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Monday, July 13, 2020

How I Approach Problems: Plantar Fasciitis with Sudden Onset and No Obvious Swelling

    This is a new series of blog posts on various injuries entitled "How I Approach Problems". I will be going through common injuries to start and then the areas that prove more complex challenges. I hope my thought process will help you if you are treating this injury or have this injury or injured area.

           Plantar Fasciitis: Acute in Nature and without Swelling

Most heel pain is diagnosed as plantar fasciitis, and everyone knows the ice, stretch, and support protocol. But what if it is not plantar fasciitis. One subset of patients that I see have a sudden onset of pain (not plantar fasciitis), and without swelling that I can note on exam, and therefore fall into one of these 2 diagnoses.

With the acute (sudden) onset of pain, without noticeable swelling in the heel, the 2 common diagnoses are:
  1. Heel Bursitis (only deep palpation away from the plantar fascia finds a painful bursal sac)
  2. Heel Neuritis (this can cause heel rim pain or radiating pain or other neuropathic symptoms)
Plantar fasciitis can morph into bursitis due to chronic low grade inflammation, but this is not the type we are discussing. The heel pain that is sudden with a plantar heel painful palpable mass, is called infra calcaneal (heel) bursitis.  There may or may not be a reason for the bursae to swell causing the pain that the patient will remember (like stepping on a rock barefoot at the beach). There is a bursal sac that is there when needed to protect bony prominences (like side of hip, front of knee, under the metatarsals), and only gets sore and swollen when irritated.

You can perhaps make the diagnosis with barefoot walking. Plantar fasciitis typically hurts the worse at push off, so walking on the toes may hurt. Heel bursitis hurts more when asked to walk on the heels alone (bursitis sufferers usually do not like this at all).

Heel neuritis can be local (Baxter's nerve entrapment) or referred pain from the tarsal tunnel or higher up (low back and even cervical issues). Like any peripheral nerve problem, you always have to think that it could be from higher up the chain (called Double Crush syndrome). In Double Crush, the nerve would be irritated at the heel (say a pes cavus foot with bony heel and no fat pad---the perfect storm), and is being irritated at the back, piriformis, behind the knee due to a baker's cyst, or in tight hamstrings or calves. What complicates this is that there is no test that confirms that the nerve is irritatable. Nerve tests like nerve conduction studies are looking for damaged nerves not excitable nerves.

 This photo may be alittle difficult, but it is of all the nerves on the bottom of your foot. Look at the nerves just under the heel bone. Any of these can get irritated locally or from a signal from higher.

So, when heel pain, initially diagnosed as plantar fasciitis is not getting better from plantar fascial treatment, you must start looking for another working diagnosis. When there is no obvious swelling, typically ruling out problems like plantar fascial tearing and heel stress fractures or bone bruises, you should look for heel bursitis and heel neuritis.

My next posts will go over the treatments for each separately.

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.