Most patients with plantar heel pain seek treatment in a primary care setting and are diagnosed with plantar fasciitis. Although plantar fasciitis is the most common reason for heel pain, other pathologies should be included in the differential. The potential differential diagnosis list includes plantar fasciitis, heel pad atrophy, calcaneal stress fracture, nerve entrapment, Achilles tendonopathy, neuroma and plantar wart. The order from most to least likely is based upon further clinical clues provided by the patient's history, age, gender and physical exam.
Plantar fasciitis is attributed to excessive strain on the plantar fascia at the insertion into the calcaneus. Excessive pronation, for example, causes such strain and creates microtears, inflammation and pain.1-3
The risk factors for plantar fasciitis are broad; excessive foot pronation, high frequency of running or standing, pes cavus, leg length discrepancy, Achilles tendon tightness and obesity all contribute. Other risks include occupations that require standing or walking and, on the opposing spectrum, a sedentary lifestyle.
Plantar fasciitis can affect young runners, but it is most common in people ages 40 to 60.1,4 Higher occurrence has also been noted in patients who have decreased dorsiflexion range, increased weight bearing and increased body mass index. Interestingly, 85% of plantar fasciitis cases have unknown etiologies.5
The primary clinical feature of plantar fasciitis is severe pain on the plantar area of the foot. This pain is most prevalent in the morning. Pain is most severe during the first steps of the day and decreases after a few minutes, worsening again at the end of the day. Palpation of the plantar fascia over the medial heel will recreate the pain.5 Patients may present with high arches, hypomobile gastrocnemius/soleus muscles and pain while extending toes passively and actively.3 Patients who stand for prolonged periods have increased pain as the day goes on. Pain with passive ankle dorsiflexion also indicates irritation of the fascia.1
If history and examination findings are not consistent with plantar fasciitis, other etiologies must be considered. A common cause of point tenderness on the foot surface is plantar wart, which produces a raised lesion on the foot where the pain occurs. It is important to examine the foot superficially before considering other differential diagnoses.
While plantar fasciitis is the most common cause of plantar heel pain, it has a history that is distinct from the second most common cause, heel pad atrophy.6 Patients with heel pad atrophy complain of point tenderness over the plantar heel, but the pain persists at rest. Heel pad atrophy usually presents bilaterally, while plantar fasciitis presents unilaterally. In both cases, pain is reproducible with palpation over the calcaneal region of the heel. Classically, plantar fasciitis pain is more medial2 and heel pad atrophy pain is more peripheral.6
Burning, tingling, numbness or sensation disturbances in the feet suggest a neurologic cause. In such cases, nerve entrapment or neuroma should be higher on the differential list. Some patients may have plantar fasciitis first and later develop nerve entrapment.7,8 Symptoms are relieved by rest and worsened by activity. Nerve entrapment should be highly suspected if a patient has undergone recent surgery or trauma.
A neuroma can be felt upon palpation as a mass on the heel. If it does not present in this way, patients may be diagnosed with plantar fasciitis and later be diagnosed with neuroma based on treatment failure. In these patients, a clue to rule out plantar fasciitis is pain that worsens throughout the day and may produce parasthesias, burning or tingling.
