 1 cc of 0.5% bupivacaine, 4 mg of dexamethasone phosphate and 3 mg of betamethasone (Celestone Soluspan). The patient was soon completely pain-free and has not had a complaint of heel pain in the two years since that injury.
When A Runner’s Heel Pain Does Not Respond To Treatment
A 50-year-old female runner presented with left heel pain, which coincided with an increase in training a few weeks prior to the visit. She stated that the pain was worse upon first steps and that it felt better after warming up. The patient also had an ingrown nail and noted this was the main reason she presented to my office. She stated that a previous corticosteroid shot relieved all her pain in her other heel.
A physical examination revealed a rectus foot type. She exhibited pain at the plantar medial calcaneus at the attachment of the plantar fascia. Radiographs did not reveal any signs of a fracture or spurring. We discussed wearing supportive shoes during the day as she works on her feet and she elected to have an injection, which consisted of 1 cc of 0.5% bupivacaine and 4 mg of dexamethasone phosphate. We advised her to follow the aforementioned protocol and taped her foot with a kinesiology-type tape.
The patient followed up a week later with increased pain. She said the injection helped with the pain but the stretching seemed to aggravate her foot. A physical exam on the second visit revealed increased pain at the attachment. We discussed the possibility that there may be a tear of the fascia but the patient refused a MRI at that visit. She elected to proceed with ESWT, which we administered with both radial ESWT and focused ESWT machines. We advised her to limit her activity more and limit any stretch or activity that causes increased pain.
The patient improved after the first two ESWT treatments. However, when she presented for the third ESWT treatment, she stated that the heel had become more painful over the last week when she tried to increase her activity. At this point, the patient elected to have a MRI, which revealed a stress fracture of the calcaneus along with thickening of the plantar fascia consistent with plantar fasciitis. However, there were no signs of a plantar fascia tear.
The patient proceeded to wear a CAM boot for the next four weeks. We added 2,000 IUs of vitamin D daily and advised her to take a calcium supplement as well. It is important to note that ESWT will also help the fracture heal.15 The patient is still under treatment but I expect a minimum of eight to 12 weeks before she will be able to resume running and continues to run without pain.
In Conclusion
Sometimes clinicians mistakenly assume that all plantar heel pain is plantar fasciitis. However, when the patient presents without post-static dyskinesia and the pain is not at the attachment of the fascia in the heel, one should consider another possible diagnosis, especially if the initial treatment plan fails to alleviate the patient’s pain.
Dr. Fullem is a Fellow of the American Academy of Podiatric Sports Medicine and is in private practice in Clearwater, Fla.
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