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There may be a tendency to leap to a plantar fasciitis diagnosis when patients present with heel pain. However, this author emphasizes the importance of a thorough differential diagnosis. Accordingly, he offers diagnostic insights on a variety of potential causes ranging from calcaneal spur fractures and neurogenic heel pain to systemic etiologies.
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Continuing Education Course #158
November 2007
| I am pleased to introduce the latest article, “A Guide To The Differential Diagnosis Of Plantar Fasciitis,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of complimentary CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.
Given the frequency with which podiatrists see heel pain in their practices, Charles Peebles, DPM, cautions against assuming that plantar fasciitis is the diagnosis. Accordingly, he reviews other conditions and associated symptomatology that DPMs should consider in determining the cause of the patient’s heel pain. Dr. Peebles also offers pertinent insights on diagnostic imaging and treatment tips once one has arrived at the appropriate diagnosis.
At the end of this article, you’ll find a nine-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.
Sincerely,
Jeff A. Hall
Executive Editor
Podiatry Today
INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 77 and successfully answering the questions on pg. 82. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Peebles has disclosed that he has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of his presentation.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists
RELEASE DATE: November 2007
EXPIRATION DATE: November 30, 2008
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• cite common causes of plantar fascial tears and calcaneal spur fractures;
• discuss clinical signs and symptoms of calcaneal stress fractures;
• discuss key clinical signs of nerve entrapment with chronic heel pain;
• identify possible patient symptoms that may occur with tarsal tunnel syndrome; and
• describe key considerations in the differential diagnosis for pediatric heel pain.
Sponsored by the North American Center for Continuing Medical Education.
| Heel pain is the most common complaint that foot and ankle specialists see in practice. This is particularly the case for those who emphasize sports medicine in their practices. The typical patient description is surprisingly similar and all the phrases are well known. You will hear “pain with my first few steps,” “it loosens up after a few steps” and “it feels like a stone bruise.” Unfortunately, we hear these phrases and are quick to jump to whatever our treatment protocol is for plantar fasciitis.
However, sometimes our protocol does not work. That is when we need to take a few steps back, listen to our patient and refuse the urge to complete the patient’s “phrases” for him or her. There are many etiologies of heel pain. When our treatment plan is not working or, better yet, prior to formulating a treatment plan, we need to at least consider the remote possibilities as far as the diagnosis goes and not just be looking for the most likely causes.
One can often hone in on the diagnosis by listening to the patient’s symptoms, performing a thorough physical exam, and using radiographic and laboratory studies to assist in evaluating the patient. Subtleties in patient communication, such as “it does not hurt in the morning” and “it feels best barefoot,” should be triggers that we may be dealing with a different problem. Bear in mind that someone can have plantar fasciitis in combination with, or prior to developing, problems such as entrapment of the first branch of the lateral plantar nerve or a calcaneal stress fracture. Prior to pigeonholing a patient with heel pain into the diagnosis of plantar fasciitis, it is important to differentiate the heel pain from other etiologies of pain in and around this region.
|  | | This lateral radiograph shows a calcaneal spur avulsion fracture. |
What About Plantar Fascial Tears And Calcaneal Spur Fractures?
When pain begins acutely in the heel, especially after a specific trauma, this may involve the plantar fascia but one may need to consider a different treatment protocol. In regard to plantar fascial tears and calcaneal spur fractures, these acute injuries to the plantar fascial complex often occur when the patient attempts to jump over things, tries to take off or stop quickly (especially common in tennis) or when he or she runs or sprints on soft surfaces (such as at the beach).
Often these patients may have already had some pain in the heel but it was not to the point of needing medical attention. They may have already been undergoing treatment and overexerted their foot. Perhaps the patient received a steroid injection just prior to activity and sustained a rupture of the plantar fascia or an avulsion injury of the plantar calcaneal spur.1,2
Pain with these injuries is usually localized to one site and is not diffuse in nature. One will see localized edema and, in some cases, ecchymosis. In this clinical scenario, the pain does not usually remit or “loosen up” with increased walking.
