Heel pain can be more than just an annoyance. It may make simple everyday tasks, such as getting out of bed, heading to your vehicle, and standing for work, more painful than they should be. A heel condition called plantar fasciitis can be the culprit, but it’s not the only one. In fact, there are several causes of heel pain that can generate similar symptoms, and treating the wrong one will only add to your woes. This is where a clinical diagnosis becomes important because pinpointing the cause allows your clinician to recommend suitable plantar fasciitis treatments, develop a personalised treatment plan, or consider an alternative approach. The truth is, heel pain isn’t something you can accurately self-diagnose by simply examining the location of the pain.
Taking a thorough medical and activity history
One of the most important things to do in the first stages of assessing the source of plantar heel pain is to ask the right questions. How long have you had this heel pain? Does the pain come on first thing in the morning and disappear with movement, or does it increase after a few hours of standing? These questions are seemingly simple but give a clinician a good amount of insight. Heel pain that is most noticeable after rest and gets slightly better with movement can be an indicator of plantar fasciitis, and pain that tends to build throughout the day has its own problems, although they do sometimes overlap. A patient will be asked about recent changes in activity levels, walking distance, shoe choice, body weight, and at work, including if they’ve recently increased running mileage quickly or spent longer on hard floors. Past injuries can also play a part, and the kicker here is really understanding how the pain came to be and what seems to make it worse.
Physical Examination and Palpation of the Heel
The doctor will then examine your foot and feel for tender areas. When you have plantar fasciitis, tenderness can be found around the inside of the heel, at the spot where the plantar fascia attaches to the heel. Applying light pressure to this spot may reproduce the pain. That can help confirm the diagnosis, but it doesn’t prove it. The doctor may also test the arch and the heel pad itself, as well as the ankle and soft tissues surrounding it. Tenderness around other structures can suggest alternative reasons for the pain. The doctor may look for swelling, discoloration, skin abnormalities, and other clues that need to be explored. Consider your other foot, even if it is not painful. Come on, that painful spot is important, but it is just one piece of information. The goal is to bring the examination results into a logical connection with your symptoms – not to fit every case into one pre-made diagnosis.
Checking Foot Mechanics and Walking Patterns
What you do when you stand or walk can also determine the stress on your foot. In the clinic, a person’s walking pattern and foot posture, arch motion, and ankle movement are assessed. Clinicians will often view the foot and how it is rolling in and out during walking, check heel function, and assess the amount of upward movement in the ankle joint. An ankle joint that doesn’t move well can alter how your foot loads and functions throughout the gait cycle, but foot posture alone doesn’t explain every problem with heel pain, and many people with flat feet or high arches experience no problems. All of these factors, alongside ankle movement, walk time, and other observations, can be considered, and a more specific plan put into action in terms of footwear, exercises, load management, or orthotics.
Using Specific Clinical Tests to Further Clarify the Diagnosis
A number of different examination techniques can be used to tell apart plantar fasciitis from other causes of heel pain. One is the windlass test, where the examiner delicately raises the big toe to put tension through the plantar fascia. If this reproduces the pain that the person is experiencing, then this can be taken as additional evidence that they do have plantar fasciitis, although the test does not need to be positive for the diagnosis to be present. The flexibility of the calf muscles and the ankle joint are also examined, as they can be tight and pull on the painful foot as we walk. Other tests may be used to look for nerve irritation, including sensation, muscle strength, and whether certain movements set up pins and needles, burning sensations, or shooting pain. In the case of a heel stress fracture, a different assessment is needed, especially if there has been an increase in pain after each load cycle. No test is foolproof, but the pictures in this article demonstrate how a composite of clinical observations can lead to focused examination rather than a mindless checklist.
Other Conditions Causing Heel Pain
These other causes are not so much searched for as they are not considered in the first place. Plantar fasciitis hogs the limelight, but we need to be aware that there are other differential diagnoses. Heel fat pad syndrome can cause a bruised feeling in the middle of the heel and is aggravated by walking barefoot on hard surfaces. A calcaneal stress fracture can cause a progressively worsening pain following repetitive impact or a sudden increase in activity. Nerve symptoms can cause burning, tingling, numbness, or pain extending beyond one small area. Achilles tendinopathy causes pain towards the back of the heel rather than underneath it, but their features can be similar. Inflammatory joint pathology or other systemic illnesses can be part of the picture if there are other signs and symptoms affecting multiple joints. The other things to inquire about are violent night pain, fever, swelling that is not explained by injury, or inability to bear weight. Find out what is wrong and avoid the mistake of attributing every sore heel to plantar fasciitis.
When Imaging and Further Investigations Are Needed
The clinical history and examination of the foot can usually help in the diagnosis in most cases. Further investigations may not always be necessary. Often, imaging does not add to the clarity of the clinical diagnosis and is not always necessary if the clinical presentation is uncomplicated. Nonetheless, investigations can sometimes be helpful, particularly where the presentation is unusual or severe, or there has been a long history or failure to respond to conventional therapy. X-rays can sometimes show certain bony abnormalities and help exclude other causes of heel pain, but they may not always show plantar fasciitis. Ultrasound can sometimes show pathology of the plantar fascia, including thickening, and can sometimes be used to check for some soft tissue problems. MRI can be considered if a stress fracture, soft tissue damage, or other condition may be suspected. Blood tests can sometimes be useful when the presentation suggests an inflammatory or infective process.
Conclusion: Correct Diagnosis Before Treatment Begins
Pinpointing the cause of plantar heel pain is never just a matter of finding pain in the heel and advising rest. An appropriate assessment is a synthesis of the patient’s history, pattern of pain, clinical examination, biomechanical assessment, and any other required investigations. An accurate diagnosis guides the design of treatment that is specific to the individual and the demands they place on their feet and goals for treatment, such as training adjustments, footwear modification, specific exercises, and other treatment options. Heel pain management should be determined by the clinical diagnosis, not simply the fact that heel pain is prevalent. If pain continues, walking is impacted, or there is no improvement, then an appointment with a podiatrist in Townsville QLD residents can rely on is a wise next step. A podiatrist can discuss chronic heel pain with the patient, discover the underlying problem, and advise on the next step that can help manage or solve the problem. The objective is clear; diagnose the pain source, then address the problem.
