Plantar heel pain is commonly diagnosed by various types of healthcare professionals,
including chiropractors and sports clinicians, often resulting due to
mechanical, neurologic, traumatic or other systemic conditions. Plantar fasciitis is one of the most frequent pathology among many sport settings. However, other circumstances of heel pain may be formerly studied when evaluating an athlete with heel pain.
Approximately up to 2 million Americans report feeling symptoms of heel pain every year, adding up to an estimate cost of up to $400 million in medical bills. Despite everything,
not much is known about the pathophysiology and etiology of plantar heel pain.
By highlighting the causes of plantar fasciitis as well as examining other
common mechanical issues behind heel pain, including plantar fascia
tears/rupture, heel pain of neural origin, calcaneal stress fractures and
atrophy of the heel pad, individuals can learn to understand the diagnostic
criteria and possible treatment options available to treat their plantar heel pain.
Plantar Fasciitis
The plantar fascia is a fibrous aponeurosis which extends from the
calcaneal tuberosity in the heel, to the proximal phalanges in the toe. Plantar
fasciitis most commonly occurs as a result of mechanical overload due to either
bio-mechanical faults, obesity and work habits.
The plantar fascia functions to support the medial longitudinal arch,
acting as a shock absorber, through both passive tensioning of the plantar
fascia, known as the Windlass mechanism, and through the active tension of the
plantar intrinsic foot muscles, including the flexor hallicus brevis, the
adductor hallicus and the plantar interossei, as well as the tibialis posterior.
It has been suggested that intrinsic foot muscle weakness can lead to increased
loads on the plantar fascia. Because testing the strength of these muscles can
be very difficult, researchers have utilized volume estimates of the intrinsic
foot muscles and the tibialis posterior muscles to identify whether there’s a
distinction in volume between these muscles in people with plantar heel pain. There
was no particular difference in the volume of the tibialis posterior and there
was only a 5 percent variation in the forefoot volume of the intrinsic foot
muscles in comparison with the asymptomatic foot.
Evaluation and Diagnosis of Heel Pain
Individuals diagnosed
with plantar fasciitis frequently experience symptoms of pain on the first few
steps they take in the morning when getting out of bed or after resting for an
extended period of time, medically termed as post-static dyskinesia. Tenderness
is also generally reported to occur over the origin of the plantar fascia on
the medial calcaneal tuberosity. In order to test the integrity of the plantar
fascia and the Windlass mechanism, the Jack’s test may be utilized, which
involves the passive extension of the first MTP joint, or the
metatarsophalangeal joint. It’s been demonstrated that the reduced dorsiflexion
range of motion, increased body mass index and poor biomechanics are probable
risk factors for plantar fasciitis.
A full
biomechanical assessment should be initiated to help determine these risk
factors. This would include but should not be limited to: midtarsal, subtalar
and ankle range of motion, calf flexibility, gait evaluation and footwear
inspection.
Often, healthcare professionals diagnose the presence or absence of
calcaneal spurs through the use of ultrasound, although weight bearing
radiographs may also be effective to determine the height of the calcaneal fat
pad. In the case of plantar fasciitis, evaluations utilize ultrasound at the
proximal insertion of the plantar fascia to identify whether there was a
fascial thickening greater than 4 to 5 mm, deceased echogenicity and/or
perifascial effusions may occasionally be diagnosed.
Several healthcare professionals who specialize in the diagnosis and
treatment of sports injuries and conditions, can effectively determine the
cause behind an individual’s plantar heel pain. Chiropractic care focuses on restoring
and maintaining the overall health of the body, primarily focusing on the spine
and its surrounding structures. When it comes to plantar fasciitis and the
onset of plantar heel pain, a chiropractor can help diagnose the origin of the
individual’s symptoms to properly develop an effective measure of treatment to
follow. Chiropractic treatment generally consists of mobilization and
myofascial release techniques and massages to relieve pain and discomfort from
muscle tissues along with other surrounding structures associated with plantar
heel pain and plantar fasciitis.
