Mastering Plantar Heel Pain In Athletes

By Patrick J. Nunan, DPM

   Plantar heel pain is one of the most common maladies we see in podiatric practice. Patients learn on their first visit that the symptoms usually respond to conservative treatment over a six- to 12-week timeframe, although some individuals may take six to 12 months to be totally pain-free. Athletes may have difficulty accepting the fact that they may have lingering pain over six to 12 months. Not only may the athlete be upset, one may also draw the ire of the coach, athletic trainer, agent or parent.

   When treating an athlete with plantar heel pain, podiatrists must understand the mechanism of injury, the biomechanical demands of the sport, shoe gear and playing surface, the age of the athlete and the psychosocial effect of the sport on the athlete.

   Plantar heel pain among athletes is usually due to overuse and poor biomechanics. However, traumatic causes such as slipping off a curb when running or a baseball player coming down too hard on first base can occur. Excessive pronation is often associated with plantar heel pain, although it can occur in the supinated or pes cavus foot. Muscle strength imbalance and muscle tightness have also been indicated as causes of plantar heel pain. Other possible contributing factors to plantar heel pain include loss of the plantar fat pad with advancing age, increased body weight or hard playing surfaces.1,2

Essential Keys To A Thorough Examination

   When working with students and residents, I tell them 90 percent of the time they can diagnose a patient’s problem if they listen to the patient and actually touch the patient. Obtaining a thorough patient history and performing a comprehensive physical examination are vitally important when treating athletes.

   In addition to determining whether there is a family history of heel pain, the patient history should document the type of shoes the patient wears for sports and for everyday wear, the type of surfaces the patient trains and plays on, and whether there have been any recent changes in training. One should also ascertain whether the patient has experienced a recent weight gain, and note any previous injuries and prior treatment.

   Clinicians should ask the patient what aggravates the injury. Does it feel worse with shoes on or off? Is it painful after rest? Does the patient have worse pain the more he or she is on their feet? Does the pain intensity increase as the patient bears weight? Does the patient’s heel pain result in swelling that occurs throughout the day? We should also find out what, if anything, makes the foot feel better.

   One should conduct the physical examination in a systematic manner, evaluating nerves, muscle strength, range of motion and the location of pain.

   Palpate or tap the peripheral nerves around the ankle to see if there is shooting pain. Proceed to palpate the posterior tibial nerve and sural nerves more thoroughly to see if this elicits pain. Then palpate the superior and inferior aspect of the abductor hallucis muscle to see if this elicits pain from the plantar or calcaneal nerves. Test muscle strength on both feet and record the strength along with any pain. Check the range of motion for the ankle, subtalar, midtarsal and first MTP joints as well as the hamstrings. Pain location may be the most important part of the examination.

   Does the patient have medial plantar pain only or does the patient’s pain extend to the middle and lateral aspect of the heel? Is there pain with side to side compression or with palpation of the medial calcaneal nerves at the same time? Does the pain occur just with palpation of the medial wall of the calcaneus or does he or she experience pain with palpation of both the medial and lateral walls? Is the pain located around the edges or rim of the calcaneus? One should also compress the calcaneus from the posterior to anterior manner. Compression pain could indicate a stress fracture.

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