"How I Approach Problems": Heel Pain, Sudden Onset, 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.

With the description of heel pain, sudden onset (you can remember the day), and swelling, you are not dealing with plantar fasciitis, but either a heel bone stress fracture or plantar fascial tear. The post today will look at the calcaneal (heel) stress fracture and the thought process in treatment. 

In the 2 MRIs above, the patient's sudden heel pain with swelling was diagnosed as a calcaneal (heel bone) stress fracture. The xrays taken the week before were completely negative. This case completely resolved with the repeat MRI 6 months later.
     When you talk about any stress fracture, or gross fracture for that matter, you have to ask yourself if the patient deserved the fracture by how they treated their foot. By this I mean, did they seem to overdo or over stress the foot, and seemed to get what they deserved. If your answer is no, then you have to look for other reasons a bone would break like low Vitamin D, low bone density, eating disorders, celiac's disease, history of osteoporosis, etc. Even if they seem to deserve it, over 50 years old, I get a bone density, and ask about family history of osteoporosis, and a personal history of low Vitamin D or funny diets.
     I am going to attach the original video I did on heel pain so you can see the examination of someone pointing to a heel stress fracture. Heel stress fractures are treated very differently than plantar fasciitis as the patient was initially diagnosed due to heel pain. Heel stress fractures need soft cushions, perhaps custom Hannaford orthotic devices, bone density and Vitamin D blood levels, possible bone stimulator, and occasionally they break all the way through and need some surgical pinning. Making the correct diagnosis at the beginning of the process saves alot of time.

https://youtu.be/plbBvPASXwM

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.

"How I Approach Problems": Plantar Fasciitis with Heel Pain with 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 proven more complex challenges. I hope my thought process will help you if you are treating this injury or have this injury or injured area.

     Heel Pain with Swelling: This is Not Plantar Fasciitis

The “itis” from plantar fasciitis is deep swelling and inflammation that is really hard to feel. The patient does not appreciate any swelling or fullness to the tissues. So, when a patient presents with heel pain, with or without the previous diagnosis being plantar fasciitis, and there is obvious swelling in the tissues, the injury is not plantar fasciitis. From my last post, here is how I summarized Acute heel pain (pain that comes on quickly). 

With an acute (sudden) onset of pain, and swelling in the heel, the 2 common diagnoses are:

1. Plantar Fascial Tears
2. Heel (Calcaneal) Stress Fractures

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

Therefore, an acute onset of heel pain, with the presence of swelling is either a Stage 2-3 plantar fascial injury or a boney injury to the heel (commonly a stress fracture). MRI is the image of choice, and even though the treatment is 3 months of immobilization for both, it is different thought process in treatment when the injury is fascial or bone. 

With fascial injuries, you made need to use plantar fascial treatments of taping, orthotic devices, and physical therapy after the period of immobilization.

With calcaneal heel bone injuries, you have to think about bone stimulators, overall bone health, bone density testing, Vit D, and the extent of the fracture up into the vulnerable subtalar joint. 

My next post I will discuss the protocol of plantar fascial stage 2 or 3 injuries, also known as partial or complete tears. 

“How I Approach Problems”: Plantar Fasciitis Not Responding to Treatment

    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 to be 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 Not Responding to Treatment 

Many heel and foot problems are called plantar fasciitis when they are not. Plantar fasciitis is a Grade or Stage I Ligament Sprain. It is inflammation from being pulled on too much in some manner typically in an overuse fashion. In the last blog post we talked about what is and what is not plantar fasciitis. And even though there are always exceptions to every rule, most of these are true. Plantar Fasciitis has the hallmarks of:

• Gradual onset of pain
• Worse in the morning
• Pain after prolonged sitting
• Minimal to no swelling
• Typically at the heel 
• Responds well to treatments of stretching, icing, and taping 
• Responds well to some forms of arch support where the weight is transferred forward off the sore heel

Therefore, it is good if the patient or yourself has this pattern of symptoms, and you are probably correct at calling it Plantar Fasciitis. But what happens if your initial treatment of stretching, icing, and taping does not help. And one or two forms of arch support are not helpful or even seem to make it feel worse. I personally like to follow my patients monthly and I expect if I have made the correct diagnosis, the patient begins to improve. Each visit I have with the patient after the first will show steady and gradual improvement. It is hard to measure time to complete success, as some patients want to pin me down. But, progress is key month by month if your treatment and diagnosis are in sync.

