Plantar Heal Pain - Causes, Symptoms, Diagnosis, and Treatment

What Is Plantar Heel Pain?

Plantar heel pain is described as pain, swelling, and stiffness of one or both heels of the feet. It is a common problem for adults. It causes severe pain and disability in physically active people. Plantar heel pain is the most common lower limb musculoskeletal problem. It significantly impacts a person's quality of life-related to health, including day-to-day work and physical activities.

Plantar heel pain most commonly affects middle-aged persons. Women are more prone, which may be due to early menopause. The hormonal changes in women can contribute to the weakening of fascia.

What Are the Causes of Plantar Heel Pain?

Plantar heel pain is caused by various pathologies.

1. Skeletal Pathology Includes:

• Calcaneal stress fractures.

• Apophysitis of the calcaneus (Sevier's disease).

• Osteomyelitis.

2. Soft Tissue Pathology Includes:

• Plantar fasciitis.

• Plantar fascia rupture.

• Fat pad atrophy or contusion.

3. Nerve Pathology Includes:

• Entrapment of Baxter's nerve (first branch of the lateral plantar nerve).

• Entrapment of nerve to abductor digit quinti muscle.

• S1 radiculopathy.

• Peripheral neuropathy.

• Tarsal tunnel syndrome.

4. Systemic Causes Includes:

• Rheumatoid arthritis.

• Seronegative spondyloarthropathies.

What Are the Risk Factors for Plantar Heel Pain?

Several risk factors cause plantar heel pain. They are:

• Inappropriate footwear.

• Excessive running.

• Prolonged standing.

• Reduced ankle dorsiflexion.

• Obesity.

• Stress.

• Pes planus (flat feet).

What Are the Symptoms of Plantar Heel Pain?

The symptoms of plantar heel pain vary with their causes.

Plantar Fasciitis

Persons with plantar fasciitis typically experience heel pain at the first step in the morning after getting out of bed. In severe cases, heel pain usually persists throughout the day, while walking, and even at rest times. Tenderness may be present over the medial calcaneal tubercle.

Heel Fat Atrophy

People with heel fat atrophy are presented with heel pain in the center region. The heel pain gets aggravated by walking on a hard surface with a bare foot. Tenderness may be presented on the central part of the calcaneus.

Calcaneal Stress Fractures

Patients with calcaneal stress fractures are presented with diffuse pain in their heels. Shows positive tenderness on medial and lateral compression of the calcaneus (This is said as a positive squeeze test).

Tarsal Tunnel Syndrome

In Tarsal Tunnel syndrome, the patients are presented with tingling pain and hypoesthesia on the plantar surface. On examining, tapping behind the medial malleolus shows a positive Tinel's sign.

Medial Calcaneal Neuropathy

The heel pain caused by medial calcaneal neuropathy is burning pain. Paresthesia may be present over the skin of the calcaneus. Tinel's sign shows positive on the medial surface of the calcaneus bone.

Baxter Nerve Neuropathy

The patient may experience sharp and radiating pain along Baxter's nerve. The pain gets worse while walking and at night. Examination shows positive tenderness and Tinel's sign.

S1 Radiculopathy

Patients present with a history of chronic lower back pain. Patients may experience numbness and radicular pain from the lower back to the heel. Examination reveals hamstring, peroneal, and foot muscles and reduced ankle reflex.

Systemic Cause

There are several symptoms for the systemic cause of plantar heel pain. Some are psoriasis, lower gastrointestinal symptoms, uveitis, polyarthritis, balanitis, etc.

How Is Plantar Heel Pain Diagnosed?

The causes of plantar heel pain can be diagnosed by clinical examination in most cases. Laboratory tests, imaging tests, and electrophysiologic studies also diagnose it. The diagnosis also includes a gait assessment.

Clinical Examination

Clinical examination of plantar heel pain includes palpitation, dorsiflexion-eversion neurodynamic test, Tinel's test, squeeze test, etc.

Laboratory Tests

Laboratory tests to identify the cause of plantar heel pain includes acute phase reactants, anti-cyclic citrullinated peptide antibodies, rheumatoid factor, and HLA-B27.

X-Rays and CT (Computed Tomography) Scan

Doctors recommend plain radiographs and CT scans to diagnose plantar calcaneal spurs and stress fractures.

MRI (Magnetic Resonance Imaging)

MRI is considered a functional imaging technique to diagnose entrapment of the tibial nerve, plantar fasciitis, bone cyst, stress fractures, and tumors.

Musculoskeletal Ultrasound

• Musculoskeletal ultrasound is mainly used to identify whether the cause of heel pain is soft tissue pathology. For patients who experience heel pain due to plantar fasciitis, healthcare providers may identify the thickening of the plantar fascia on the medial surface of calcaneus tuberosity. The thickening may be greater than 4 mm.

• If the heel pain is due to heel fat atrophy, the investigators may find the heel pad is thin from about 12 to 14 mm, if a patient is in non-weight bearing condition.

• Tarsal Tunnel Syndrome is diagnosed by investigating the surface area of the tibial nerve on the tarsal tunnel. If the cross-section of the nerve is greater than 9.26 mm. square, the condition is called Tarsal Tunnel syndrome.

• To diagnose entrapment neuropathies, healthcare providers use ultrasound to identify the changes in the muscles surrounding the nerves.

• In seronegative spondyloarthropathies, the ultrasound shows entheses erosion and enthesis's.

How Is Plantar Heel Pain Treated?

The treatments for plantar heel pain vary according to its causes.

• Plantar Fasciitis - If the patient is experiencing heel pain due to plantar fasciitis, they need conservative treatments such as reduction of weight, modification of the improperly fitting shoes, stretching exercises, and non-steroidal anti-inflammatory drugs (NSAIDs). If the patient's pain is not relieved by conservative treatments, they may be treated with shockwave therapy or ultrasound-guided Corticosteroids.

• Heel Fat Pad Atrophy - If the heel pain is by heel fat pad atrophy, the patient is treated by recommending proper rest, heel cups, ice packs, NSAIDs, tapping, and proper footwear. These treatments help to reduce heel pain.

• Calcaneal Stress Fractures - The treatment for this cause aims to prevent the progression of fractures and reduce pain by ensuring the patients do daily activities without pain. The therapy includes NSAIDs, bed rest, shoes inserted with 4-point weight-bearing crutches, and half-an-inch sponge rubber. Calcium, calcitonin, and vitamin D injection are suggested. Pulsed magnetic field therapy helps to promote healing and reduce pain.

• Entrapment of Nerves - Anticonvulsants and NSAIDs treat this cause. If the patient does not respond to the above medications, ultrasound-guided corticosteroid injections, radio frequency, and hydro dissection are used. In severe cases, surgical compression is recommended.

What Is the Differential Diagnosis of Plantar Heel Pain?

The differential diagnosis of plantar heel pain is:

• Distal plantar fasciitis.

• Haglund syndrome.

• Plantar fibromatosis.

• Tarsal Tunnel syndrome.

• Achilles tendon injuries.

Conclusion

Plantar heel pain is also known as plantar fasciitis. It is a common foot condition. It is characterized by pain in the heel, especially during the first steps in the morning or after prolonged periods of rest. Plantar heel pain can be relieved by various treatment modalities depending on the causes. Reaching out to healthcare providers is the best choice to get rid of the pain.