Plantar Heel Pain

Chapter
10

Plantar Heel Pain

Plantar heel pain is not the diagnosis! Clinician must aim to arrive at etiological diagnosis!

Diagnosis of Plantar Heel Pain

To arrive at a correct diagnosis, answers should be sought for the following three questions:

Question 1: Is heel pain referred from same joint or not?

Answer: Refer to Box 10.1.

Box 10.1 Causes of heel pain.

♦ Local cause

♦ Distant cause/Referred pain from:

• Spine and sacroiliac (SI) joint

• Knee

• Hip

Points of Differential Diagnosis

♦ Signs and symptoms of original condition such as back, knee, or hip pain is predominant than foot and ankle pain

♦ Foot and ankle examination is normal

♦ Pain is in the specific dermatome

♦ Investigations help in the diagnosis

Question 2: What is the underlying pathology of heel pain?

Answer: Refer to Box 10.2.

Box 10.2 Underlying pathology heel pain.

♦ Local pathology (foot and ankle)

♦ Systemic pathology

Point of Differential Diagnosis

♦ Heel pain due to systemic etiology would be mostly bilateral

Question 3: What is the etiology for locally originating heel pain?

Answer: Refer to Box 10.3.

Box 10.3 Etiology of heel pain

♦ Mechanical

♦ Neuritic

♦ Bony

♦ Infective

♦ Combined

Points of Differential Diagnosis

♦ Mechanical—abnormal foot and ankle mechanics in the form of pes planus, pes cavus or deformed foot

♦ Neurological—neuritic pain that also radiates

♦ Bony—bony abnormality such as plantar exostosis following malunited fracture calcaneus

♦ Infective—foot and ankle infection such as osteomyelitis, Madura mycosis or tuberculous sinuses

♦ Combined—more than two problems may be associated as cause for plantar heel pain

Points of Significance in History

♦ Bilateral heel pain suggests systemic etiology

♦ Pain in other joints in the body suggests systemic etiology

♦ Night pain suggests infective or neoplastic etiology

♦ Burning pain or tingling numbness suggests neuritic etiology

♦ Pain at heel strike can be due to fat pad atrophy or stress fracture of calcaneus

♦ Pain at toe off can be due to plantar fasciitis

♦ Pain at the back of heel can be due to tendo Achilles disorders

♦ Painful first step in the morning suggests plantar fasciitis

♦ Radiation of pain suggests neuritic etiology

♦ History of amount of weight-bearing time spent is equally important as the amount of weight gained

♦ History of recent change in the activities and weight gain is important

Points of Significance in Clinical Examination

♦ Location of pain: This is the key feature. Ask the patient to point out at the location of pain (Fig. 10.1). The precise location of pain will help the examiner in deducing a probable cause for the pain (Table 10.1).

Fig. 10.1 Various locations of pain can direct examiner toward possible cause. ADQ, abductor digiti quinti.

Table 10.1 Location of heel pain and probable cause

Location of pain	Probable cause
Medial calcaneal tubercle	Proximal plantar fasciitis
Distal aspect of plantar fascia	Distal plantar fasciitis
Body of calcaneus	Stress fracture
Lateral border of heel	Entrapment of nerve to abductor digiti quinti
Central plantar aspect of heel	Fat pad atrophy
Posterior aspect of heel	Tendo Achilles tendinopathies
Master knot of Henry	Flexor hallucis longus (FHL) tendinitis
Medial side of ankle	Tarsal tunnel syndrome
Central part of plantar fascia	Plantar fibromatosis