An infracalcaneal spur may occasionally be
present as these have also been found in asymptomatic individuals and removing
the spur won’t add to the success of surgery to heal plantar heel pain, if
considered. Thickening of the plantar enthesis has also been associated with a
reduction in energy dissipation ratio of the calcaneal fat pad which may
further increase plantar fascia load.
Treatment for Plantar Fasciitis
The Heel Pain Committee of the American College of Foot and Ankle
Surgeons, concluded there were three tiers of treatment modalities for plantar
fasciitis. They declared that Tier 1 treatment options must first be established,
including: padding and strapping of the foot, stretches and exercises of the
calf and foot, home cryotherapy, avoiding walking on flat shoes or barefoot,
over-the-counter arch supports/heel cups, oral anti-inflammatories,
corticosteroid injections and weight loss.
If no reaction was recognized after six weeks of treatment, then, Tier 2
based treatment options must be started while continuing Tier 1 treatments.
Tier 2 treatment options include: night splints, further injections,
immobilization and prescription orthotics. The combination of using foot
orthotics and dorsiflexion night splints has been demonstrated to be more
effective than the utilization of orthotics alone. Following these suggestions,
85 to 90 percent of individuals respond to treatment within 8 to 12 weeks and
experience full recovery by one year. The Tier 3 treatment option described
refers to surgery, which should solely be considered for individuals who failed
Tier 1 and Tier 2 treatment option pathways.
With regard
to plantar fasciitis, corticosteroid is the traditional injection of choice,
but, evidence and research studies have revealed that there only serve as a
temporal, short-term relief option. Other risk factors have also been
associated with corticosteroid injections, including poor, long-term outcomes
such as fat pad atrophy, osteomyelitis of the calcaneus and iatrogenic
ruptures. Platelet rich plasma, or PRP, the concentration of platelets derived
from the plasma portion of autologous blood, including growth factors, has also
been tested as a possible treatment option for plantar fasciitis. Researchers
compared corticosteroid injections and platelet rich plasma, concluding identical
results within three weeks and six months, approximately a 50 percent drop in
VAS scores, claiming that considering the risk components related with
corticosteroid injections and platelet rich plasma could be a preferred
treatment option. Other researchers compared botulinum toxin type A, or botox,
with corticosteroid injections, or CSI, and concluded that the botox group was
reported slightly better results at one month while showing considerably better
results than the CSI group at both six and twelve months.
Exercise to Prevent Ankle Sprains
Plantar Fascia Tears and Ruptures
Generally, acute plantar fascia strains occur
commonly during sports and physical activities. Frequently, if these happen in
isolation, the injury may respond relatively quickly to treatment. These are
regularly associated with plantar fasciitis, specifically if a corticosteroid
injection has been previously tested on the individual. Athletes with an acute
tear report feeling heel pain along with tenderness over the region of the
plantar fascia. A palpable lump may be present if a partial or complete rupture
occurs. Individuals with considerable tears often report feeling pain upon weight-bearing.
Initially involving a non-weight-bearing boot, treatment is generally
symptomatic and its combined with progressive weight-bearing along with
supportive taping and/or orthotics according to the symptoms.
Heel Pain Caused by Neural Issues
Approximately
15 to 20 percent of individuals experiencing plantar heel pain can attribute
their symptoms to impingement or compression of the tibial nerve branches. The
most common cause of plantar heel pain caused by nerve complications involves
the entrapment of the first branch of the lateral plantar nerve. This nerve can
become pinched at three potential sites: first, it can become entrapped where
the nerve passes at the sharp edge of the abductor hallucis; second, it can
become entrapped just distal to the medial edge of the calcaneus; and last, it
can become entrapped due to compression from the abductor hallucis and the quadratus
plantae muscles.
