Atypical Plantar Heel Pain
Talysha Reeve
Musculoskeletal Podiatrist & Clinical Educator - I want to work with you to help you stay at the forefront of evidence-based practice and achieve great clinical outcomes.
Today we're diving into plantar heel pain and some signs that may indicate we're not dealing with a "typical" presentation.
Identification of atypical signs and symptoms is essential, as this will influence all aspects of your clinical management.
If you have a client who has not responded to standard treatments, it also pays to "go back to the drawing board" and consider your differentials.
Plantar heel pain can develop in active people, sedentary people, older people and younger people... Essentially, it can develop in anyone with a plantar fascia and the right combination of risk factors, coupled with the application of mechanical load.
When it comes to assessing and addressing plantar heel pain, clinicians will often hyper-focus on biomechanical & anatomical factors.
However, the majority of biomechanical & anatomical factors are considered correlative not causative.
“Investigations into the relationships between these mechanical factors and heel pain are limited to cross-sectional studies, which are unable to determine if these factors have a role in the aetiology of the condition… Studies with higher levels of evidence, particularly prospective cohort studies, would assist in determining whether these associated factors are causative or consequential…” Sullivan, Pappas & Burns (2020)
This isn't to say that biomechanics don't matter for some, more so that they're not always in the driving seat, especially if we're dealing with an 'atypical' presentation.
Before we get to our atypical presentations, let's review what comprises a typical presentation.
A typical presentation of plantar heel pain still has a multitude of variables that require individual consideration and individualised management.
The Plantar Fasciopathy Clinical Decision-Making Framework & user guide (get it here) provides a systematic approach to individualise your management.
Developing a robust assessment framework helps us identify if we're dealing with an overloaded or underloaded tissue, a compressive vs tensile driven pathology, as well as other factors that are driving an individual's clinical presentation, it then guides what our management pathway may look like based on the person's individual elements.
Typical Presentation of Plantar Fasciopathy
Self-Reported Symptoms
Plantar medial heel pain (+/- pain along the course of the plantar fascia).
Most noticeable / worse during initial steps after a period of rest or inactivity, that may also worsen following periods of prolonged weight-bearing (walking &/or standing).
+/- ↓
Progressively worsening over time.
Intensity of pain, duration of pain (eg: longer to ease after inactivity &/or shorter duration to flare after periods of weight-bearing).
Interventions may become less successful over time (eg: footwear or stretching may no longer provide symptomatic relief).
Worse after bouts of higher-intensity activities, ie: pain/discomfort worse the following morning after a long &/or intense running session, or prolonged period of time weight-bearing (that is outside of individual’s normal activities).
Tensile vs Compressive
Plantar Fasciopathy can result from both compressive &/or tensile loads.
The clinical history, individual presentation, clinical assessment & response to trial interventions can all help indicate what the potential primary driver of your client’s pathology is.
Remember both can be concurrent drivers of pathology.
“While plantar fasciitis is believed to result from excessive tensile force within the fascia, histological observations indicate that bending, shear and compression may have a potential role...” Wearing (2006) & Kirby (2017)
Paying attention to how a client is presenting can often guide the appropriate management pathway.
For typical presentations, an individual approach to typical treatments is key.
Atypical Presentations of Plantar Fasciopathy
Things become difficult when we're applying typical treatment interventions to atypical clinical presentations.
This highlights the importance of our clinical history taking, clinical assessments and regular monitoring of treatment response.
If someone isn't responding to your treatments something may have been missed. Reassess or refer to someone who may be able to help your client take the next steps.
What are the steps that we can work through to rule-in / rule-out some differentials for our plantar heel pain presentations?
STEP 1 - Clinical History & Mechanisms of Injury
Remember the NOLDCATS framework;
Nature
Overall description of symptoms.
Onset
When did the pain begin? How did it begin? What was it like when you first experienced the pain?
Location
Where does it hurt? Is it localised? Does the location change or fluctuate?
Duration
How long has the pain been present for? When it is present, how long does it last (seconds, minutes, hours, days)?
Characteristics
Pain descriptions, sharp, dull, shooting, burning, aching, deep, superficial, plus associated symptoms - tingling, numbness, weakness.
Alleviating & Aggravating Factors
What appears to help or harm? Does it improve or worsen with movement? Does it feel/worse standing on hard/soft surfaces, or no difference?
Timing
Is the pain intermittent or constant? Does it fluctuate throughout the day? Are there particular times of day that the pain is worse?
