Classically, patients complain of pain with the first step after periods of inactivity. Pain may decrease briefly with activity and then return with prolonged activity. This commonly occurs in patients with extreme foot types, such as pes cavus or pes planus, in which the fascia experiences more stress due to biomechanical forces.
During the physical exam, one can locate the maximum area of pain, determine the type of pain and the foot type, perform a gait evaluation (if not too antalgic), and check for edema and any neuritic pain.
Initial treatment can include: PRICE (protection, restricted activity, ice, compression and elevation); low Dye strapping/accommodative padding (Cobra, longitudinal arch pad, medial heel skive); prefabricated insoles; non-steroidal anti-inflammatory drugs (NSAIDs); cortisone injections; stretching; and shoe modifications/recommendations.
I strongly advise patients not to wear flip-flops during this initial period of time. Frequently, younger patients will spend a significant portion of time during the day in their favorite footwear.
I always recommend caution with starting stretching too soon in the acute phase as stretching can actually aggravate and prolong the recovery if one does this too early and too aggressively.
In the more chronic and recalcitrant cases, custom functional orthotics, night splints, physical therapy, cortisone injections (repeated) and possibly a walking boot may be indicated.
Surgical management is rarely necessary or indicated, but a plantar fasciotomy (endoscopic) or extracorporeal shockwave therapy (ESWT) could be alternatives. Usually, attempts at conservative care last for at least six months. If a patient is not improving after four to six weeks of conservative care, it is often necessary to rethink the diagnosis of heel pain as there are many causes.
Cross-training activities will help keep up a patient’s level of fitness as he or she will need to curtail weightbearing activities. Swimming, biking, using an elliptical trainer and doing circuit weight training are all good options for patients seeking to maintain their fitness level.
Other Considerations In The Differential Diagnosis Of Plantar Heel Pain
Other causes of plantar heel pain include stress fracture, tarsal tunnel syndrome, rheumatoid arthritis and infection. Clinicians also should consider the possibilities of calcaneal apophysitis and heel pad syndrome.
Calcaneal apophysitis/Sever’s disease. Also known as Sever’s disease, calcaneal apophysitis is another very common cause of heel pain in youth. This is a traction apophysitis at the calcaneus due to the pull of the Achilles tendon insertion and the origin of the plantar fascia. The pain can be on the plantar aspect of the heel, posterior aspect of the heel or in both areas. I will do a “squeeze test” with medial and lateral compression of the heel. Typically, we see this presentation in children participating in athletic activity. Possible causes include (but are not limited to): obesity/being overweight; an increase in activity, especially running and jumping; shoes with poor support and cushioning; posterior calf tightness; and equinus.
Usually, this condition will resolve on its own with time but it is best to treat the symptoms with taping, shoe recommendations, ice, stretching and cross-training. Return to activity depends on symptoms and conditioning. Custom functional orthotics with a deep heel cup, medial heel skive and slight heel lift can be helpful in young athletes, who frequently can participate in most of their activities after treatment concludes. Stretching the calf and arch are also very important when patients are asymptomatic.