Cath Lab Digest

Although plantar fasciitis is the most common cause of heel pain, one should not overlook other possible etiologies. Accordingly, this author reviews pertinent keys to the patient history, physical exam and diagnostic testing that can help facilitate an accurate diagnosis.

   Plantar fasciitis is by far the most common cause of heel pain. Given the high number of cases reported per year, it is not uncommon for a doctor to diagnose a patient with plantar fasciitis without paying adequate attention to other potential causes of heel pain.

   It is essential for foot and ankle specialists to consider the range of possible causes prior to coming to a conclusion on the etiology of heel pain in any patient.

   Plantar fasciitis involves an inflammation and micro-tearing of the plantar fascia along its course. Plantar fasciitis is most commonly painful in the heel region at the attachment of the fascia to the plantar calcaneus.

   Patients will often complain of pain with the first steps in the morning or after sitting for a period of time and then standing. After a period of walking, the fascia tends to stretch out and there is far less pain. The problem can have a rapid onset and be very painful in a short period of time.

   However, plantar fasciitis may also be slow to progress and gradually increase in severity. Often patients will note that plantar fascia and/or Achilles stretching, or improved quality in shoewear will decrease their pain. Insoles or orthotics may also help to decrease pain.

   It is rare to see a patient with plantar fasciitis present shortly after he or she has experienced the pain. Most commonly, patients present after trying multiple home therapies and experiencing weeks to months of chronic low-grade pain.

   The only time that a patient will present with acute plantar fascia pain is when he or she has an actual fascia tear. This usually occurs with intense exercise and can be associated with or without previous plantar fascia pain. In such a patient, the pain is very severe and very rapid in its course. The patient may have noted a “pop” at the time of injury and may have pain at all times with ambulation.

   Although plantar fascia problems are the most common presenting factors with heel pain, there are a variety of other etiologies that are commonly associated with heel pain and are often misdiagnosed as plantar fasciitis. A short list of these etiologies includes:

   • plantar fascia tear
   • tarsal tunnel syndrome
   • Baxter’s nerve entrapment
   • calcaneal stress fracture
   • calcaneal cysts
   • soft tissue mass
   • short flexor tendon tear
   • gout
   • systemic arthritis (lupus, rheumatoid arthritis, psoriatic arthritis)

   Although one may note other causes of heel pain such as Achilles tendonitis/tendinosis, sural nerve entrapment or peroneal tendon tear, these problems are in different areas of the heel and are far more simple to diagnose.

   Accordingly, let us take a closer look at the most common causes of plantar heel pain.

Emphasizing The Value Of The Patient History

   A comprehensive patient history is essential to getting an early idea about the possible cause of the heel pain.

   How long has the patient had the problem? How often does the pain occur and for how long does it last? What improves the problem or makes it worse? What types of treatment has the patient previously attempted and have the treatments been helpful? Was there any associated trauma? Is there a family history of heel pain and/or a systemic arthritic condition?