Plantar fasciosis (fasciitis)
Infracalcaneal fat pad atrophy
Medical calcaneal nerve entrapment
Tarsal tunnel syndrome
Systemic lupus erythematosus
Lateral plantar nerve branch to abductor digiti quinti
Calcaneal stress fracture
Intraosseous edema of calcaneus
A Guide To Neurogenic Etiologies Of Heel Pain
While heel pain is the most common condition podiatrists see in practice, heel pain can often be complex and occasionally difficult to treat.1 In recent years, we have seen the introduction of new treatments as logical conservative preludes to fasciotomy, including extracorporeal shockwave therapy, injection of the plantar fascia with autologous growth factors and coblation therapy.2
Clinicians are able to employ some of these modalities, such as autologous growth factors, due to a better understanding of the true histological and physiological etiologic mechanism that occurs at the cellular level.3-5 The basic medical science research at the cellular level of tendonopathy has been a critical catalyst in changing our understanding of heel pain etiology. Lemont, et. al., reinforced this point when they observed no histological presence of inflammatory mediators in 50 specimens (100 percent) of plantar fascia that had been resected for the treatment of heel pain.6
These findings must propel us toward a change in our treatment paradigms. Equally important, if not more so, are similar findings and clinical experience in treating other analogous musculoskeletal conditions such as lateral epicondylitis or “tennis elbow.”7,8 While neurogenic etiologies of heel pain comprise the focus of this article, the prevalence of multiple etiology heel pain in clinical practice clearly indicates that our basic understanding of plantar fasciitis is changing and may in fact have been significantly erroneous all this time.
Furthermore, the presence of multiple etiology refutes the mistaken tendency to categorize all heel pain as plantar fasciitis when the more correct terminology is plantar fasciosis. The previous catch-all categorization has led to misdiagnosis and less than desirable outcomes in some patients.
Understanding The Array Of Potential Etiologies In Heel Pain
Clinicians often fail to recognize that heel pain can commonly have an isolated neurogenic etiology or it can present concomitantly with other etiological mechanisms.9-11 There is frequently an interplay between the presence of plantar fasciosis and nerve entrapment. Fredericson, et. al., documented via MRI imaging that chronic inflammation of the proximal portion of the plantar fascia can predispose the lateral plantar nerve to entrapment.12 Heel pain etiologies can range from infracalcaneal fat pad atrophy to Reiter’s syndrome (see “A Guide To Potential Heel Pain Etiologies” below).1
More than 2 million patients will be diagnosed with heel pain in a given year, according to estimates from extrapolated data from the American Podiatric Medical Association.13 While the effectiveness of conservative management of plantar fasciitis (fasciosis) is well established, there are no specific studies that document the efficacy of conservative care for managing heel pain when it has a sole neurogenic etiology.1
Given the aforementioned numbers, even for a condition that is successfully diagnosed and treated conservatively more than 90 percent of the time, this still presents approximately 200,000 cases that are of neurogenic or mixed etiology, which may require more definitive and aggressive treatment. Sadly, many cases that fit this description are erroneously attributed to a “recalcitrant” plantar fasciitis status.