Welcome to the first of a series of 3 articles about plantar fasciitis that I hope will help you understand the processes involved in achieving resolution of this often frustrating and sometimes debilitating foot condition. In this article we will look at assessment of the problem.
To keep terminology simple, I will use the label “heel pain” even though sometimes symptoms may vary from just pain and they may be located adjacent to the heel or further from it. So that brings us to one of the first important points we need to assess when looking at heel pain.
Where is the pain located?
A vague description won’t help us here as the foot is anatomically very complex with 26 bones, 33 joints, and more than a hundred muscles, tendons and ligaments. In just the sole of the foot where the plantarfascia is, there are 4 layers of muscles each with their own origins, insertions, functions and directions of pull. Directly under the heel bone itself (called the calcaneum) there is fascial tissue, fat pad, dermis, and epidermis.
Any of these tissues can get damaged so we need to look at the specific location of symptoms in order to ascertain which anatomical structure(s) may be involved. Is the pain on the inside or outside or back or underneath the heel? Is it on the bony part or the soft part of the heel? Is it nearer one of the ankle bones or further into the arch of the foot?
By pinpointing the symptom location(s) if possible, it gives us a great start to the assessment process. Remember that Podiatrists know foot anatomy intimately so can identify the structures affected.
Tell Jonathan Small, Lead Podiatrist, the story of your symptoms – right from the beginning
After introducing myself to a patient presenting with heel pain, and running through their medical history, I then move to learning about the problem that has brought them to see me, and their expectations of what they want from me. Often they are in a hurry to tell me about how it is at this moment in time (or at least within the past couple of days as its amazing how many say “its feeling easier now I’ve come to see you with it” – now if only I could bottle that magic and send it to all with foot pain!).
However HISTORY, HISTORY, HISTORY is so important for us to assess in order that we can help to fix the problem as quickly as possible and don’t waste time, energy, effort or money on chasing red herrings. So I want to know when the pain first started, during what activity, how did it progress, and how was it managed back then. The story then unfolds of the treatments tried, the limiting effects of the condition, the advice followed from others, and how the patient has ended up on my door as the person they hope can fix their feet. Once we’ve explored the past and established a historical timeline, we can then look at the present.
Describe your problem as of now
The next piece of the initial assessment process is about getting a comprehensive understanding of what the heel pain is like at present. What type of pain is it (such as burning, throbbing, shooting, stabbing, aching etc)? Does it move or even radiate? When does it feel worse/better? Is it present every day? All day? Which footwear helps/hinders the problem? There are many many more questions that we may ask depending on what any previous answers are, but once this process is finished, we will have a full picture of the symptoms in all their multi-coloured glory. This will be vital to record as we will reflect back on it at future appointments to ensure we are making progress with any treatment plan that the patient embarks upon.
Now let me take a look at you
Through advances in medical science, there are many investigations that can be carried out to help achieve a correct diagnosis and establish an effective treatment plan. The first investigation should ideally involve some form of hands/eyes-on check of what is going on, otherwise important things can be easily missed. For instance, it is quite common for heel pain to be caused by a foreign body such as an embedded animal hair or a shard of broken glass, but because of the nature and location of the skin under the heel, it is hidden from the untrained eye. On many occasions I have seen patients who have a lot of information from “Dr. Google” for completely the wrong diagnosis, but we will cover this more in the next article.
You may have heard of the term ‘biomechanical assessment’. This is the process of looking at how your body functions with regard to movement such as walking / running. This can be as simple or as indepth as necessary, but it should always add to the pot of information regarding the presenting condition. It shouldn’t just be carried out for the sake of it. So using the example above, you should not need a biomechanical assessment for a foreign body causing pain in your heel, as long as that is the only cause of pain.
Therefore beware of people who advocate biomechanical assessments just because they can do them (to a greater or lesser extent) or because that is their only assessment tool. Saying that, a lot of heel pain (but not all) has a mechanical cause or contributing factor(s), and such assessment is likely to be more useful than an X-ray for example, as this only looks at one type of structure (bone) on the simplest level. Biomechanical assessments should involve 3 main stages, none of which will give a complete picture on their own, but when brought together they can really help to understand what is stopping resolution of plantarfasciitis for example. These 3 stages involve assessing the patient on the couch, assessing them standing, and assessing them when walking/running (and possibly other activities). During each activity your Podiatrist will be looking at how the joints, muscles, nerves etc are all functioning. They are not just looking to see if you have flat feet, high arches, pronation, supination, or any other of the simplistic descriptors of foot position / function frequently mentioned alongside heel pain.
Other useful (but generally not essential) assessments for heel pain are 3D gait analysis, force/pressure assessment, ultrasound investigation, MRI scans and blood tests. Knowing your Podiatrist is able to carry these assessments out, or have access to them via referral if necessary, would help to reassure that you are in good hands to get your heel pain sorted. However it is important to treat the patient, not the test results as they may be spurious.
So that’s the assessment stage covered
From all of these steps that make up assessment of heel pain (“plantar fasciitis”), we should now be able to make a diagnosis or at least have some differential diagnoses to help guide our treatments. In the next article, we will cover diagnosis in more detail.
The above indepth assessments of heel pain / plantarfasciitis are available from Jonathan Small, Lead Podiatrist at Health First Foot & Gait Clinic in Southam, Warwickshire, and Theorem Health & Wellness in Alcester, Warwickshire. Remember that Podiatrists are the Foot Specialists – #PodsHealHeels and #PodsFixFeet.
01926 811272 firstname.lastname@example.org
Review on Google from Beverley Spicer:
“If you are suffering with Plantar Fasciitis Jonathan Small is your man. I was in agony for months and knew I needed a biometrics expert. Jonathan assessed my feet and provided a variety of insoles including one that he cast a mould of my foot to make. They were expensive, professional health care is not cheap, but years later I am still wearing and benefiting from my investment. My feet had hurt all of my life, but no longer! I am just back from a weekend walking in the Alps with happy feet! :)”