Cath Lab Digest

While plantar fasciitis is a common diagnosis for inferior heel pain, these authors emphasize the importance of a proper workup and differential diagnosis. They also offer pearls on conservative treatments such as corticosteroid injections and provide insights on surgical procedures such as plantar fasciotomy.

   When it comes to inferior heel pain, the most common diagnosis is plantar fasciitis. The well-known signs and symptoms include post-static dyskinesia, point tenderness to the plantar medial tubercle and radiating pain to the ankle and/or midfoot. While plantar fasciitis is the most common diagnosis, physicians should consider the long list of differential diagnoses for inferior heel pain.

   Many times, patients fail all manner of conservative care, go on to surgical intervention and fail to improve their symptoms because the initial diagnosis was incorrect or inadequate to treat the patient properly.

   One can find 80 percent of the information necessary to diagnose a patient successfully in the history and physical exam. Have a high suspicion of other etiologies of plantar heel pain if the patient does not fit nicely into the plantar fasciitis mold or does not respond to initial therapy. Examine the superstructure of the patient to see if the foot is compensating for a biomechanical abnormality in the leg. Inferior heel pain can be plantar fasciitis or it can be arch fatigue manifesting itself as inferior heel pain.

   Pain is a symptom that is difficult for the practitioner to assess and for the patient to describe. Key words are important in distinguishing different types of pain. Sharp, stabbing, burning, shocking, throbbing, aching and tingling are all words we should be using when asking patients about their pain in order to discriminate between mechanical and neurological pain. When you fully examine and palpate all surrounding joints, you may find pathology that could be causing pain that originates in the ankle, subtalar joint or midtarsal joints to the inferior heel.

   One may consider arthrography or diagnostic joint injections when there is no clear etiology for the patient’s inferior heel pain. Use the needle as an extension of the physical exam. If the local anesthetic takes away the patient’s pain, then you have a targeted area for therapy. In some cases, this may prove more beneficial than information one obtains with magnetic resonance imaging (MRI).

   The differential diagnosis may include:

   • plantar fasciitis;
   • calcaneal bony cyst/tumors;
   • plantar fibromatosis;
   • calcaneal intraosseous lipoma;
   • calcaneal stress fracture;
   • diffuse idiopathic skeletal hyperostosis (DISH) disease;
   • Reiter’s syndrome;
   • Baxter’s neuritis; and
   • medial calcaneal nerve entrapment.

   After arriving at a diagnosis, formulate a directed plan of therapy for not only that current visit but for the follow-up visit, always thinking about what to recommend to patients as the next step. Start with basic conservative therapy including modification of shoe gear. Many times, patients will only be wearing unsupportive sandals. Once patients get into more supportive tennis shoes, their symptoms lessen or resolve completely.

   Conservative therapy options also include changing shoe gear, strapping/ padding, stretching, physical therapy and passive and dynamic night splints. Other options are local anesthetic/corticosteroid injections in a series of up to three injections, custom orthoses or using a short leg walking cast for three weeks.