A calcaneal stress fracture may be present with a patient history of trauma or increased activity. Physical exam signs such as a positive squeeze test can warrant plain films of the heel.2 Unlike plantar fasciitis, swelling and bruising are usually present on inspection of the heel, and the location of pain involves the entire hindfoot rather than point tenderness on the heel.2
Achilles tendonopathy should be included on the differential list when a history of overuse or trauma exists. In the presence of this condition, pain occurs and a nodule can be felt on the insertion point of the Achilles at the posterior portion of the heel instead of the plantar surface. Pain is reproducible with passive dorsiflexion.9
Diagnostic Studies for Plantar Fasciitis
Plain radiographs taken while the patient is weight bearing allow for visualization of anatomical faults, strain and bone spurs. If bone spurs exist, pathology is likely to last at least 6 to 12 months.10 However, not every patient with plantar fasciitis has bone spurs, and vice versa.10
Ultrasound can show thickness of the plantar aponeurosis and soft tissue injuries. Fascia thicker than 4 mm indicates plantar fasciitis.1,11 Diffuse hypo-echogenicity indicates edema at the attachment site of the fascia, supporting a diagnosis of plantar fasciitis. Magnetic resonance imaging (MRI) is not necessary for diagnosis but has good sensitivity.4
Treatment for Plantar Fasciitis
Therapy decisions for plantar fasciitis are determined by the severity and duration of symptoms. Conservative management should always be the first choice. In 80% to 90% of patients, symptoms are self-limiting and resolve within 1 year.1,4,10
Patients who have an acute onset of symptoms should take nonsteroidal anti-inflammatory drugs (NSAIDs) and alternate applications of ice and heat. Massage and stretching of plantar and gastrocnemius-soleus muscles are also helpful.4 Padding and strapping of the foot or use of orthotics with arch support are also recommended.4,10 Steroid injections and night splints are more aggressive options.
If symptoms do not improve after 6 to12 months, plantar fasciotomy or extracorporeal shock wave therapy should be considered.4 Extracorporeal shock wave therapy increases healing by neovascularization and without an invasive procedure. Although this is a relatively new therapy, it has been suggested as a safer alternative to fasciotomy.11
Heel Pad Atrophy
Heel pad atrophy presents as a deep, aching pain in the middle of the heel. It is often confused with plantar fasciitis. Pain is reproduced with firm palpation and is caused by degeneration of the fat pad.7 Incidence is highest in elderly patients, since atrophy of the heel pad increases over time.
To make a diagnosis, a lateral view radiograph should be taken while the patient is weight bearing. This shows the height of the fat pad and permits comparison of the height differences between the patient's feet. This view is especially informative in slender or elderly patients.8
Treatment for heel pad atrophy includes rest, ice, decreased weight bearing, NSAIDs, heel cups and taping.7 Patients should wear shoes with extra padding or use orthotics. Unlike patients with plantar fasciitis, patients with heel pad atrophy do not have the treatment option of steroid injections because the injection itself may lead to further atrophy, which could worsen the patient's condition. Surgery is not an option for these patients, adding importance to the need for proper diagnosis of heel pain.12
Calcaneal Stress Fracture
Patients with calcaneal stress fracture experience pain onset soon after increasing their activity, especially when the activity causes repetitive load on the heel.7 The most commonly affected patients are athletes ages 17 to 26, military personnel and runners.7,8
The diagnosis of calcaneal stress fracture should be suspected based on physical exam findings of tenderness on the lateral wall of the calcaneus, positive squeeze test and bruising or swelling.2 The history may include a fall from a higher surface and landing directly on the heel.
The diagnosis of calcaneal stress fracture can be confirmed with technetium bone scan or MRI. Radiographic imaging may not reveal a fracture, but if visible, it appears as a sclerosing line.8
To treat this fracture, a short leg cast should be applied. Patients should not bear weight until tenderness resolves.12
Nerve entrapment that causes heel pain most often involves the lateral plantar nerve. This entrapment can include the medial calcaneal nerve, medial plantar nerve, posterior tibial nerve and sural nerve.13
The clinical presentation of nerve entrapment includes a history of surgery, overuse or trauma. Some patients who have been diagnosed with plantar fasciitis also develop nerve entrapment. Symptoms of nerve involvement besides pain include burning, tingling, numbness and paresthesias.7,8 The pain often radiates, worsens with activity and improves with rest. Clinical testing includes the Tinel sign, the dorsiflexion-eversion test and the plantar flexion-inversion test.13