These patients have a severely antalgic gait and the tautness of a portion of the plantar fascia is absent. One may reproduce the pain with dorsiflexion of the foot and the toes. Radiographs may reveal a fracture or avulsion of the infracalcaneal spur or they may be negative with a plantar fascial tear.
Treatment of these conditions varies due to the need to immobilize the region and allow the plantar fascial complex to heal prior to returning to activity. A removable walking cast and crutches are often useful for initial partial weightbearing assistance to allow stabilization both during everyday activities and for sleep to maintain the fascia and/or osseous spur during the healing time.
After a four- to eight-week period of immobilization, the patient may progress back to activity with continued support of the arch while you attempt to address any predisposing etiologies. As mentioned above, these patients often have had symptoms prior to their acute event.
Recognizing The Signs Of A Calcaneal Stress Fracture
Calcaneal stress fractures, like most stress fractures, are not very painful with the first step of the day but usually become worse with increased activity. There are many etiologies that one must consider when evaluating for this condition. Changes in activity, shoe gear and job requirements may have added extra stress to normal bones. Stress fractures can also occur due to weakening of the osseous structure and this may be the initial presenting episode for someone with osteopenic or osteoporotic bone.
Pain is typically worse as the day progresses and the patient may describe swelling in the region although ecchymosis is unlikely. Pain is usually not as significant with plantar palpation but there may be increased pain intensity with a direct side-to-side compression of the heel. Initial radiographs are often negative, as is the case with many stress fractures. However, serial radiographs will often display the classic sclerotic opacity, which indicates a healed stress fracture. Bone scans are beneficial in early differentiation and magnetic resonance imaging (MRI) can also help rule out other soft tissue pathology. Take serial radiographs not only to evaluate healing but to monitor for potential collapse of the posterior facet of the subtalar joint.
The treatment of calcaneal stress fractures involves removing the stress and protecting the osseous structures to allow healing to occur. Immobilization through the use of a weightbearing removable or below-knee cast allows the healing to occur without joint compromise. Non-weightbearing activities such as swimming or aqua jogging may continue to allow the patient to maintain fitness while recovering.
The use of bone densitometry is beneficial in determining possible bone deficits. One should consider it for any patient who has a stress fracture without a clear overuse etiology or in patients with multiple stress fractures. The most important concern with treating a calcaneal stress fracture is to determine the underlying cause so one can correct the condition or prevent a recurrence to limit further complications.
What You Should Know About Neurogenic Heel Pain
As with any type of pain that is not “classic,” it is important to look at neurogenic etiologies. The patient with multiple back surgeries raises our suspicion for a radicular cause of heel pain. It is important to ask the questions to rule out more proximal etiologies that may result in symptoms that mimic plantar fasciitis.
One of the more common symptoms that should stimulate thought regarding nerve-related pain is when the patient has pain when resting or when attempting to go to sleep.
When a patient does not have classic symptoms and the clinician cannot reproduce the pain with palpation plantarly, this should raise suspicion for possible impingement either in the low back or throughout the distribution of the sciatic nerve and its distal branches. The physician can use a simple straight leg raise test to rule these out clinically and a neurology referral may be beneficial to evaluate these cases that do not respond to typical treatments.
Two specific nerve-related etiologies are localized to the foot and ankle and one can treat these in specific ways based on their underlying cause.
A Closer Look At Nerve Entrapment
Entrapment of the first branch of the lateral plantar nerve is a very common cause of chronic heel pain and clinicians often overlook this when the patient presents with an initial complaint of heel pain.3,4
In regard to this etiology of heel pain, there is often a component of plantar fasciitis early on and this often clouds the evaluation based on the patient’s history. The classic first step pain is common early with this condition and the patient often relates this has continued although the pain has seemed to shift in either a medial proximal direction or that it extends to the lateral aspect of the foot toward the midfoot. Patients may relate that they are unable to abduct the fifth toe due to the muscular innervation of the abductor digiti quinti, although many patients do not notice this until prompted.
