When Neurosensory Testing Can Help Pinpoint The Cause Of Heel Pain

By David Soomekh, DPM and Babak Baravarian, DPM

While there are many different causes of primary heel pain, it is often misdiagnosed as simple plantar fasciitis without the proper diagnostic tools. This is especially true for patients who have recurring symptoms and/or have failed multiple conservative and or surgical treatments. It takes a conscientious clinician to know when to begin thinking of a different diagnosis and a new course of treatment.
This is especially true when it comes to heel pain. Many of the patients who walk into our offices complaining of heel pain have either been told by another doctor they have plantar fasciitis or have diagnosed themselves. Armed with that knowledge, it would be easy to assume this is the correct diagnosis and to perform only the minimum of diagnostic examinations. However, this approach would be ineffective in treating the patient and his or her symptoms fairly. A more effective approach would be one that we have employed in our offices.

Key Pointers On Making An Accurate Diagnosis
After obtaining a thorough history of the symptoms and complaints, one should perform a physical examination. Begin by palpating the medial tuberosity of the calcaneus and the surrounding areas to determine the point of maximum tenderness. If the patient relates a specific area of pinpoint tenderness at this site, one cannot assume a diagnosis of plantar fasciitis even if there is a correlation of subjective signs. A further examination of the heel should include side to side compression of the calcaneus to rule out any fractures.

Proceed to gently tap on the posterior tibial nerve with a finger or reflex hammer as it passes posterior to the medial malleolus to determine any nerve involvement. Use the same approach at the level of the medial calcaneal branch as well. If the patient relates any positive reaction from the nerve palpation, one may suspect nerve pathology. To complete the physical exam, clinicians should determine the presence of ankle equinus.
Proceed to perform an ultrasound examination of the plantar fascia of the symptomatic and non-symptomatic foot. If the plantar fascia is less than 4 mm, one cannot make a diagnosis of plantar fasciitis. If there is hypertrophy of the fascia, you will be able to see an increase in its thickness from 5 mm and higher. You can also determine if there is any attenuation or complete tear in the fascia. Using ultrasound also allows one to visualize the plantar calcaneal bursae. Keep in mind that pathology of the bursae can mimic symptoms of plantar fasciitis without any pathology to the fascia itself.
At this point, if you are satisfied that a diagnosis of plantar fasciitis is accurate, proceed with conservative treatment. If there is any suspicion of nerve involvement at this time or any time during the treatment course, then a neurosensory examination is indicated.

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