Severity
How intense is the pain? Often using the Visual Analog Scale of Pain (VAS-P).
BUT, don't just ask about pain, we need to focus on function.
Functional assessments & patient-reported outcome measures (PROMS) can give a clinician an in-depth understanding of the level of functional impairment resulting from their condition.
When taking your clinical history, pay attention to WHAT they say and HOW they say it.
“Psychological factors, such as pain catastrophising and kinesiophobia, require consideration in the management of patients with plantar heel pain, as they are associated with numerous negative outcomes such as increased pain severity, disability, poor treatment outcomes, increased medication use and negative mood.” Cotchett et al (2017)
STEP 2 - Anatomical Approach to Clinical Assessment
When it comes to assessing musculoskeletal injuries, an anatomical framework approach will help ensure that we are considering all potential structures that may be involved.
Applying the Anatomical Framework to plantar heel pain will lead to considering a number of differentials for our diagnosis.
STEP 3 - Clinical Assessment with Functional Stressors
When we are undertaking our clinical assessments we move from the subjective information our client has provided to our objective assessments.
These will typically involve palpation, passive movement, active movement, specific tests, and various functional tests.
If during our typical objective and loading tests we are not finding anything that indicates plantar fascia involvement, we then move to our differential assessments.
Common Plantar Fascia Assessments; windlass tests, plantar fascia-dominant loading assessments, strapping to assess compressive drivers.
For some of our differentials, we will be able to identify these from our subjective history. For example; acute calcaneal fracture or tarsal tunnel syndrome.
Case #1; Male, 19yrs.
Jumped off a 2m high retaining wall. Sharp heel pain at the time, shifted to a "dull ache" that has lasted 2 weeks and not improving. X-ray imaging confirmed non-displaced, partial thickness fracture of the calcaneus.
? Clinical suspicion of fracture from mechanism of injury.
? Point tenderness on palpation.
? X-ray confirmed
Case #2; Female, 39yrs.
Previously diagnosed with plantar fasciopathy 4/12 ago, has been under standard treatment from another clinician. Noticed over the last 6 weeks a change in the pattern of pain.
Previous pain pattern was consistent with "typical" plantar heel pain; first-step pain, alleviates with movement.
Current pain pattern; fine first thing in the morning, discomfort worsens with prolonged weight-bearing, subtle, intermittent tingling from sub-medial malleolus to plantar heel & proximal plantar medial arch.
? Negative for pain on palpation plantar medial calcaneal tubercle.
? Negative NWB or WB windlass tests.
? Reduced ankle dorsiflexion ROM (weight-bearing lunge test).
? Subtle reproduction of tingling sensation with Tinel's Test.
Tinel's Test: Sensitivity 25% to 75%; Specificity is 70% to 90%. Kiel & Kaiser (2022)
? Negative response with dorsiflexion eversion, straight leg raise and slump tests.
STEP 4 - Identification of an Atypical Presentation
If we have a clinical suspicion of a differential driver of our patient's clinical presentation resulting from our clinical history-taking, objective & functional assessments, we then begin to consider alternate management pathways.
For a number of differentials, the management may be somewhat similar to typical plantar fascia pathologies. For others, they may differ significantly.
Depending on the differential we are suspicious of, we may utilise diagnostic imaging, as this may help guide our management.
Delving into the nuanced management is beyond the scope of what we're exploring today, but... If you would like to learn more about all things plantar fasciopathy assessment, management & rehabilitation please keep reading...
The Plantar Fasciopathy Rehabilitation Masterclass is a gold mine for clinically-relevant, easy to apply information to help you master assessing & managing plantar heel pain.
Plantar Fasciopathy Rehabilitation Masterclass - ONLINE find out more
Also, we're running the Plantar Fasciopathy Rehabilitation Masterclass LIVE WORKSHOP in Melbourne on the 23rd of June 2024.
Plantar Fasciopathy Rehabilitation Masterclass - LIVE find out more
What our course participants are saying:
References:
Wearing, S., Smeathers, J., Urry, S., Hennig, E., & Hills, A. (2006). The Pathomechanics of Plantar Fasciitis.?Sports Medicine,?36(7), 585-611. doi: 10.2165/00007256-200636070-00004
Great insights! ?? Assessing heel pain requires a deeper look beyond surface symptoms. - Aristotle reminds us, knowing yourself is the beginning of all wisdom; in this case, knowing your patient's specific needs is crucial.