|  | | With a calcaneal stress fracture, pain is usually not as significant with plantar palpation but there may be increased pain intensity with a direct side-to-side compression of the heel as shown above. |
Clinical examination may reveal induration at the plantar medial portion of the heel. The most consistent finding related to this condition is pain with palpation at the junction of the plantar and medial portion of the heel as opposed to pain with direct plantar palpation. The pain tends to become worse as the day progresses. This is due to increased edema in the region as this branch of the lateral plantar nerve courses between the abductor hallucis and flexor hallucis brevis muscle bellies while traversing toward the lateral aspect of the foot.
Adjunctive testing, including plain film radiographs, MRI and bone scans, are beneficial in ruling out other processes but do not have any classic findings for this diagnosis. Electrodiagnostic studies are not specific for this condition although one may use such studies in order to rule out more proximal etiologies or entrapments.
Treatment initially involves decreasing the strain on the region through functional support in combination with cryotherapy to decrease inflammation in the region. One may make more localized attempts, using corticosteroid injections to decrease the irritation and inflammation around the nerve. If conservative modalities fail, surgical intervention through the release of this nerve has been beneficial in the treatment of this condition.
One would perform surgical release through an oblique incision paralleling the medial calcaneal nerve branches in order to try to prevent further nerve complications. Carry dissection to the deep fascia over the abductor muscle with the plantar fascia visualized at this time. Make an inverted T at the dorsal margin of the plantar fascia and through the abductor fascia. This allows retraction of the abductor muscle belly and exposure of the fascia, and helps separate the abductor hallucis from the flexor hallucis brevis.
Make a vertical linear incision through this fascia and remove a portion of the tissue to release the entrapment of the nerve. Then release the medial band of the plantar fascia to eliminate any contributing influence on the pain. One may institute local infiltration of a corticosteroid at this time.
Postoperative care involves non-weightbearing in a short leg cast or splint with the foot maintained at 90 degrees to the leg for three weeks. One should subsequently emphasize three weeks of weightbearing in a removable walking cast prior to having the patient return to functional orthotic support.
Podiatrists often overlook this condition in the treatment of chronic heel pain. Traditional aggressive treatments with plantar fascial release or extracorporeal shockwave therapy have been ineffective as these treatments do not address the entrapment of the first branch of the lateral plantar nerve.
Key Insights On Tarsal Tunnel Syndrome
Tarsal tunnel syndrome is another type of neurogenic heel pain produced by compression of the posterior tibial nerve or its branches, the medial and lateral plantar nerves, as they course from their retromalleolar position into the arch of the foot. These symptoms are often not “typical” for plantar fasciitis and include radiating pain, pain with percussion proximal to the heel or at the abductor canal, and possibly atypical varicosities.
The compression on the nerve is commonly caused by the functional strain on the tissue and deep fascia, which form the tarsal tunnel. However, this syndrome may also be induced by intrinsic space-occupying pathologies such as tumors, varicosities, osteophytes, accessory muscles or tendon pathology.
Pain typically becomes worse with increased activity and often continues even with rest. Radiographic examinations will rule out osseous space-occupying lesions and MRI may be beneficial in differentiating other soft tissue pathology that may be occurring in the region. Electrodiagnostic studies can be beneficial in identifying the nerve compression but, depending on technique, may yield false negatives. In regard to tarsal tunnel syndrome, one typically identifies it via high clinical suspicion and subsequent adjunctive testing to differentiate the underlying etiology.
Treatments range from conservative modalities such as functional support and physical therapy to cryotherapy and injections. Surgical release may be indicated if conservative options fail or if one identifies space-occupying pathologies. This condition can be challenging in that it may mimic plantar fasciitis and traditional plantar fascia treatment modalities do not often produce results.
Should Osseous And Soft Tissue Tumors Be In Your Differential Diagnosis?
