Welcome to the second in 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 diagnosis 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. As we explore possible diagnoses in more depth, you will see that the common label of “plantar fasciitis” is just one of many possible labels, any of which could be more accurate and therefore lead to more appropriate interventions and better treatment outcomes.
If we break down the wording, then plantar fasciitis means inflammation of the fibrous tissue on the sole of the foot. The definition of inflammation is “a localised physical condition in which part of the body becomes reddened, swollen, hot, and often painful, especially as a reaction to injury or infection”. But this applies to only a small percentage of heel pain presentations. Indeed once you have looked through the list of possible diagnoses with below, you will see from their simplified explanations that true plantar fasciitis is probably not the correct diagnosis for many people who believe it is.
Heel pain caused by mechanical skeletal tissue stress
Acute Calcaneal Fracture – broken heel bone as a result of a single trauma such as landing on the heel from a height
Calcaneal Apophysitis – formerly known as “Sever’s disease” in which the heel growth plate becomes irritated in children
Calcaneal Tumour – any tumour affecting the heel bone will lead to mechanical weakness of the structure
Systemic Arthridities – the effects of a generalised arthritic condition may affect the capacity of the heel bone to cope with mechanical stress
Heel pain caused by mechanical soft tissue stress
Plantar fasciopathy – acute or chronic disorder of any part of the plantarfascia that runs from the heel bone to the toes
Plantar fasciosis – irritation and thickening of any part of the plantarfascia, generally chronic (long-standing) in its nature
Achilles Tendinitis / Tendinopathy – the Achilles tendon connects the calf muscle to the heel bone and this can get inflamed or damaged
Heel Contusion – a bruise generally as a result of a single trauma such as landing on the heel from a height
Fat Pad Atrophy – underneath the heel there is a shock-absorbing fat pad that can waste away especially with age
Plantar Fascia Rupture – a tear for the plantar fascia itself
Posterior Tibial Tendinitis / Tendinopathy – the tendon of one of the foot stabilising muscles (posterior tibialis) runs close to the heel and this can get inflamed or damaged
Retrocalcaneal Bursitis – a deep fluid-filled sac, like a blister, but closer to bone and develop and become inflammed
Enthesitis / enthesopathy – an enthesis is where a ligament inserts into a bone and any of these can get inflamed or damaged, including the plantar calcaneal enthesis where the plantar fascia inserts into the heel bone
Metabolic disorders (ones that occur when the energy process in your body is disrupted)
Osteomalacia – “soft bones” often caused by lack of vitamin D can cause bone pain and muscle weakness
Hyperparathyroidism – an increase in parathyroid hormone levels causes blood calcium levels to rise
Hypothyroidism – an underactive thyroid can cause several types of foot pain, including joint and muscle pain
Neurological disorders (ones associated with nerves)
Medial calcaneal nerve entrapment – one of several nerves that can be trapped around the ankle & heel area
Baxter’s nerve entrapment – compression of the first branch of the lateral plantar nerve (Baxter’s) may account for up to 20% of heel pain
Tarsal tunnel syndrome – also known as posterior tibial neuralgia, it is a compression neuropathy and in which the tibial nerve is compressed as it travels through the tarsal tunnel
S1 Radiculopathy – problems with nerve roots in the spine can manifest in the foot
Systemic diseases (ones that affect the whole body)
All of the following medical conditions can result in heel pain:
Tuberculosis, Ankylosing Spondylitis, Seronegative Arthropathies, Seropositive Arthropathies, Reiter’s Syndrome, Inflammatory bowel disease, Gout, Rheumatoid arthritis, Psoriatic Arthritis
Tumours are swellings, generally without inflammation, caused by an abnormal growth of tissue, whether benign or malignant. There are many that can cause heel pain, including:
Metastatic tumour, Osteogenic sarcoma, Chondrosarcoma, Ewing’s sarcoma, Unicameral bone cyst, Osteoid osteoma, Intraosseous lipoma, Aneurysmal bone cyst, Giant cell tumour
Whilst we are always mindful of malignancies in any aspect of medicine, we have to realise than common things are common, and rare things are rare. There is a phrase “think horses rather than zebras”, and only by carrying out a thorough assessment as discussed in the first article, can we be reassured that the diagnosis is likely to be one of the more common conditions. Once we have narrowed down our diagnoses, we can then look at appropriate treatment options, and this is discussed in the next article.
Exploration of the above comprehensive diagnoses of heel pain / plantarfasciitis is available with 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 Facebook from Sue Ball:
“Have been suffering from plantar fasciitis for some time. After treatment and advice from the Foot and Gait Clinic my condition is manageable. Thank you I am now pain free.”
Review on Facebook from John Newbold:
“Very professional and friendly service – solved my foot problems where many others had failed -highly recomended.”