Although electromyography identifies abnormalities in the nerves supplying the plantar aspect of the foot, it is not diagnostic for nerve entrapment. Quantitative sensory testing with pain, temperature and electrical impulses detects abnormalities in patients with high thresholds. Ultrasound locates nerve swelling but it does not have diagnostic significance except to rule out additional pathology.13
Treatment for nerve compression is similar to that for plantar fasciitis. Common conservative approaches include rest, decreasing pressure on the foot, stretching and strengthening exercises, and orthotics. NSAIDs and ice may also be helpful. As with plantar fasciitis, surgery should be considered if conservative therapy does not lead to symptom improvement in 6 to 12 months.7
Achilles tendonopathy is associated with lower extremity overuse. It is common in runners, overweight patients and women who wear high heels. The overall incidence is higher in men than women.7,9,14 Older adults who take fluoroquinolones are at increased risk for Achilles tendonopathy and rupture.7 The presentation of pain is usually achy and sharp, located in the back of the heel.7 Palpation usually detects a thickened nodule on the proximal third of the Achilles tendon.9 Palpation of this nodule or passive dorsiflexion reproduces the pain.7 Pain is worsened by running, jumping, walking down stairs and walking up hills worsen. However, no limit in muscle function exists.9
If diagnosis based on clinical findings alone is unclear, radiographic imaging may show spurring at the insertion site or calcifications in the tendon.8 Ultrasound is commonly used and shows thickening of the Achilles tendon. Doppler study will show increased blood flow to the region of pain if a tear is present.9
Because the body needs to undergo regeneration and remodeling of collagen tissue, diagnosis and treatment should occur early to interrupt this process and allow faster healing. Treatment includes the discontinuation of pain-inducing activities. Night splints relieve morning pain. Passive and well-controlled active stretches are necessary to improve collagen alignment in the healing process. NSAIDs are not effective and delay healing of the tendon.
If the initial treatment approach of stretching does not relieve the pain, the clinician should progress to sclerosing injections, glyceryl trinitrate, extracorporeal shock wave therapy or percutaneous longitudinal tenotomy. Surgery for refractory pain may be necessary if nonsurgical treatment attempts are unsuccessful.9
Neuromas are caused by direct trauma or chronic microtrauma. A neuroma can form on branches of the tibial nerve. The associated pain is characterized as burning, tingling or paresthesias. The pain radiates across the heel but it is most localized on the central aspect of the plantar heel. Palpation of this central area may reveal a mass and will reproduce the pain. Patients with neuroma complain of pain that worsens throughout the day. Diagnosis is usually considered after plantar fasciitis treatments are unsuccessful.
Ultrasound can identify a neuroma as a hypoechoic region. Radiographs are only used to rule out other pathologies. The gold standard for a definitive diagnosis is a biopsy and histologic exam of the mass.15
The treatment of neuromas seeks to sclerose the nerve with alcohol injections over a series of two weeks. Heel cups absorb shock, and minimizing weightbearing activities helps relieve pain. If conservative treatment does not reduce symptoms after 3 months, surgical removal of the neuroma should be considered.15
Plantar warts are an easily missed cause of plantar pain. These warts are caused by human papillomavirus.16 They are tender to palpation. A raised lesion on the plantar surface of the heel is visible upon inspection. No diagnostic studies are necessary to confirm diagnosis.
Plantar warts are usually self-limiting; treatment options include removal of the wart via cryotherapy, laser therapy or shaving. Topical over-the-counter creams that contain salicylic acid can resolve the wart and can help patients return to activity faster.7
NPs and PAs in primary care settings encounter many patients who report "heel pain." The first step in diagnosis is gathering a detailed history of recent trauma, surgery, pain location and conditions that exacerbate or relieve the pain. Examine the bottom of the foot to determine if a plantar wart is present. The most common diagnosis is plantar fasciitis, but it is important to avoid dismissing other plausible causes of heel pain. This is especially important in heel pad atrophy, which is commonly confused for plantar fasciitis.
Knowing the limitations of imaging prevents unnecessary time spent on studies that will not provide an adequate view of pathology. Although conservative treatments for heel pain pathology resemble each other, the selection of next-phase treatment is specific to each diagnosis. For patients who lose functional ability due to heel pain, correct diagnosis and treatment can help improve quality of life and the patient-provider relationship.
Caroline Poirier is a student in the physician assistant program at Georgia Regents University in Augusta, Ga. Sara Haddow-Liebel is the director of education for the program. The authors have completed disclosure statements and report no relationships related to this article.
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