While the diagnosis of an osseous or soft tissue tumor mimicking plantar fasciitis is rare, it is important to keep it in the differential for heel pain. The symptoms may be variable and many of us have stories of a patient or two who came in for heel pain and left wondering how they could possibly have some type of tumor. While tumors are relatively rare in this region, one should be able to identify them rapidly and obtain a subsequent biopsy if necessary.
Patients who relate a rapid swelling in the arch or at the heel should receive more thorough evaluations via ancillary exams. Take radiographs of every patient with heel pain. (The patient expects it and, more importantly, radiographs rule out osseous pathologies such as tumors or stress fractures.) Depending on the results of the exams, the physician can manage this or obtain appropriate consults in order to facilitate the best outcome for the patient.
Key Pearls On Recognizing Systemic Etiologies
In some cases, the signs and symptoms do not add up, and the typical treatments do not produce the results that we expect. It is important to go back to the patient’s history and expand the search for other underlying etiologies. Heel pain may have other etiologies including metabolic, inflammatory or infection-related conditions.
Metabolic conditions involving bone formation, calcium maintenance, gout or other hormonal imbalances may produce pain in the heel or arch region. When there is heel pain in the presence of fever, wounds and significant edema and erythema, physicians should consider the possibility of an infectious etiology.
It has been well documented in the literature that systemic arthritic conditions may produce enthesiopathies and pain at the insertion site of the plantar fascia.5,6 Accordingly, the physician must piece the puzzle together by asking the additional questions and incorporating additional laboratory testing. While it is not common to order additional laboratory testing at the first visit, it is worthwhile if you have a high clinical suspicion of arthritic etiology and the patient has not responded to traditional therapy.
|  | | This lateral radiograph reveals a healed calcaneal body stress fracture. |
In these cases, it is more common for the seronegative arthridities to be involved and a typical profile involves ANA, ESR, HLA-B27, uric acid and rheumatoid factor. These tests may yield false negatives but they can be beneficial in identifying the patient who is not responding to treatment due to an underlying inflammatory condition. A rheumatologic consult may be beneficial in the further evaluation and treatment of these systemic conditions.
While these conditions may be rare, the traditional treatment plans for plantar fasciitis will fail if the physician does not address the underlying etiology and more significant problems may occur. The initial presentation to a foot and ankle specialist’s office may be the first notice of these disease processes. When the symptoms do not seem to be consistent with some of the aforementioned conditions, be sure to consider other etiologies.
How To Differentiate Heel Pain In Children
The most common source of heel pain in children and adolescents is calcaneal apophysitis. Unfortunately, our approach to this patient is similar to our approach with adult heel pain in that we tend to steer our minds toward this diagnosis as soon as we see a chart for heel pain in the 8- to 16-year-old age group.
However, as children and adolescents have become increasingly active and have begun year-round athletic pursuits, overuse injuries such as plantar fasciitis have become more common. This is especially true in the adolescent years as the calcaneal apophysitis has closed and now the strain of the Achilles tendon/calcaneus/plantar fascial complex comes to rest on the plantar fascia.
Other considerations in your differential diagnosis for heel pain in children would include juvenile rheumatoid arthritis (Still’s disease), benign or malignant tumors, infectious processes and congenital conditions.7
Again, listening to the patient’s description of his or her symptoms, and having a more thorough differential diagnosis for heel pain in children will assist in developing an appropriate treatment plan that will keep these young people active. Early intervention and aggressive conservative treatment will allow a rapid return to activity with limited downtime.
Final Thoughts
The treatment of heel pain is very rewarding in that it is a challenge for many patients and one can provide hope and facilitate resolution of the pain.
The difficulty lies in determining the correct diagnosis through listening to the patient’s version of the story, performing a thorough clinical exam, and using appropriate adjunctive radiographic or laboratory studies to differentiate among the many sources of heel pain.
By thinking of all the possibilities during the evaluation process and identifying the most likely etiology, the physician can manage heel pain and identify the challenging cases earlier. This in turn typically provides for a more expedient resolution of this condition for our patients.
References
1. Saliman JR. Plantar fascia rupture associated with corticosteroid injection. Foot and Ankle International. 15 (7): 376-381, 1994.
