Heel Pain. Is it Plantar Fasciitis, Fat Pad Syndrome or something else?
There are many things to consider when evaluating heel pain which is why obtaining a proper diagnosis early is very important in the prognosis of your injury. We need to get you an accurate diagnosis so we can implement the proper treatment as soon as possible to get you back to your sport or daily routines.
The first thing that comes to mind when hearing heel pain is Plantar Fasciitis. Plantar Fasciitis is very common but that does not mean that you have plantar fasciitis. Other injuries that can cause heel pain include, but are not limited to: heel spurs, heel stress fractures, fat pad syndrome/contusion, and nerve entrapments (of medial plantar nerve, later plantar nerve and nerve to the abductor digiti minimi).
Let's talk about these four diagnoses to get better acquainted with them.
Plantar Fasciitis is the most common cause of heel pain. historically, plantar fasciitis was considered an inflammatory condition but recent studies have shown that no inflammation actually occurs. Plantar fasciitis is more of a degenerative process than an inflammatory process which led to the name change from Plantar Fasciitis to Plantar Fasciosis (since "-itis" is the medical term for inflammation)
The clinical features that differentiates Plantar Fasciitis from the other injuries include: pain with first few steps in the morning, pain near the inside of the heel, pain with hyper-flexion of the big toe (windlass test), and plain along plantar fascia.
Treatment includes rest (decreasing physical activity), mobilization of ankle joint, strengthening intrinsic muscles at the bottom of the foot, arch support, night splint to be worn at night and soft tissue work to plantar fascia and posterior lower leg muscles.
A heel spur is calcium deposits that causes bone overgrowth at the heel of the foot, can sometimes be asymptomatic and is often an incidental finding on X-Rays/MRIs of the foot. About 50% of patients with Plantar Fasciitis will have a heel spur that may or may not be contributing to the patients symptoms.
The clinical features that help rule in a heel spur is imagining (X-rays/MRI).
Treatment includes treating the plantar fascia as mentioned above. Non-surgical treatment is often very effective but if your pain does not resolve within 9-12 months, surgical options may be considered. These surgeries include a release of the plantar fascia and surgical removal of the heel spur. ALWAYS consider non-surgical options first!
Heel Stress Fracture
Heel (Calcaneal) Stress Fractures can be very painful and cut your athletic season short if you are not careful. These stress fractures can progress into actual fractures where the bone separates from itself - which will definitely end your season. you have to be very careful if you suspect you have a heel stress fracture (or a stress fracture anywhere in your body, for that matter).
The clinical features that differentiates a heel stress fracture are heel pain with activity and at rest, pain that is very focal and distinctive, can be seen with X-Ray/MRI and pain with most weight bearing activities, including walking.
Treatment includes a non-weight bearing period, decrease in activity level, heel pads to take pressure off the heel, range of motion exercises, soft tissue treatment and rehabilitation once the stress fracture is nearly healed.
Fat Pad Syndrome/Contusion
Fat Pad Syndrome/Contusion can be caused by repetitive loading onto the heel of the foot as in long distance running or marching and can also be cause by an sudden impact to the heel as in a fall onto the heel of your foot.
The clinical features that help differentiates Fat Pad Syndrome/Contusion are pain near the middle or outside of the heel, deep bruise like pain, pain that increases with activity, and pain with weight bearing activities such as walking. These features are very similar to the heel stress fracture and one way to differentiate the two is by squeezing the fat pad to see if it reproduces symptoms and fat pad syndrome has more of a diffuse pain pattern when compared to the local pain pattern of a heel stress fracture.
Treatment includes a non-weight bearing period, decrease in activity level, heel pads to take pressure off the heel, range of motion exercises, soft tissue treatment and rehabilitation once the inflammation decreases.
Nerve Entrapments often arise from overuse activities, trauma, previous injury or after a surgery. There are three main nerves that may become entrapped that can cause heel pain. these nerves include medial plantar nerve, later plantar nerve and the nerve to the abductor digiti minimi. You must also rule out the lower back - Radiculopathy of L4-S2 may also cause pain that travels to the heel.
The clinical features that help differentiate nerve entrapments are sensations of burning, tingling or numbness, bouts of sharp, shooting pain that lasts a few seconds and quickly goes away and pain with increase activity. lower back pain and increased pain with lower back movement may suggest L4-S2 Radiculopathy although more tests should be performed.
Treatment includes rest, decrease activity level, rehabilitation and strengthening exercises, mobilizations, soft tissue treatment such as Graston Technique and mobilization/manipulation of the lower back if radiculopathy is suspected and shown on MRI.
I hope you found some benefit in reading about the differences in these different, yet so similar in presentation, injuries. You should never try to diagnosis yourself and should always seek help from your sports chiropractor to give you an accurate diagnoses. If you wait too long to get a accurate diagnosis, you're risking further injury and a prolonged recovery period.
If you are currently dealing with an injury, give my office a call at (626)792-1221 so we can help you become pain-free again.
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Thank you and always keep moving!
Dr. Andres T. De La Cruz, D.C., CSCS
Doctor of Chiropractic
Certified Strength and Conditioning Specialist
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