Last week we started talking about plantar fasciitis as the cause of 50-80% of all plantar heel pain podiatrists treat. Let’s review the other problems that we will typically see which make up 20-50% of all of the other plantar heel cases. Our working diagnosis may be plantar fasciitis, but we need to have a common differential diagnosis also. This is really our next best guess. Where Occam’s Razor points to plantar fasciitis as the most probable cause of most plantar heel pain, we have to have a Plan B if the patient is not responding to our treatment of taping, stretching, and icing, etc.
Common causes of plantar heel pain are:
- Plantar Fasciitis
- Plantar Fascial Tearing (either Stage 2 or 3)
- Heel Bursitis
- Heel Bone Bruise or Contusion
- Calcaneal Stress Fracture
- Baxter’s Neuritis
- Combination
I throw into the differential “Combination” since our lovely patients can present with multiple diagnoses at once just to make life interesting.
We talked last week about how your working diagnosis is proven based on the patient’s response to your protocol treatment regimens. Therefore, at the first followup of a patient with diagnosed plantar fasciitis, if the patient is not progressing well, I tend to switch diagnoses. I challenge myself that, from the time I first see the patient, they should be better and better with each visit. If this is not the case, I have to decide if my treatment is not adequate, or my diagnosis is not correct. If I am still sure of my diagnosis, the treatment has to get more advanced in each category. Taping morphs into custom orthotic devices, and stretching and icing morphs into physical therapy with deep tissue work and iontophoresis or EGS for example. However, if there are parts of this patient’s history and physical exam that are non-plantar fasciitis-like, perhaps a change in diagnosis is in order.
Let’s first summarize from last visit what plantar fasciitis looked like to you when you made the diagnosis. The patient typically has:
- No swelling
- Heel Pain only at the medial calcaneal tubercle
- Worse pain in the morning that took less than an hour to loosen up
- The onset of pain was gradual, not a sudden event
- The pain is gradually getting worse, and still may not affect their ability to run
- No pain with heel walking on examination, or side to side bone compression pain
This is the presentation of typical plantar fasciitis, and I personally dislike other presentations. Red flags mentally unfurl in my head when someone is calling other forms of heel pain, plantar fasciitis.
How do the other diagnoses differ from the usual presentation? Let us look at each one separately.
- Plantar fascial Tear (stage 2 or 3) will have swelling, typically a more acute onset, with the swelling causing bone on bone pain with calcaneal compression, but the worse pain may still be in the morning or constant throughout the day.
- Heel Bursitis plantarly has swelling in our examination, and typically not on historical review. The pain is quite severe if the patient walks on the heels only.
- Heel Bone Bruise or Contusion has swelling, onset of symptoms acute, side to side compression pain, increased pain walking only on heels
- Calcaneal stress fracture are swollen, acute in nature, side to side compression pain calcaneus, and inability to walk on heels only when asked politely
- Baxter’s nerve entrapment symptoms depend on the acuteness of the nerve. Typically has some nerve symptoms in historical review. Pain is not morning pain. Patients can walk on heels. No swelling seen.
I hope this helped differentiate plantar fasciitis from other causes of heel pain. Please comment if there are other subtleties that you have found. When the problem is plantar fasciitis, it responds to our conservative care easily. Next week we will talk about when to place these plantar fasciitis patients into custom made functional orthotics. Thanks for reading.