The second
most common cause of heel pain as a result of neural complications involves the
impingement or compression of the medial calcaneal nerve which runs through the
heel fat pad and superficial tissues overlapping the inferior calcaneum. A majority of the branches of this nerve can
be found running through the superficial intrinsic muscles of the foot, making
them less probable to be entrapped within these muscles, however, they may be
irritated following heel pad atrophy. Compression or impingement of the medial
plantar nerve, which innervates some of the intrinsic muscles of the foot, has
been previously diagnosed but is considered rare in isolation.
Evaluation and Diagnosis of Neural Heel Pain
Individuals with plantar heel pain originating as a result of neural
issues commonly describe their pain as sharp, shooting, electric or shock-like
pain which radiates either proximally or distally along the length of the
nerve. As with plantar fasciitis, the pain can generally worsen over periods of
rest but may also occur at rest and in non-weight-bearing positions. Although paresthesia
or anesthesia are uncommon, it’s commonly described around the medial or plantar
surfaces of the heel. On physical
examination, nerve compression or impingement should be suspected if the site
of maximal tenderness is found over the nerve.
Neurodynamic assessments can help properly diagnose whether nerve complications
can be associated with an individual’s plantar heel pain. Modified straight leg
evaluations with added dorsiflexion, eversion and toe extension can increase
tension along the tibial nerve, when hip flexion is added, no further loading
on the plantar fascia was noted. Adding hip flexion can help differentiate the
plantar fascia and the tibial nerve.
Treatment for Neural Complications
Current research suggests that the treatment for plantar heel pain
resulting from neurological complications should be similar in nature to that
for plantar fasciitis. Nonetheless, the lack of specific treatment option
alternatives to treat the various presentations of heel pain is believed to be
one of the reasons why plantar heel pain may not respond positively to
treatment. Researchers have proposed that interface work and nerve gliding or
sliding exercises recommended by healthcare professionals such as chiropractors
or sports specialists, may be useful to treat and prevent further impingement
or compression of these tissues. Further studies must be done to determine the
most effective treatment for these nerve entrapment syndromes of the foot.
Fat Pad Atrophy and/or Contusion
The calcaneal fat pad is made up of elastic
fibrous tissue and closely arranged fat cells which function as a shock
absorber on heel strike. This condition is commonly associated with plantar
fasciitis, although, it can occur entirely on its own. Individuals with fat pad
atrophy describe feeling their symptoms of pain worsen with walking, especially
in hard shoes or on hard surfaces. The pain generally occurs around the fat
without any symptoms of tenderness over the medial calcaneal tuberosity. Commonly
as a result of the heel strike pattern, pain often develops over the lateral
aspect of the heel, helping to differentiate it apart from plantar fasciitis. MRI
is the modality of choice utilized to diagnose a fat pad pathology,
demonstrated by decreased signals on T1 weighted images and increased signals
on T2 images. Treatment involves decreasing compressive load against the fat
pad which may include taping, silicone gel heel cups and orthotics.
Stress Fractures of the Calcaneum
Calcaneum stress fractures are relatively frequent, commonly occurring
along the upper posterior margin of the os calcis or adjacent to the medial
calcaneal tuberosity. These fractures should be premeditated in runners,
jumpers, dancers or military service members. Individuals or athletes with a
calcaneal stress fracture generally describe feeling symptoms of heel pain,
which unlike other plantar fasciitis instances, symptoms usually worsen with
activity. On palpation, tenderness can be felt over the medial and/or lateral
aspect of the calcaneum and pain will be reproduced by the squeeze test. A simple
X-ray or MRI may be utilized to confirm the diagnosis.
In conclusion, treatment of calcaneal stress fractures comprises of a course of
non-weight-bearing rest until the pain and discomfort is reduced or eliminated. Walking and a gradual return to activity may be allowed after the use of soft heel pads together with training exercises to improve the individual’s biomechanics.
Furthermore, when evaluating and diagnosing individuals or athletes with plantar heel
pain, several pathologies should be considered and properly assessed to determine the presence of a specific injury and/or condition, to direct treatment towards preventing pain and other symptoms, making
sure to address the patient's potential predisposing factors.
By Dr. Alex Jimenez