2. Rolf C, Guntner P, Ericsater J, Turan I. Plantar fascia rupture: diagnosis and treatment. J Foot Ankle Surg 36(2): 112-114, 1997.
3. Baxter DE, Pfeffer GB. Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop 279:229, 1992.
4. Goecker RM, Banks AS. Analysis of release of the first branch of the lateral plantar nerve. J Am Pod Med Assoc 90(6):281-286, 2000.
5. Gerster JC. Plantar fasciitis and Achilles tendonitis among 150 cases of seronegative spondyloarthritis. Rheumatol Rehab 19:218, 1980.
6. Scherer PR, Gordon D, Kashanian A, Belvill A. Misdiagnosed recalcitrant heel pain associated with HLA-B27 Antigen. J Am Pod Med Assoc 85(10): 538-542, 1995.
7. Kim CW, Shea K, Chambers HG. Heel pain in children: diagnosis and treatment. J Am Pod Med Assoc 89(2): 67-74, 1999.
For related articles, see “Mastering Plantar Heel Pain In Athletes” in the November 2004 issue of Podiatry Today, “How To Evaluate And Treat Calcaneal Fractures” in the November 2005 issue and “Should You Change Your Approach To Plantar Fascisosis?” in the November 2006 issue.
Also check out the archives at www.podiatrytoday.com.
| CE Exam #158 | Choose the single best answer to the following questions.
1. _______________ often occur when athletes try to jump over things, take off or stop quickly (especially common in tennis) or when they run or sprint on soft surfaces (such as at the beach).
a) Calcaneal stress fractures
b) Calcaneal apophysitis
c) Acute injuries to the plantar fascial complex
d) None of the above
2. Which of these statements is true in regard to plantar fascial tears and calcaneal spur fractures?
a) One will usually see ecchymosis and, in some cases, localized edema.
b) Patients with these injuries will have a severely antalgic gait.
c) With these injuries, the pain is usually diffuse in nature.
d) All of the above.
3. Which of the following statements is false in regard to calcaneal stress fractures?
a) With these fractures, patients say their sharpest pain occurs with the first steps of the day but the pain eases at night.
b) Serial radiographs often display the classic sclerotic opacity, which indicates a lack of healing with stress fractures.
c) Pain tends to dissipate as the day progresses and the patient often has ecchymosis in the affected region.
d) All of the above
4. When a patient presents with heel pain and has had multiple back surgeries in the past, there is a higher index of suspicion for …
a) entrapment of the first branch of the lateral plantar nerve
b) tarsal tunnel syndrome
c) a radicular cause of heel pain
d) none of the above
5. One of the more common symptoms that should stimulate thought regarding ______ is when the patient has heel pain when resting or attempting to sleep.
a) nerve-related pain
b) a calcaneal stress fracture
c) a plantar fascial tear
d) none of the above
6. In regard to entrapment of the first branch of the lateral plantar nerve, the most consistent finding in the clinical examination is …
a) induration at the plantar medial portion of the heel
b) extreme pain with direct plantar palpation
c) pain with palpation at the junction of the plantar and medial portion of the heel
d) none of the above
7. Radiating pain, pain with percussion proximal to the heel or at the abductor canal, and possible atypical varicosities are symptoms one might encounter with …
a) soft tissue tumors of the heel
b) calcaneal spur fractures
c) tarsal tunnel syndrome
d) none of the above
8. When there is heel pain in the presence of fever, wounds and significant edema and erythema, physicians should consider the possibility of …
a) entrapment of the first branch of the lateral plantar nerve
b) a soft tissue tumor
c) an infectious etiology
d) none of the above
9. The most common source of heel pain in children and adolescents is …
a) calcaneal apophysitis
b) juvenile rheumatoid arthritis
c) plantar fasciitis
d) none of the above |
Instructions for Submitting Exams
Fill out the enclosed card that appears on the following page or fax the form to the NACCME at (610) 560-0502. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam. Responses will be accepted up to 12 months from the publication date. |