Each diagnosis has very different treatments so it is important to make an exact diagnosis when you are not improving. What are some of the typical signs from the patient that the problem may be something other than plantar fascia?

• The Onset of Pain Happened on one day
• The worse may is not when you first get out of bed in the morning
• The involved heel is more swollen than the other side
• The pain radiates into the arch or toes
• It hurts more when you walk on your heel then when you lift your heel

With an acute (sudden) onset of pain, and swelling in the heel, the 2 common diagnoses are:

1. Plantar Fascial Tears
2. Heel (Calcaneal) Stress Fractures

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

So, I have tried to show the myriad of patients who are not improving in their treatment of plantar fasciitis, typically because their heel pain was called  plantar fasciitis and it was something else. That something else, needing totally different treatments, was either:

• Plantar Fascial Tearing or Fasciosis
• Calcaneal Stress Fractures
• Plantar Calcaneal Bursitis
• Infra Calcaneal Neuritis

Each of these problems will be discussed separately in posts later. 

New Series: How I Approach Problems: Plantar Fasciitis

     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 proven 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

So, you have made (or been given) the diagnosis of plantar fasciitis (inflammation of the thick ligament under your arch that runs from your heel to your toes).

It is typically at its attachment at the heel where it is palpably sore on examination. If the soreness is somewhere else than its attachment, then the diagnosis should be in question. Since rare cases occur elsewhere, and if you are certain, the next diagnostic test will actually be the treatment to be prescribed. Plantar fasciitis should respond to this treatment.

The next test of the diagnosis is in the symptoms. Plantar fasciitis progressively gets sore over weeks and months. If the onset of pain is sudden, and the pain is under the heel bone, it is not plantar fasciitis. My next “How I Approach Problems” will be on sudden onset heel pain which is definitely not plantar fasciitis.

Plantar fasciitis also is always the worst in the morning when you get out of bed. Even though you should never use always in medicine, this is a pretty accurate rule. If the pain is not worse in the morning, it probably is something else. Again, we should see how it responds to treatment for plantar fasciitis.

Plantar fasciitis should have little to no soft tissue swelling. The patient typically can not feel heel swelling, but a doctor or therapist should. If there is significant swelling between the two sides of the body, it is probably not plantar fasciitis. Again, one of my next posts on “How I Approach Problems” will be on heel pain with swelling.

Plantar fasciitis should respond to typical treatments of ice massage, plantar fascial stretching, and taping. It can take a few months, but you should feel better and better each month. I love patients to continue doing activities that they can keep in the 0-2 pain range, even if it hurts more after. You do not run again until you are at the base line pain.

Treatment #1: Freeze a sport water bottle after filling 1/2 full of water. Roll over the painful area for 5 minutes 2-3 times a day with a towel on the floor as you sit and roll.

Treatment #2: I love the 2 achilles and 1 plantar fascial stretches described in the video below. These are typically done 3 times a day, especially before and after exercise like running.

https://youtu.be/0eAqJ4-oKTM



Treatment #3: Tape the arch to immobilize the pull of the plantar fascia. I have replaced the time-consuming, but wonderful, low dye taping with Quick Tape from Support the Foot. This is typically left on 5-7 days at a time.

https://youtu.be/41Or2rdpxbY



Plantar fasciitis always gets a lot better with this regimen. If there is little to no improvement, I doubt the patient (you) have plantar fasciitis at all. Next blog post will go over the decision making of no treatment response. If the patient gets 50% or so improvement but plateaus, we typically have to increase the treatment. Tomorrow I will discuss this scenario with partial success with plantar fascial treatment or no treatment success.

Plantar fascial treatment should allow full, but modified, activities. A non-response to treatment for plantar fasciitis, typically means that there is no plantar fasciitis but it can take a month of treatment to know that. A partial response to plantar fascial treatment typically means more specialized treatment is needed with inserts and PT.